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1.  Marijuana-Using Drivers, Alcohol-Using drivers and Their Passengers: Prevalence and Risk Factors Among Underage College Students 
JAMA pediatrics  2014;168(7):618-624.
Driving after marijuana use increases the risk of a motor vehicle crash. Understanding this behavior among young drivers and how it may differ from alcohol-related driving behaviors could inform prevention efforts.
To describe prevalence, sex differences, and risk factors associated with underage college students’ driving after using marijuana, driving after drinking alcohol, or riding with a driver using these substances.
Design, Setting, Participants
Cross-sectional telephone survey of a random sample of 315 first-year college students (aged 18-20 years) from 2 large public universities, who were participating in an ongoing longitudinal study. At recruitment, 52.8% of eligible individuals consented to participate; retention was 93.2% one year later when data for this report was collected.
Main Outcome Measure(s)
Self-reported past-28-day driving after marijuana use, riding with a marijuana-using driver, driving after alcohol use, and riding with an alcohol-using driver.
In the prior month, 20.3% of students had used marijuana. Among marijuana-using students, 43.9% of males and 8.7% of females drove after using marijuana (p<0.001) and 51.2% of male and 34.8% of female students rode as a passenger with a marijuana-using driver (p=0.21). Most students (65.1%) drank alcohol, and among this group 12.0% of male students and 2.7% of female students drove after drinking (p=0.01), with 20.7% and 11.5% (p=0.07), respectively, reporting riding with a drinking driver. Controlling for demographics and substance use behaviors, driving after substance use was associated with at least a 2-fold increase in risk of being a passenger with another user; the reverse was also true. A 1% increase in the reported percentage of friends using marijuana was associated with a 2% increased risk of riding with a marijuana using driver (95% CI=1.01-1.03). Among students using any substances, past 28-day use of only marijuana was associated with a 6.24-fold increased risk of driving after substance use compared to using only alcohol (95% CI=1.89-21.7).
Conclusions and Relevance
Driving and riding after marijuana use is common among underage, marijuana-using college students. This is concerning given recent legislation that may increase marijuana availability.
PMCID: PMC4090688  PMID: 24820649
2.  Triage of Children with Moderate and Severe Traumatic Brain Injury to Trauma Centers 
Journal of Neurotrauma  2013;30(13):1129-1136.
Outcomes after pediatric traumatic brain injury (TBI) are related to pre-treatment factors including age, injury severity, and mechanism of injury, and may be positively affected by treatment at trauma centers relative to non-trauma centers. This study estimated the proportion of children with moderate to severe TBI who receive care at trauma centers, and examined factors associated with receipt of care at adult (ATC), pediatric (PTC), and adult/pediatric trauma centers (APTC), compared with care at non-trauma centers (NTC) using a nationally representative database. The Kids' Inpatient Database was used to identify hospitalizations for moderate to severe pediatric TBI. Pediatric inpatients ages 0 to 17 years with at least one diagnosis of TBI and a maximum head Abbreviated Injury Scale score of ≥3 were studied. Multinomial logistic regression was performed to examine factors predictive of the level and type of facility where care was received. A total of 16.7% of patients were hospitalized at NTC, 44.2% at Level I or II ATC, 17.9% at Level I or II PTC, and 21.2% at Level I or II APTC. Multiple regression analyses showed receipt of care at a trauma center was associated with age and polytrauma. We concluded that almost 84% of children with moderate to severe TBI currently receive care at a Level I or Level II trauma center. Children with trauma to multiple body regions in addition to more severe TBI are more likely to receive care a trauma center relative to a NTC.
PMCID: PMC3700462  PMID: 23343131
brain injury; pediatrics; trauma; trauma center
3.  The burden of traumatic brain injury among adolescent and young adult workers in Washington State 
Journal of safety research  2013;45:133-139.
This study describes injury characteristics and costs of work-related traumatic brain injury (WRTBI) among 16–24 year olds in Washington State between 1998 and 2008.
WRTBIs were identified in the Washington Trauma Registry (WTR) and linked to workers’ compensation (WC) claims data. Medical and time-loss compensation costs were compared between workers with isolated TBI and TBI with other trauma.
Of 273 WRTBI cases identified, most (61.5%) were TBI with other trauma. One-third of WRTBI did not link to a WC claim. Medical costs averaged $88,307 (median $16,426) for isolated TBI cases, compared to $73,669 (median $41,167) for TBI with other trauma.
Results highlight the financial impact of WRTBI among young workers. Multiple data sources provided a more comprehensive picture than a single data source alone. This linked-data approach holds great potential for future traumatic occupational injury research.
PMCID: PMC3659310  PMID: 23710080
Occupational health; Head injuries; Youth; Work-related injuries; Costs of work-related TBI; Workers’ compensation data
4.  Disparities in Disability After Traumatic Brain Injury Among Hispanic Children and Adolescents 
Pediatrics  2013;131(6):e1850-e1856.
To compare the extent of disability in multiple areas of functioning after mild, moderate, and severe traumatic brain injury (TBI) between Hispanic and non-Hispanic white (NHW) children.
This was a prospective cohort study of children aged <18 years treated for a TBI between March 1, 2007, and September 30, 2008. Hispanic (n = 74) and NHW (n = 457) children were included in the study. Outcome measures were disability in health-related quality of life, adaptive skills, and participation in activities 3, 12, 24, and 36 months after injury compared with preinjury functioning. We compared change in outcome scores between Hispanic and NHW children at each follow-up time. All analyses were adjusted for age, gender, severity and intent of injury, insurance, family function at baseline, parental education, and income.
The health-related quality of life for all children was lower at all follow-up times compared with baseline. Although NHW children showed some improvement during the first 3 years after injury, Hispanic children remained significantly impaired. Significant differences were also observed in the domains of communication and self-care abilities after TBI. Differences between groups in scores for participation in activities were also present but were only significant 3 months after injury.
Hispanic children with TBI report larger and long-term reductions in their quality of life, participation in activities, communication, and self-care abilities compared with NHW children. The reasons for these differences need to be better understood and interventions implemented to improve the outcomes of these children.
PMCID: PMC3666112  PMID: 23650302
disability; disparities; Hispanic children; traumatic brain injury
5.  Perioperative Analgesic Treatment in Latino and non-Latino Pediatric Patients 
Adult studies suggest pain treatment is influenced by patient’s race/ethnicity. The present study aims to evaluate the effect of the patient’s race/ethnicity on pain treatment in children.
Retrospective cohort study comparing perioperative analgesic administration for tonsillectomy and adenoidectomy (T&A) surgery in Latino and Caucasian patients younger than 18 years of age.
Ninety-four (94) patients were included (47 Latino, 47 Caucasian), mean age 8.44 yrs (SD 3.45), 43% female. Administration of non-opioid analgesics and intraoperative opioids was similar in both groups. Early post-operative administration of opioid analgesics was significantly different between groups. Latino subjects received 30% less opioid analgesics than Caucasians; median amount in morphine equivalents was 0.05 (0–0.14) vs. 0.07 (0–0.90) mg/kg for Latino and Caucasian patients respectively (p=.02).
This study suggests that perioperative pain treatment in children is correlated with the patient’s ethnicity. The cause of this difference is unknown and prospective studies are necessary to elucidate the reasons.
PMCID: PMC4011632  PMID: 20173265
Ethnicity; Latino; pediatric; pain
6.  Ethnoracial Variations in Acute PTSD Symptoms Among Hospitalized Survivors of Traumatic Injury 
Journal of traumatic stress  2010;23(3):384-392.
Ethnoracial minority status contributes to an increased risk for posttraumatic stress disorder (PTSD) after trauma exposure, beyond other risk factors. A population-based sampling frame was used to examine the associations between ethnoracial groups and early PTSD symptoms while adjusting for relevant clinical and demographic characteristics. Acutely injured trauma center inpatients (N = 623) were screened with the PTSD Checklist. American Indian and African American patients reported the highest levels of posttraumatic stress and preinjury cumulative trauma burden. African American heritage was independently associated with an increased risk of higher acute PTSD symptom levels. Disparities in trauma history, PTSD symptoms, and event related factors emphasize the need for acute care services to incorporate culturally competent approaches for treating these diverse populations.
PMCID: PMC3947745  PMID: 20564368
7.  Modifying Media Content for Preschool Children: A Randomized Controlled Trial 
Pediatrics  2013;131(3):431-438.
Although previous studies have revealed that preschool-aged children imitate both aggression and prosocial behaviors on screen, there have been few population-based studies designed to reduce aggression in preschool-aged children by modifying what they watch.
We devised a media diet intervention wherein parents were assisted in substituting high quality prosocial and educational programming for aggression-laden programming without trying to reduce total screen time. We conducted a randomized controlled trial of 565 parents of preschool-aged children ages 3 to 5 years recruited from community pediatric practices. Outcomes were derived from the Social Competence and Behavior Evaluation at 6 and 12 months.
At 6 months, the overall mean Social Competence and Behavior Evaluation score was 2.11 points better (95% confidence interval [CI]: 0.78–3.44) in the intervention group as compared with the controls, and similar effects were observed for the externalizing subscale (0.68 [95% CI: 0.06–1.30]) and the social competence subscale (1.04 [95% CI: 0.34–1.74]). The effect for the internalizing subscale was in a positive direction but was not statistically significant (0.42 [95% CI: −0.14 to 0.99]). Although the effect sizes did not noticeably decay at 12 months, the effect on the externalizing subscale was no longer statistically significant (P = .05). In a stratified analysis of the effect on the overall scores, low-income boys appeared to derive the greatest benefit (6.48 [95% CI: 1.60–11.37]).
An intervention to reduce exposure to screen violence and increase exposure to prosocial programming can positively impact child behavior.
PMCID: PMC3581844  PMID: 23420911
aggression; TV; preschool; prosocial; behavior
8.  A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors 
Annals of surgery  2013;257(3):390-399.
To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury.
Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings.
The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined, care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at one-, three-, six-, nine-, and twelve-months after the index injury admission.
Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared to controls (group by time effect, CAPS, F(2, 185) = 5.50, P < 0.01; PCL-C, F(4, 185) = 5.45, P < 0.001). Clinically and statistically significant PTSD treatment effects were observed at the six-, nine-, and twelve-month post-injury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function (MOS SF-36 PCS main effect, F(1, 172) = 9.87, P < 0.01).
Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at United States trauma centers. (Trial Registration: identifier: NCT00270959)
PMCID: PMC3582367  PMID: 23222034
9.  Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) for Alcohol at Trauma Centers Study Design 
General hospital psychiatry  2012;35(2):174-180.
In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high quality alcohol screening and brief intervention (SBI) services at trauma centers.
Twenty sites selected from all US Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma center-based alcohol SBI with blood alcohol positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed.
The investigation has successfully recruited provider, patient, and trauma center staff samples into the study and outcomes are being followed longitudinally.
When completed, the DO-SBIS trial will inform future American College of Surgeons’ policy targeting the sustained integration of high quality alcohol SBI at trauma centers nationwide.
PMCID: PMC3594343  PMID: 23273831
Acute care medical trauma centers; Injury; Alcohol; Screening and brief intervention; American College of Surgeons
10.  Substance Use and PTSD Symptoms in Trauma Center Patients Receiving Mandated Alcohol SBI 
In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of College policy targeting integrated substance abuse treatment at trauma centers.
PMCID: PMC3528356  PMID: 22999379
11.  Bullying and School Safety 
The Journal of pediatrics  2007;152(1):10.1016/j.jpeds.2007.05.045.
To identify an association between involvement in bullying and problems in school.
Study design
This was a cross-sectional study of 5391 students in grades 7, 9, and 11 in an urban public school district. The main outcome measure was involvement in bullying. Secondary outcomes included attendance, grade point average, psychosocial distress, and perceived acceptability of carrying guns to school.
Of the 5391 children surveyed, 26% were involved in bullying either as victim, bully, or both (bully-victim). All 3 groups were significantly more likely than bystanders to feel unsafe at school and sad most days. Victims and bully-victims were more likely to say they are “no good.” Victims were more likely to feel that they “do not belong” in their school. The odds of being a victim (vs a bystander) were 10% lower for every 1 point increase in grade point average. Bully-victims were more likely to say that it is “not wrong” to take a gun to school.
Associations between involvement in bullying and academic achievement, psychological distress, and the belief that it is not wrong to take a gun to school reinforce the notion that school environment is interrelated with mental health and school success.
PMCID: PMC3839286  PMID: 18154913
12.  Correction: Harborview Burns – 1974 to 2009 
PLoS ONE  2013;8(10):10.1371/annotation/8dffa635-e876-48e1-958a-0016d3618d64.
PMCID: PMC3806627  PMID: 24194804
13.  Persistence of Disability 24 to 36 Months after Pediatric Traumatic Brain Injury: A Cohort Study 
Journal of Neurotrauma  2012;29(15):2499-2504.
This study examined the outcome of 0- to 17-year-old children 36 months after traumatic brain injury (TBI), and ascertained if there was any improvement in function between 24 and 36 months. Controls were children treated in the emergency department for an arm injury. Functional outcome 36 months after injury was measured by the Pediatric Quality of Life Inventory (PedsQL), the self-care and communication subscales of the Adaptive Behavior Assessment Scale-2nd edition (ABAS-II), and the Child and Adolescent Scale of Participation (CASP). At 36 months after TBI, those with moderate or severe TBI continued to have PedsQL scores that were 16.1 and 17.9 points, respectively, lower than at baseline, compared to the change seen among arm injury controls. Compared to the baseline assessment, children with moderate or severe TBI had significantly poorer functioning on the ABAS-II and poorer participation in activities (CASP). There was no significant improvement in any group on any outcomes between 24 and 36 months. Post-injury interventions that decrease the impact of these deficits on function and quality of life, as well as preventive interventions that reduce the likelihood of TBI, should be developed and tested.
PMCID: PMC3471122  PMID: 22757748
children and adolescents; disability; functional outcome; traumatic brain injury
14.  History of dating violence and the association with late adolescent health 
BMC Public Health  2013;13:821.
The present investigation expands upon prior studies by examining the relationship between health in late adolescence and the experience of physical/sexual and non-physical dating violence victimization, including dating violence types that are relevant to today’s adolescents (e.g., harassment via email and text messaging). We examined the relationship between physical/sexual and non-physical dating violence victimization from age 13 to 19 and health in late adolescence/early adulthood.
The sample comprised 585 subjects (ages 18 to 21; mean age, 19.8, SD = 1.0) recruited from The Ohio State University who completed an online survey to assess: 1) current health (depression, disordered eating, binge drinking, smoking, and frequent sexual behavior); and 2) dating violence victimization from age 13 to 19 (retrospectively assessed using eight questions covering physical, sexual, and non-physical abuse, including technology-related abuse involving stalking/harassment via text messaging and email). Multivariable models compared health indicators in never-exposed subjects to those exposed to physical/sexual or non-physical dating violence only. The multivariable models were adjusted for age and other non-dating abuse victimization (bullying; punched, kicked, choked by a parent/guardian; touched in a sexual place, forced to touch someone sexually).
In adjusted analyses, compared to non-exposed females, females with physical/sexual dating violence victimization were at increased risk of smoking (prevalence ratio = 3.95); depressive symptoms (down/hopeless, PR = 2.00; lost interest, PR = 1.79); eating disorders (using diet aids, PR = 1.98; fasting, PR = 4.71; vomiting to lose weight, PR = 4.33); and frequent sexual behavior (5+ intercourse and oral sex partners, PR = 2.49, PR = 2.02; having anal sex, PR = 2.82). Compared to non-exposed females, females with non-physical dating violence only were at increased risk of smoking (PR = 3.61), depressive symptoms (down/hopeless, PR = 1.41; lost interest, PR = 1.36), eating disorders (fasting, PR = 3.37; vomiting, PR = 2.66), having 5+ intercourse partners (PR = 2.20), and having anal sex (PR = 2.18). For males, no health differences were observed for those experiencing physical/sexual dating violence compared to those who did not. Compared to non-exposed males, males with non-physical dating violence only were at increased risk of smoking (PR = 3.91) and disordered eating (fasting, using diet aids, vomiting, PR = 2.93).
For females, more pronounced adverse health was observed for those exposed to physical/sexual versus non-physical dating violence. For both females and males, non-physical dating violence victimization contributed to poor health.
PMCID: PMC3847300  PMID: 24015863
Adolescents; Adolescent sexual behavior; Dating violence; Depression; Eating disorders
15.  Variation in adherence to new quality of care indicators for the acute rehabilitation of children with traumatic brain injury 
To determine variations in care provided by nine inpatient rehabilitation units for children with TBI using newly developed quality indicators.
Retrospective cohort study
Study conducted in 9 inpatient rehabilitation units.
174 children 0–17 years admitted for the inpatient rehabilitation of moderate to severe TBI.
Not applicable
Main Outcome Measures
Adherence to 119 newly developed quality of care indicators in seven different domains: general care, family-centered care, cognitive-communication, motor, neuropsychological, school and community integration.
There was substantial variation both within and between institutions in the percent of patients receiving recommended care in the seven domains. The lowest scores were found for the school domain. Only five institutions scored above 50% for all quality indicators and only one institution scored above 70% overall. Greater adherence to quality indicators was found for facilities with a higher proportion of therapists with pediatric training and for facilities that only admitted children. Patient volume was not associated with adherence to quality indicators.
The results indicate a tremendous variability and opportunity for improvement in the care children with TBI.
PMCID: PMC3408840  PMID: 22446294
Traumatic brain injury; children and adolescents; inpatient rehabilitation; quality of care
16.  Assessment of the Status of Prehospital Care in 13 Low- and Middle-Income Countries 
Prehospital Emergency Care  2012;16(3):381-389.
Injury and other medical emergencies are becoming increasingly common in low- and middle-income countries (LMICs). Many to most of the deaths from these conditions occur outside of hospitals, necessitating the development of prehospital care. Prehospital capabilities are inadequately developed to meet the growing needs for emergency care in most LMICs. In order to better plan for development of prehospital care globally, this study sought to better understand the current status of prehospital care in a wide range of LMICs.
A survey was conducted of emergency medical services (EMS) leaders and other key informants in 13 LMICs in Africa, Asia, and Latin America. Questions addressed methods of transport to hospital, training and certification of EMS providers, organization and funding of EMS systems, public access to prehospital care, and barriers to EMS development.
Prehospital care capabilities varied significantly, but in general, were less developed in low-income countries and in rural areas, where utilization of formal emergency medical services was often very low. Commercial drivers, volunteers, and other bystanders provided a large proportion of prehospital transport and occasionally also provide first aid in many locations. Although taxes and mandatory motor vehicle insurance provided supplemental funds to EMS in 85% of the countries, the most frequently cited barriers to further development of prehospital care was inadequate funding (36% of barriers cited). The next most commonly sited barriers were lack of leadership within the system (18%) and lack of legislation setting standards (18%).
Expansion of prehospital care to currently under- or un-served areas, especially in low-income countries and in rural areas, could make use of the already existing networks of first responders, such as commercial drivers and lay persons. Efforts to increase their effectiveness, such as more widespread first aid training, and better encompassing their efforts within formal EMS, are warranted. In terms of existing formal EMS, there is a need for increased and more regular funding, integration and coordination among existing services, and improved organization and leadership, as could be accomplished by making EMS administration and leadership a more desirable career path.
PMCID: PMC3360803  PMID: 22490009
developing country; emergency; emergency medical services; global; injury; low income country; low or middle income country; middle income country; prehospital care; trauma
17.  Utilization and Costs of Health Care after Geriatric Traumatic Brain Injury 
Journal of Neurotrauma  2012;29(10):1864-1871.
Despite the growing number of older adults experiencing traumatic brain injury (TBI), little information exists regarding their utilization and cost of health care services. Identifying patterns in the type of care received and determining their costs is an important first step toward understanding the return on investment and potential areas for improvement. We performed a health care utilization and cost analysis using the National Study on the Costs and Outcomes of Trauma (NSCOT) dataset. Subjects were persons 55–84 years of age with TBI treated in 69 U.S. hospitals located in 14 states (n=414, weighted n=1038). Health outcomes, health care utilization, and 1-year costs of care following TBI in 2005 U.S. dollars were estimated from hospital bills, patient surveys, medical records, and Medicare claims data. The subjects were further analyzed in three subgroups (55–64, 65–74, and 75–84 years of age). Unadjusted cost models were built, followed by a second set of models adjusting for demographic and pre-injury health status. Those in the oldest category (75–84 years) had significantly higher numbers of re-hospitalizations, home health care visits, and hours per week of unpaid care, and significantly lower numbers of physician and mental health professional visits than younger age groups (age 55–64 and 65–74 years). Significant age-related differences were seen in all health outcomes tested at 12 months post-injury except for incidence of depressive symptoms. One-year total treatment costs did not differ significantly across age categories for brain-injured older adults in either the unadjusted or adjusted models. The unadjusted total mean 1-year cost of care was $77,872 in persons aged 55–64 years, $76,903 in persons aged 65–74 years, and $72,733 in persons aged 75–84 years. There were significant differences in cost drivers among the age groups. In the unadjusted model index hospitalization costs and inpatient rehabilitation costs were significantly lower in the oldest age category, while outpatient care costs and nursing home stays were lower in the younger age categories. In the adjusted model, in addition to these cost drivers, re-hospitalization costs were significantly higher among those 75–84 years of age, and receipt of informal care from friends and family was significantly different, being lowest among those aged 65–74 years, and highest among those aged 75–84 years. Identifying variations in care that these patients are receiving and determining the costs versus benefits is an important next step in understanding potential areas for improvement.
PMCID: PMC3390979  PMID: 22435729
head injury; health services; informal care outcome
18.  Comparison of Telephone with World Wide Web-Based Responses by Parents and Teens to a Follow-Up Survey after Injury 
Health Services Research  2011;46(3):964-981.
To identify sociodemographic factors associated with completing a follow-up survey about health status on the web versus by telephone, and to examine differences in reported health-related quality of life by method of response.
Data Sources/Study Settings
Survey about child health status of 896 parents of children aged 0–17 years treated in a hospital emergency department or admitted for a traumatic brain injury or arm injury, and 227 injured adolescents aged 14–17 years.
Study Design
The main outcomes were characteristics of those who completed a follow-up survey on the web versus by telephone and health-related quality of life by method of response.
Principal Findings
Email addresses were provided by 76.9 percent of parents and 56.5 percent of adolescents at baseline. The survey was completed on the web by 64.9 percent of parents and 40.2 percent of adolescents through email. Parents with email access who were Blacks, Hispanics, had lower incomes, and those who were not working were less likely to choose the web mode for completing the survey. Unlike adolescents, the amount of time for parents to complete the survey online was significantly shorter than completion by telephone. Differences by survey mode were small but statistically significant in some of the six functional outcome measures examined.
Survey mode was associated with several sociodemographic characteristics. Sole use of web surveys could provide biased data.
PMCID: PMC3097411  PMID: 21275989
Injuries; surveys; Internet; telephone; children
19.  Quality of care indicators for the rehabilitation of children with traumatic brain injury 
To develop measurement tools for assessing compliance with identifiable processes of inpatient care for children with traumatic brain injury that are reliable, valid, and amenable to implementation.
Literature review and expert panel using the RAND/UCLA Appropriateness Method and a Delphi technique.
Not applicable
Children with traumatic brain injury (TBI)
Not applicable
Main outcome measures
Quality of care indicators
A total of 119 indicators were developed across the domains of general management; family-centered care; cognitive-communication, speech, language and swallowing impairments; gross and fine motor skill impairments; neuropsychological, social and behavioral impairments; school re-entry; community integration. There was a high degree of agreement on these indicators as valid and feasible quality measures for children with TBI.
These indicators are an important step toward building a better base of evidence about the effectiveness and efficiency of the components of acute inpatient rehabilitation for pediatric patients with TBI.
PMCID: PMC3290736  PMID: 22280892
brain injuries; quality of health care
20.  Quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury 
To develop evidence-based and expert-driven quality indicators for measuring variations in the structure and organization of acute inpatient rehabilitation for children after traumatic brain injury (TBI) and to survey centers across the United States to determine the degree of variation in care.
Quality indicators were developed using the RAND/UCLA modified Delphi method. Adherence to these indicators was determined from a survey of rehabilitation facilities.
Inpatient rehabilitation units in the United States.
A sample of rehabilitation programs identified using data from the National Association of Children’s Hospitals and Related Institutions, Uniform Data System for Medical Rehabilitation, and the Commission on Accreditation of Rehabilitation Facilities yielded 74 inpatient units treating children with TBI. Survey respondents comprised 31 pediatric and 28 all-age units.
Not applicable
Main Outcome Measures
Variations in structure and organization of care among institutions providing acute inpatient rehabilitation for children with TBI.
Twelve indicators were developed. Pediatric inpatient rehabilitation units and units with higher volumes of children with TBI were more likely to have: a census of at least one child admitted with a TBI for at least 90% of the time; adequate specialized equipment; a classroom; a pediatric subspecialty trained medical director; and greater than 75% of therapists with pediatric training.
There were clinically and statistically significant variations in the structure and organization of acute pediatric rehabilitation based on the pediatric focus of the unit and volume of children with TBI.
PMCID: PMC3290746  PMID: 22280893
brain injuries; rehabilitation; quality of care; outcome and process assessment; pediatrics
21.  The Longitudinal Course, Risk Factors, and Impact of Sleep Disturbances in Children with Traumatic Brain Injury 
Journal of Neurotrauma  2012;29(1):154-161.
This study aimed to examine the prevalence and trajectory of sleep disturbances and their associated risk factors in children up to 24 months following a traumatic brain injury (TBI). In addition, the longitudinal association between sleep disturbances and children's functional outcomes was assessed. This was a prospective study of a cohort of children with TBI and a comparison cohort of children with orthopedic injury (OI). Parental reports of pre-injury sleep disturbances were compared to reports of post-injury changes at 3, 12, and 24 months. Risk factors for sleep disturbances were examined, including severity of TBI, presence of psychosocial problems, and pain. Sleep disturbances were also examined as a predictor of children's functional outcomes in the areas of adaptive behavior skills and activity participation. Both cohorts (children with TBI and OI) displayed increased sleep disturbances after injury. However, children with TBI experienced higher severity and more prolonged duration of sleep disturbances compared to children with OI. Risk factors for disturbed sleep included mild TBI, psychosocial problems, and frequent pain. Sleep disturbances emerged as significant predictors of poorer functional outcomes in children with moderate or severe TBI. Children with TBI experienced persistent sleep disturbances over 24 months. Findings suggest a potential negative impact of disturbed sleep on children's functional outcomes, highlighting the need for further research on sleep in children with TBI.
PMCID: PMC3253307  PMID: 22029569
pediatric; risk factors; sleep disturbances; traumatic brain injury
22.  Variability in the Characteristics and Quality of Care for Injured Youth Treated at Trauma Centers 
The Journal of pediatrics  2011;159(6):1012-1016.
To survey US Level I trauma centers in order to assess the characteristics of child and adolescent psychosocial service delivery.
Study design
Trauma program staff at US Level I trauma centers were asked to complete a survey regarding the characteristics and quality of service delivery for youth. The presence of pediatric services and screening of injured youth for alcohol use problems and posttraumatic stress disorder (PTSD) symptoms were assessed.
150 of 202 (74%) of trauma centers responded to the survey. Substantial variability was observed in trauma center age cutoffs for pediatric and adolescent patients. Although the majority of sites endorsed having specialized pediatric, intensive care unit, and surgical services, marked differences were found in the reported percentage of youth receiving psychosocial services. Even though the majority of sites screened injured youth for alcohol use problems, variability was observed in the actual percentage of children and adolescents screened. Only 20% of sites endorsed specialized PTSD services.
Our investigation observed marked variability across trauma centers in the delivery of child and adolescent services. Future research could develop high quality pediatric psychosocial services in order to inform trauma center standards nationwide.
PMCID: PMC3202660  PMID: 21784440
Quality of Care; Children; Adolescents; Psychiatry; PTSD; Alcohol
23.  A National Study of Trauma Level Designation and Renal Trauma Outcomes 
The Journal of urology  2011;187(2):536-541.
We examined the initial management of renal trauma and assessed patterns of management based on hospital trauma level designation.
Materials and Methods
The National Trauma Data Bank is a comprehensive trauma registry with records from hospitals in the United States and Puerto Rico. Renal injuries treated at a member hospital from 2002 to 2007 were identified. We classified initial management as expectant, minimally invasive (angiography, embolization, ureteral stent or nephrostomy) or open surgical management based on ICD-9 procedure codes. The primary outcome was use of secondary therapies.
Of 3,247,955 trauma injuries in the National Trauma Data Bank 9,002 were renal injuries (0.3%). High grade injuries demonstrated significantly higher rates of definitive success with the first urological intervention at level I trauma centers vs other trauma centers (minimally invasive 52% vs 26%, p <0.001), and were more likely treated successfully with conservative management (89% vs 82%, p <0.001). When adjusting for other known indices of injury severity, and examining low and high grade injuries, level I trauma centers were 90% more likely to offer an initial trial of conservative management (OR 1.90; 95% CI 1.19, 3.05) and had a 30% lower chance of patients requiring multiple procedures (OR 0.70; 95% CI 0.52, 0.95).
Following multivariate analysis conservative therapy was more common at level I trauma centers despite the patient population being more severely injured. Initial intervention strategies were also more definitive at level I trauma centers, providing additional support for tiered delivery of trauma care.
PMCID: PMC3463997  PMID: 22177171
wounds and injuries; kidney; outcome assessment (health care); health facilities
24.  Analysis of Diagnostic Angiography and Angioembolization in the Acute Management of Renal Trauma Using a National Data Set 
The Journal of urology  2011;185(4):1316-1320.
To our knowledge data on diagnostic angiography and angioembolization after renal trauma have been limited to single institution series with small numbers. We used the National Trauma Data Bank® to investigate national patterns of diagnostic angiography and angioembolization after blunt and penetrating renal trauma.
Materials and Methods
All renal injuries treated between 2002 and 2007 were identified in the National Trauma Data Bank by Abbreviated Injury Scale codes and converted to American Association for the Surgery of Trauma renal injury grades. Diagnostic angiography and angioembolization were identified by ICD-9 codes and examined. Initial angioembolization was considered a failure if subsequent therapy was needed. Repeat diagnostic angiography was not considered a failure.
A total of 9,002 renal injuries were available for analysis. A total of 165 patients (2%) underwent diagnostic angiography after renal injury, including 77 (47%) who underwent concomitant angioembolization. Of the patients 78% sustained grade III–V renal injuries. Of the 77 patients with initial angioembolization 68 required successive therapy. Repeat angioembolization was the most common management choice (29% of patients). Secondary angioembolization was durable during the index hospitalization with success in 35 of 36 cases. Successive therapy was required after initial angioembolization for all grade IV and V renal injuries in 48 patients. The overall renal salvage rate was 92%, including 88% for grade IV and V injuries.
Successive therapy is common after initial management of renal injury by angioembolization. Close observation is highly recommended after initial angioembolization for grade IV–V renal injuries. National agreement on the use of diagnostic angiography and angioembolization is needed since these procedures may be overused after grade I–III renal injuries.
PMCID: PMC3464000  PMID: 21334643
kidney; wounds, penetrating; wounds, nonpenetrating; angiography; embolization, therapeutic
25.  Conservative Management vs Early Surgery for High Grade Pediatric Renal Trauma—Do Nephrectomy Rates Differ? 
The Journal of urology  2012;187(5):1817-1822.
Guidelines for management of pediatric high grade renal injuries are currently based on limited pediatric data and algorithms from adults, for whom initial nonoperative management is associated with decreased nephrectomy risk. Using a national database, we compared nephrectomy rates between children with high grade renal injury managed conservatively and those undergoing early surgical intervention.
Materials and Methods
All children with high grade renal injuries were identified in the National Trauma Data Bank®. High grade renal injuries were defined as American Association for the Surgery of Trauma grade IV or V renal injuries. After excluding fatalities within 24 hours of hospitalization, 419 pediatric patients comprised our study cohort. A total of 81 patients underwent early (within 24 hours of hospitalization) surgical intervention, while 338 were initially treated conservatively. Using stratified analysis with adjustment for relevant covariates, we compared nephrectomy rates between these groups.
Nephrectomy was performed less often in patients treated conservatively (RR 0.24, 95% CI 0.16 to 0.36, adjusted for age, renal injury grade and injury mechanism). The decreased risk of nephrectomy was more marked among children with grade IV vs grade V renal injuries (adjusted RR 0.16, 95% CI 0.08 to 0.23). Multiple procedures were more common in patients initially observed. Of pediatric patients with grade IV and V renal injuries 11% still underwent nephrectomy.
Conservative management of high grade renal injuries is common in children. Although mechanism of injury and renal injury grade impact initial clinical management decisions, the risk of nephrectomy was consistently decreased in children with high grade renal trauma managed conservatively regardless of injury characteristics.
PMCID: PMC3464002  PMID: 22424678
adolescent; child; kidney; retrospective studies; wounds and injuries

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