Morgan Slater

Are school zones effective? An examination of motor vehicle versus child pedestrian crashes near schools.

Objective: To analyse the relationships between factors related to school location and motor vehicle versus child pedestrian collisions. Methods: Data on all police-reported motor vehicle collisions involving pedestrians less than 18 years of age that occurred in Toronto, Canada, between 2000 and 2005 were analysed. Geographic information systems (GIS) software was used to assess the distance of each collision relative to school location. The relationships between distance from school and collision-related factors such as temporal patterns of school travel times and crossing locations were analysed. Results: Study data showed a total of 2717 motor vehicle versus child (<18) pedestrian collisions. The area density of collisions (collisions/area), particularly fatal collisions, was highest in school zones and decreased as distance from schools increased. The highest proportion of collisions (37.3%) occurred among 10–14-year-olds. Within school zones, collisions were more likely to occur among 5–9-year-old children as they travelled to and from school during months when school was in session. Most collisions within school zones occurred at midblock locations versus intersections. Conclusions: Focusing interventions around schools with attention to age, travel times, and crossing location will reduce the burden of injury in children. Future studies that take into account traffic and pedestrian volume surrounding schools would be useful for prevention efforts as well as for promotion of walking. These results will help identify priorities and emphasise the importance of considering spatial and temporal patterns in child pedestrian research.

A systematic review of RIFLE criteria in children, and its application and association with measures of mortality and morbidity

The RIFLE criteria were developed to improve consistency in the assessment of acute kidney injury. The high face validity, collaborative development method, and validation against mortality have supported the widespread adoption of the RIFLE to evaluate adult patients; however, its inconsistent application in adult studies is associated with significant effects on the estimated incidence of acute kidney injury. As the RIFLE criteria are now being used to determine acute kidney injury in children, we conducted a systematic review to describe its application and assess associations between the RIFLE and measures of mortality and morbidity in pediatric patients. In 12 studies we found wide variation in the application of the RIFLE, including the range of assessed RIFLE categories, omission of urine output criteria, varying definitions of baseline renal function, and methods for handling missing baseline measurements. Limited and conflicting associations between the RIFLE and mortality, length of stay, illness severity, and measures of kidney function were found. Thus, although the RIFLE was developed to improve the consistency of defining acute kidney injury, there are still major discrepancies in its use in pediatric patients that may undermine its potential utility as a standardized measure of acute kidney injury in children.

A comparison of booster seat use in Canadian provinces with and without legislation

Background: The use of booster seats continues to be low, despite their effectiveness in reducing injury in motor vehicle collisions. Many jurisdictions have introduced legislation requiring the use of booster seats. To date, there have been no Canadian studies evaluating the effectiveness of legislation on booster seat use. Objectives: To describe restraint use among Canadian children aged 4–8 years, and compare booster seat use between provinces/territories with and without legislation. Methods: The data were obtained from a National Survey of Child Restraint Use/Misuse conducted between June and August 2006. A roadside observation survey was conducted at 182 sites across Canada. Weighted statistical analyses of differences in proportions were conducted, accounting for sampling stratification and clustering by car effects. Results: The roadside survey estimated that 24.6% of children aged 4–8 were restrained in booster seats in provinces with legislation, compared with 16.6% in provinces without (p<0.001). Conclusion: This is the first Canadian national study using direct observation to determine the effect of legislation on booster seat use. Provinces with legislation had higher booster seat use, but overall rates were still disappointingly low. Ongoing surveillance of child safety seat use and evaluation of effective adjuncts to legislation is required in order to see collision-related child deaths and injuries drop in the future.

Brain drain and "brain waste": experiences of international medical graduates in Ontario.

Background “Brain drain” is a colloquial term used to describe the migration of health care workers from low-income and middle-income countries to higher-income countries. The consequences of this migration can be significant for donor countries where physician densities are already low. In addition, a significant number of migrating physicians fall victim to “brain waste” upon arrival in higher-income countries, with their skills either underutilized or not utilized at all. In order to better understand the phenomena of brain drain and brain waste, we conducted an anonymous online survey of international medical graduates (IMGs) from low-income and middle-income countries who were actively pursuing a medical residency position in Ontario, Canada. Methods Approximately 6,000 physicians were contacted by email and asked to fill out an online survey consisting of closed-ended and open-ended questions. The data collected were analyzed using both descriptive statistics and a thematic analysis approach. Results A total of 483 IMGs responded to our survey and 462 were eligible for participation. Many were older physicians who had spent a considerable amount of time and money trying to obtain a medical residency position. The top five reasons for respondents choosing to emigrate from their home country were: socioeconomic or political situations in their home countries; better education for children; concerns about where to raise children; quality of facilities and equipment; and opportunities for professional advancement. These same reasons were the top five reasons given for choosing to immigrate to Canada. Themes that emerged from the qualitative responses pertaining to brain waste included feelings of anger, shame, desperation, and regret. Conclusion Respondents overwhelmingly held the view that there are not enough residency positions available in Ontario and that this information is not clearly communicated to incoming IMGs. Brain waste appears common among IMGs who immigrate to Canada and should be made a priority for Canadian policy-makers.

Methodology of estimating restraint use in children: Roadside observation or parking lot interview survey

OBJECTIVE To compare the differences in Canadian national estimates of correct child restraint use obtained using the standard roadside observation method compared to a detailed parking lot interview. DESIGN A multi-stage stratified survey design was used to conduct roadside observational and interview data collection at 182 randomly selected sites across Canada. For each site, a roadside intersection location and a parking lot location were used for the roadside observational survey and the interview respectively. Weighted estimates of correct restraint use from both locations were compared. RESULTS Estimates of correct restraint use were significantly higher for all children under the age of 9 in the parking lot sample. The largest discrepancy between the two samples was in booster seat aged children (ages 4-8) where 29.1% versus 67.8% of children were observed to be correctly restrained using the roadside and the parking lot methodology respectively. There was a 67% participation refusal rate in the parking lot survey. CONCLUSIONS There are specific advantages and limitations to both survey designs. The purpose of the data collection must be considered when selecting the methodology. Parking lot surveys provide richer data regarding restraint use/misuse. Estimates of correct restraint use must be approached with caution due to the effect of consent bias resulting in over inflation of estimates. Roadside observation is adequate and appropriate for providing national estimates of correct restraint use.

Motor vehicle and pedestrian collisions: burden of severe injury on major versus neighborhood roads.

Objective: To determine whether the severity of injuries sustained by pedestrians involved in motor vehicle collisions varies by road type and age. Methods: All police-reported pedestrian motor vehicle collisions in the city of Toronto, Canada, between January 1, 2000, and December 31, 2005, were analyzed. Geographic Information Systems software was used to determine whether the collisions occurred on major or neighborhood roads. Age-specific estimates of the burden of pedestrian collisions are presented. Odds ratios and 95 percent confidence intervals were calculated to examine age-specific relationships between injury severity and road type. A second analysis comparing the distribution of severe injury location between age groups was also performed. Results: The majority of collisions involved adults (68%), although elderly pedestrians were overrepresented in fatal collisions (49%). Severe and fatal collisions involving working-age and elderly adult pedestrians were more likely on major roads. Odds of severe injury occurring on a major road were 1.36 (95% CI: 1.17–1.57) times higher for adults ages 18 to 64, and 1.55 (95% CI: 1.22–1.99) times higher for elderly aged 65+. By contrast, severe injuries among children were more common on neighborhood roads, with odds of severe injury on a major road of 0.64 (95% CI: 0.37–1.1) for children aged 5 to 9. Among children under 9, 64–67 percent of hospitalized or fatal injuries occurred on neighborhood roads, a marked difference from the distribution of such injuries in adults or the elderly, for whom only 29–30 percent of hospitalized or fatal injuries occurred on neighborhood roads (chi-square = 52.6, p ≤.001). Conclusions: Targeting interventions toward the adult pedestrian burden on major roads alone will not make child pedestrians safer. Pedestrian interventions specific to children and focused on neighborhood roads must be considered in urban centers like Toronto.

Risk Factors of Acute Kidney Injury in Critically Ill Children.

Objectives: Acute kidney injury may be promoted by critical illness, preexisting medical conditions, and treatments received both before and during ICU admission. We aimed to estimate the frequency of acute kidney injury during ICU treatment and to determine factors, occurring both before and during the ICU stay, associated with the development of acute kidney injury. Design: Cohort study of critically ill children. Setting: University-affiliated PICU. Patients: Eligible patients were admitted to the ICU between January 2006 and June 2009. We excluded those admitted with known primary renal failure, chronic renal failure or postrenal transplant, conditions with known renal complications, or metabolic conditions treated with dialysis. Patients were also excluded if they had a short ICU stay (< 6 hr) and those who had no creatinine or urine output measurements during their ICU stay. Interventions: None. Measurements and Main Results: Of the 3,865 pediatric patients who met the inclusion criteria, 915 (23.7%) developed acute kidney injury, as classified by the Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease criteria, during their ICU stay. Patients at high risk for development of acute kidney injury included those urgently admitted to the ICU (adjusted odds ratio, 1.88), those who developed respiratory dysfunction during their ICU care (adjusted odds ratio, 2.90), and those who treated with extracorporeal membrane oxygenation (adjusted odds ratio, 2.72). The single greatest risk factor for acute kidney injury was the administration of nephrotoxic medications during ICU admission (adjusted odds ratio, 3.37). Conclusions: This study, the largest evaluating the incidence of RIFLE-defined acute kidney injury in critically ill children, found that one-quarter of patients admitted to the ICU developed acute kidney injury. We identified a number of potentially modifiable risk factors, the largest of which was the administration of nephrotoxic medication. The results of this study may be used to inform targeted interventions to reduce acute kidney injury and improve the outcomes of critically ill children.

How Do People Attribute Income-Related Inequalities in Health? A Cross-Sectional Study in Ontario, Canada

Context Substantive equity-focused policy changes in Ontario, Canada have yet to be realized and may be limited by a lack of widespread public support. An understanding of how the public attributes inequalities can be informative for developing widespread support. Therefore, the objectives of this study were to examine how Ontarians attribute income-related health inequalities. Methods We conducted a telephone survey of 2,006 Ontarians using random digit dialing. The survey included thirteen questions relevant to the theme of attributions of income-related health inequalities, with each statement linked to a known social determinant of health. The statements were further categorized depending on whether the statement was framed around blaming the poor for health inequalities, the plight of the poor as a cause of health inequalities, or the privilege of the rich as a cause of health inequalities. Results There was high agreement for statements that attributed inequalities to differences between the rich and the poor in terms of employment, social status, income and food security, and conversely, the least agreement for statements that attributed inequalities to differences in terms of early childhood development, social exclusion, the social gradient and personal health practices and coping skills. Mean agreement was lower for the two statements that suggested blame for income-related health inequalities lies with the poor (43.1%) than for the three statements that attributed inequalities to the plight of the poor (58.3%) or the eight statements that attributed inequalities to the privilege of the rich (58.7%). Discussion A majority of this sample of Ontarians were willing to attribute inequalities to the social determinants of health, and were willing to accept messages that framed inequalities around the privilege of the rich or the plight of the poor. These findings will inform education campaigns, campaigns aimed at increasing public support for equity-focused public policy, and knowledge translation strategies.

Identifying High-Risk Medications Associated with Acute Kidney Injury in Critically Ill Patients: A Pharmacoepidemiologic Evaluation

BackgroundNephrotoxic medications are a common cause of acute kidney injury (AKI). Critically ill children receive more medication than other inpatients; however, the risk of nephrotoxic medication-induced AKI in these children is not well understood.ObjectiveThe aim of this study was to determine the association between exposure to nephrotoxic medications in the intensive care unit (ICU) and the development of AKI amongst critically ill children, adjusting for differences in underlying risk.MethodsWe conducted a nested case–control study among a cohort of patients admitted to a paediatric intensive care unit between January 2006 and June 2009. Cases were identified according to the RIFLE criteria. Using incidence density sampling, controls were matched 1:1 according to pre-ICU nephrotoxic drug exposure. Administration of nephrotoxic medications and other known risk factors of AKI were evaluated during the ICU stay prior to the diagnosis of AKI.ResultsA total of 914 patients in the cohort developed AKI and had an identifiable matched control. Eighty-seven percent of cases and 74% of controls were exposed to one or more nephrotoxic medications in the ICU during the study period. Furosemide (administered to 67.8% of patients), vancomycin (28.7%), and gentamicin (21.4%) were the most frequently administered nephrotoxic drugs. Patients who developed AKI were more likely to be exposed to at least one nephrotoxic medication and risk increased with increasing number of nephrotoxic medications. Ganciclovir (adjusted odds ratio [AOR] 4.7; 95% CI 1.7–13.0), furosemide (AOR 1.9; 95% CI 1.4–2.4), and gentamicin (AOR 1.8; 95% CI 1.4–2.4) significantly increased the odds of developing AKI after adjusting for underlying differences in risk factors of AKI.ConclusionThis is the first study to assess the association between risk-adjusted nephrotoxic medication exposure and the development of AKI in critically ill children. Nephrotoxic medication exposure was common amongst children in the ICU and we found AKI was associated with the administration of specific drugs after adjustment for important risk factors.

Facebook as a tool for communication, collaboration, and informal knowledge exchange among members of a multisite family health team

Objective To implement and evaluate a private Facebook group for members of a large Ontario multisite Family Health Team (FHT) to facilitate improved communication and collaboration. Design Program implementation and subsequent survey of team members. Setting A large multisite FHT in Toronto, Ontario. Participants Health professionals of the FHT. Main outcome measures Usage patterns and self-reported perceptions of the Facebook group by team members. Results At the time of the evaluation survey, the Facebook group had 43 members (37.4% of all FHT members). Activity in the group was never high, and posts by team members who were not among the researchers were infrequent throughout the study period. The content of posts fell into two broad categories: 1) information that might be useful to various team members and 2) questions posed by team members that others might be able to answer. Of the 26 team members (22.6%) who completed the evaluation survey, many reported that they never logged into the Facebook page (16 respondents), and never used it to communicate with team members outside of their own site of practice (19 respondents). Only six respondents reported no concerns with using Facebook as a professional communication tool; the most frequent concerns were regarding personal and patient privacy. Conclusion The use of social media by health care practitioners is becoming ubiquitous. However, the issues of privacy concerns and determining how to use social media without adding to provider workload must be addressed to make it a useful tool in health care.