Novelty helmet use and motorcycle rider fatality.

OBJECTIVES: To compare the risk of fatal injury across helmet types among collision-involved motorcyclists. METHODS: We used data from a cohort of motorcyclists involved in police-reported traffic collisions. Eighty-four law enforcement agencies in California collected detailed information on helmet and rider characteristics during collision investigations in June 2012 through July 2013. Multiply-adjusted risk ratios were estimated with log-binomial regression. RESULTS: The adjusted fatal injury risk ratio for novelty helmets was 1.95 (95% CI 1.11-3.40, p 0.019), comparing novelty helmets with full-face helmets. The risk ratios for modular, open-face, and half-helmets, compared with full-face helmets, were not significant. CONCLUSIONS: A more complete understanding of the inadequacy of novelty helmets can be used in educational and law enforcement countermeasures to improve helmet use among motorcycling populations in California and other US states. Law enforcement approaches to mitigating novelty helmet use would seem attractive given that novelty helmets can be visually identified by law enforcement officers with sufficient training.

Trauma Center-Based Surveillance of Nontraffic Pedestrian Injury among California Children.

INTRODUCTION: Every year in the United States, thousands of young children are injured by passenger vehicles in driveways or parking areas. Little is known about risk factors, and incidence rates are difficult to estimate because ascertainment using police collision reports or media sources is incomplete. This study used surveillance at trauma centers to identify incidents and parent interviews to obtain detailed information on incidents, vehicles, and children. METHODS: Eight California trauma centers conducted surveillance of nontraffic pedestrian collision injury to children aged 14 years or younger from January 2005 to July 2007. Three of these centers conducted follow-up interviews with family members. RESULTS: Ninety-four injured children were identified. Nine children (10%) suffered fatal injury. Seventy children (74%) were 4 years old or younger. Family members of 21 victims from this study (23%) completed an interview. Of these 21 interviewed victims, 17 (81%) were male and 13 (62%) were 1 or 2 years old. In 13 cases (62%), the child was backed over, and the driver was the mother or father in 11 cases (52%). Fifteen cases (71%) involved a sport utility vehicle, pickup truck, or van. Most collisions occurred in a residential driveway. CONCLUSION: Trauma center surveillance can be used for case ascertainment and for collecting information on circumstances of nontraffic pedestrian injuries. Adoption of a specific external cause-of-injury code would allow passive surveillance of these injuries. Research is needed to understand the contributions of family, vehicular, and environmental characteristics and injury risk to inform prevention efforts.

Swine flu: false-positive rapid flu swab with resulting misdiagnosis of a case of Legionella pneumonia.

A 59-year-old man presented with a severe flu-like illness and widespread pulmonary infiltrates on chest x-ray. A rapid influenza direct test was positive and the patient was nursed in isolation. On subsequent review, a diagnosis of probable atypical pneumonia was made, which was confirmed with positive urinary serology for Legionella pneumophila and treatment with appropriate antibiotics was started. A real-time PCR test for influenza A and B was negative at 72 h. The patient made a slow but full recovery and was discharged after 14 days.

A simple method for estimating excess mortality due to heat waves, as applied to the 2006 California heat wave.

OBJECTIVES: To characterize excess mortality during a major heat wave in California and its regions; to assess the validity of a simple method. METHODS: We calculated mortality rate ratios for the heat-wave period, using a reference period of the same number of days from the same summer. We conducted alternative analyses and compared our results with those from a time-series model. RESULTS: We estimated 655 excess deaths, a 6% increase (95% confidence interval, 3-9%), impacting varied geographic/climate regions. Alternate analyses supported model validity. CONCLUSIONS: California experienced excess heat-wave related mortality not restricted to high heat regions. As climate change is anticipated to increase heat events, public health efforts to monitor effects assume greater importance.

The 2006 California heat wave: impacts on hospitalizations and emergency department visits.

BACKGROUND: Climate models project that heat waves will increase in frequency and severity. Despite many studies of mortality from heat waves, few studies have examined morbidity. OBJECTIVES: In this study we investigated whether any age or race/ethnicity groups experienced increased hospitalizations and emergency department (ED) visits overall or for selected illnesses during the 2006 California heat wave. METHODS: We aggregated county-level hospitalizations and ED visits for all causes and for 10 cause groups into six geographic regions of California. We calculated excess morbidity and rate ratios (RRs) during the heat wave (15 July to 1 August 2006) and compared these data with those of a reference period (8-14 July and 12-22 August 2006). RESULTS: During the heat wave, 16,166 excess ED visits and 1,182 excess hospitalizations occurred statewide. ED visits for heat-related causes increased across the state [RR = 6.30; 95% confidence interval (CI), 5.67-7.01], especially in the Central Coast region, which includes San Francisco. Children (0-4 years of age) and the elderly (> or = 65 years of age) were at greatest risk. ED visits also showed significant increases for acute renal failure, cardiovascular diseases, diabetes, electrolyte imbalance, and nephritis. We observed significantly elevated RRs for hospitalizations for heat-related illnesses (RR = 10.15; 95% CI, 7.79-13.43), acute renal failure, electrolyte imbalance, and nephritis. CONCLUSIONS: The 2006 California heat wave had a substantial effect on morbidity, including regions with relatively modest temperatures. This suggests that population acclimatization and adaptive capacity influenced risk. By better understanding these impacts and population vulnerabilities, local communities can improve heat wave preparedness to cope with a globally warming future.

Passive surveillance of shaken baby syndrome using hospital inpatient data.

BACKGROUND: The conference from which these articles came addressed the question of public health surveillance for shaken baby syndrome (SBS) and explores one component of a comprehensive SBS surveillance system that would be relatively easy to implement and maintain: passive surveillance based on hospital inpatient data. Provisional exclusion and inclusion criteria are proposed for a two-level case definition of diagnosed SBS (strict definition) and cases presumed to be SBS (broad definition). The strict SBS definition is based on the single SBS code in the ICD-9-CM (995.55). The broader presumptive SBS definition is based on research studies that have identified a pattern of diagnostic codes often considered part of the clinical diagnosis of SBS. RESULTS: Based on 2006 analyses, California inpatient data are presented for 1998-2004. The strict SBS definition identified 366 cases over the 7 years, whereas the broader definition captured nearly 1000 cases. Annual rates show little fluctuation from the overall rate of 5.1 for strict SBS and 14.0 for broad SBS (per 100,000 children aged <2 years). Selected demographic and outcome characteristics are presented for each definition. The broad definition produces rates that are roughly comparable to those produced in careful clinical and population-based studies that also included children who died without being hospitalized. CONCLUSIONS: Despite the limitations of inpatient data, a passive surveillance system like the one proposed here can provide a critical component for a comprehensive SBS surveillance system and may be adequate for some purposes, including identifying high-risk areas or groups for intervention and monitoring trends over time.

Strategies to improve external cause-of-injury coding in state-based hospital discharge and emergency department data systems: recommendations of the CDC Workgroup for Improvement of External Cause-of-Injury Coding.

Each year, an estimated 50 million persons in the United States experience injuries that require medical attention. A substantial number of these persons are treated in an emergency department (ED) or a hospital, which collects their health-care data for administrative purposes. State-based morbidity data systems permit analysis of information on the mechanism and intent of injury through the use of external cause-of-injury coding (Ecoding). Ecoded state morbidity data can be used to monitor temporal changes and patterns in causes of unintentional injuries, assaults, and self-harm injuries and to set priorities for planning, implementing, and evaluating the effectiveness of injury-prevention programs. However, the quality of Ecoding varies substantially from state to state, which limits the usefulness of these data in certain states. This report discusses the value of using high-quality Ecoding to collect data in state-based morbidity data systems. Recommendations are provided to improve communication regarding Ecoding among stakeholders, enhance the completeness and accuracy of Ecoding, and make Ecoded data more useful for injury surveillance and prevention activities at the local, state, and federal levels. Implementing the recommendations outlined in this report should result in substantial improvements in the quality of external cause-of-injury data collected in hospital discharge and ED data systems in the United States and its territories.

Nonfatal traumatic brain injury-related hospitalization in very young children-15 states, 1999.

OBJECTIVE: To document age-related patterns of nonfatal hospitalization associated with traumatic brain injury (TBI) among children younger than 2 years of age, by intent/cause and diagnosis. METHODS: Data describing 2536 nonfatal TBI-related hospitalizations in 15 states for the year 1999 were obtained from the Centers for Disease Control and Prevention Central Nervous System Injury surveillance system for children younger than 2 years of age (0-23 months) at the time of injury. MAIN OUTCOME MEASURES: Incidence rates (overall, by intent/cause, and by diagnosis) were calculated by combining TBI surveillance data with population data from the US Census Bureau and the National Center for Health Statistics. RESULTS: Overall rates of nonfatal TBI-related hospitalization peaked at 1 month of age (178.0 cases per 100,000 person-years) followed by a secondary peak at 8 months of age (127.9 cases per 100,000 person-years). Rates for fall-related (unintentional) cases and assault-related cases were significantly higher for infants (0-11 months) than for 1-year-olds (12-23 months), with rates for both types of cases peaking in the earliest months of life. Rates for cases with diagnoses of skull fracture and/or intracranial injury were also significantly higher for the younger group. Assault-related cases frequently coincided with a diagnosis of intracranial injury regardless of age. CONCLUSIONS: Prevention efforts should focus on falls and assaults, which account for the majority of TBI-related hospitalizations in early childhood. Such efforts may also need to emphasize the unusually high risk during the first few months of life.

Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking.

OBJECTIVE: To determine whether there is an age-specific incidence of hospitalized cases of Shaken Baby Syndrome (SBS) that has similar properties to the previously reported "normal crying curve," as a form of indirect evidence that crying is an important stimulus for SBS. DESIGN AND SETTING: The study analyzed cases of Shaken Baby Syndrome by age at hospitalization from hospital discharge data for California hospitals from October 1996 through December 2000. PATIENTS: All cases of children less than 18 months (78 weeks) of age for whom the diagnostic code for Shaken Baby Syndrome (995.55) in the International Classification of Disease, Ninth Edition, Clinical Modification was assigned. RESULTS: There were 273 hospitalizations for SBS. Like the "normal crying curve," the curve of age-specific incidence starts at 2-3 weeks, has a clear peak, and declines to baseline by about 36 weeks of age. In contrast to the normal crying curve that peaks at 5-6 weeks, the peak of SBS hospitalizations occurs at 10-13 weeks. CONCLUSIONS: The age-specific incidence curve of hospitalized SBS cases has a similar starting point and shape to the previously reported normal crying curve but the peak occurs about 4-6 weeks later. Of the likely predisposing causes, this pattern is only consistent with the properties of early crying. There are numerous explanations for the lag in the peaks between crying and SBS hospitalizations, including the possibility of repeat shakings prior to hospitalization. The importance of crying as a stimulus to SBS may provide an opportunity for preventive intervention.

Epidemiology of hospitalizations resulting from dog bites in California, 1991-1998.

We used population-based hospital discharge data to describe hospitalizations resulting from dog bites in California from 1991 through 1998, when there were 6676 such hospitalizations (average 835 per year; range 732 to 930), and the annual cumulative incidence for all ages was 2.6 per 100 000. Children had more than twice the risk of adults, and Asians had lower rates than Whites. Children aged 0 to 9 years were more likely to suffer wounds to the head and face.

Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age.

OBJECTIVE: Mortality and morbidity data on childhood injury are used to construct developmentally appropriate intervention strategies and to guide pediatric anticipatory counseling on injury prevention topics. Effective anticipatory guidance depends on detailed injury data showing how risks change as children develop. Conventional age groupings may be too broad to show the relationship between children's development and their risk of various causes of injury. Previous studies revealed differences in overall rates and specific causes of injury by year of age. However, single year of age rates for children younger than 4 years may not reflect the variations in risk as a result of rapid developmental changes. This study was designed to analyze injury rates for children younger than 4 years by quarter-year intervals to determine more specifically the age period of highest risk for injury and for specific causes. METHODS: We used data from 1996-1998 California hospital discharges and death certificates to identify day of age and external cause of injury (E-code) for children younger than 4 years. The number of California residents for each day of age was estimated from US Census of estimates of California's population by year of age for the midpoints (1996-1998). Rates were calculated by 3-month intervals. We grouped the E-codes into major categories that would be particularly relevant for developmentally related risks of injury specific to young children. The categorization took into account physical, motor, behavioral, and cognitive developmental milestones of children 0 to 3 years. RESULTS: There were a total of 23,173 injuries; 636 resulted in death. The overall annual rate for children aged 0 to 3 years was 371/100,000. Beginning at age 3 to 5 months, the overall rate of injury rapidly increased with increased age, peaking at 15 to 17 months. The mean injury rate calculated for each single year of age did not reflect the variation and the highest rate of injury by quarter year of age for children younger than 1 year, 1 year, and 2 years. The leading major causes of injury in descending order were falls, poisoning, transportation, foreign body, and fires/burns. The overall rate of the major category of falls exceeded poisoning, the second leading cause of injury, by a factor of 2. Age-related differences were detected within each major cause of injury. For children 0 to 12 months of age, there was a different leading cause of specific injury for each 3-month period: other falls from height (0-2 months), battering (3-5 months), falls from furniture (6-8 months), and nonairway foreign body (9-11 months). Hot liquid and vapor injuries were the leading specific causes for children 12 to 17 months. Poisoning by medication was the leading specific cause of injury for all age groups from 18 to 35 months and exceeded poisoning by other substances. Pedestrian injury was the leading specific cause of injury for all age groups from 36 to 47 months. Fall from furniture has the highest rates of specific causes of falls from age 3 to 47 months. Fall from stairs peaked at age 6 to 8 months and 9 to 11 months. Fall from buildings was highest at 24 to 26 months. Poisoning by medication peaked at age 21 to 23 months, but poisoning by other substances peaked at 15 to 17 months. The motor vehicle occupant injury rates were fairly stable over the age span of this study. The pedestrian injury rate increased beginning at age 12 to 14 months and by 15 to 17 months was double that of the motor vehicle occupant. Foreign body had a marked peak at age 9 to 11 months. Both battering and neglect rates were highest among infants 0 to 2 and 3 to 5 months. Bathtub submersions had a narrow peak at age 6 to 11 months. Other submersions peaked at 12 to 14 months and remained high until 33 to 35 months. CONCLUSIONS: We departed from usual groupings of E-codes and devised groupings that would be reflective of age-related developmental characteristics. Differences in rates by narrow age groups for young children can be related to developmental achievements, w can be related to developmental achievements, which place the child at risk for specific causes of injury. We found marked variability in both rates and leading causes of injury by 3-month interval age groupings that were masked by year of age analyses. Children aged 15 to 17 months had the highest overall injury rate before age 15 years. This coincides with developmental achievements such as independent mobility, exploratory behavior, and hand-to-mouth activity. The child is able to access hazards but has not yet developed cognitive hazard awareness and avoidance skills. A remarkable finding was the high rate of battering injury among infants 0 to 5 months, suggesting the need to address potential child maltreatment in the perinatal period. Poisoning was the second major leading cause of injury; more than two thirds were medication. Cultural factors may influence views of medications, storage practices, use of poison control system telephone advice, and risk of toddler poisoning. The pedestrian injury rate doubled between 12 and 14 months and 15 and 17 months and exceeded motor vehicle occupant injury rates for each 3-month interval from 15 to 47 months. Pedestrian injury has not received sufficient attention in general and certainly not in injury prevention counseling for children younger than 4 years. Anticipatory guidance for pedestrian injury should be incorporated before 1 year of age. Effective strategies must be based on the epidemiology of childhood injury. Pediatricians and other pediatric health care providers are in a unique position to render injury prevention services to their patients. Integrating injury prevention messages in the context of developmental assessments of the child is 1 strategy. These data can also be used for complementary childhood injury prevention strategies such as early intervention programs for high-risk families for child abuse and neglect, media and advocacy campaigns, public policies, and environmental and product design.