Access to coronary catheterisation: fair shares for all?

OBJECTIVE--To determine the effects of patient''s sex and area''s material deprivation on utilisation rates of coronary catheterisation and angiography in the investigation of ischaemic heart disease. DESIGN--Retrospective analysis of routinely collected hospital statistics. SETTING--Acute hospitals throughout Northern Ireland. SUBJECTS--24,179 episodes of patients discharged from hospital with a primary diagnosis of ischaemic heart disease and 1270 episodes relating to patients with an underlying diagnosis of ischaemic heart disease who had either coronary catheterisation or angiography. MAIN OUTCOME MEASURES--Age standardised admission rates for heart disease and age standardised utilisation rates for catheterisation or angiography, or both, for 566 electoral wards ranked by Townsend "deprivation" scores. RESULTS--Catheterisation-angiography rates in men were over fivefold those of women, ranging from 85.5/100,000 v 16/100,000 in patients from "well off" areas to 123/100,000 v 22/100,000 for patients from deprived areas. After admission rates for heart disease were controlled for, the overall rate ratio for women was 0.48 (95% confidence interval 0.38 to 0.60). After differential admission rates for heart disease and other potential clinical confounders were controlled for, the investigation rates of patients from the least and most "deprived" areas were not significantly different (rate ratio 1.04 (0.87 to 1.25)). CONCLUSION--Although investigation rates were significantly lower in women than in men, further clinical data would be required before labelling this underutilisation as evidence of bias. There was no significant difference in invasive investigation rates for heart disease in areas of varying deprivation or affluence.     

Bicycle accidents in childhood.

The results of a 10 year study of bicycle fatalities and an eight year study of serious non-fatalities are reported for urban Brisbane (population 1,000,000). There were 845 serious non-fatal bicycle accidents and 46 fatalities during the study. Boys were involved in 86% of accidents. Boys have an accident rate of 134.21 per 100,000 population at risk and a fatality rate of 5.06 per 100,000 at risk. Serious bicycle accidents have increased by 50% in this decade; but considering fatal cases alone, no secular trend was evident over the 10 year period of the study. This suggests that an increase in the overall rate of bicycle accidents has been in part compensated by less serious injuries. In 70% of fatalities children had head injuries, and 87% of fatalities followed a collision between a cyclist and a motor vehicle or a train. Bicycle accidents on the roads most commonly occur to boys aged between 12 and 14 years on a straight road at "mid-block" between 3 and 5 pm in clear weather conditions and in daylight. It is concluded that injuries and fatalities after bicycle accidents can be reduced by protecting children''s heads, separating child cyclists from other road traffic, or educating and training both cyclists and other road users in safe behaviour. The compulsory use of helmets and the restriction of access to the roads by child cyclists to reduce injuries are, however, still controversial in many areas.     

Influence of changing travel patterns on child death rates from injury: trend analysis.

OBJECTIVES: To examine trends in child mortality from unintentional injury between 1985 and 1992 and to find how changes in modes of travel contributed to these trends. DESIGN: Poisson regression modelling using data from death certificates, censuses, and national travel surveys. SETTING: England and Wales. SUBJECTS: Resident children aged 0-14. MAIN OUTCOME MEASURES: Deaths from unintentional injury and poisoning. RESULTS: Child deaths from injury declined by 34% (95% confidence interval 28% to 40%) per 100,000 population between 1985 and 1992. Substantial decreases in each of the leading causes of death from injury contributed to this overall decline. On average, children walked and cycled less distance and travelled substantially more miles by car in 1992 compared with 1985. Deaths from road traffic accidents declined for pedestrians by 24% per mile walked and for cyclists by 20% per mile cycled, substantially less than the declines per 100,000 population of 37% and 38% respectively. In contrast, deaths of occupants of motor vehicles declined by 42% per mile travelled by car compared with a 21% decline per 100,000 population. CONCLUSIONS: If trends in child mortality from injury continue the government''s target to reduce the rate by 33% by the year 2005 will be achieved. A substantial proportion of the decline in pedestrian traffic and pedal cycling deaths, however, seems to have been achieved at the expense of children''s walking and cycling activities. Changes in travel patterns may exact a considerable price in terms of future health problems.     

Avoidable factors contributing to death of children with head injury.

OBJECTIVE--To assess the incidence of potentially avoidable complications contributing to death of children with head injuries. DESIGN--Retrospective review of children who died with head injuries from 1979 to 1986 from data of the Office of Population Censuses and Surveys, Hospital Activity Analyses, case notes, coroners'' records, and necropsy reports. SETTING--District general hospitals and two regional neurosurgical centres in Northern region. RESULTS--255 Children died from head injury in the region, the mortality being 5.3 per 100,000 children per year. Head injury was the single most important cause of death in children aged greater than 1 year, accounting for 15% of deaths in children aged 1-15 years and a quarter for those aged 5-15 years. 121 Potentially avoidable factors possibly or probably contributing to death occurred in 81 children (32%). Half the children (125) died before admission, 27 of whom (22%) had potentially avoidable factors possibly or probably contributing to death, and 130 died after admission, 54 of whom (42%) had 93 such factors, which included failure of diagnosis or delayed recognition of intracranial haemorrhage or associated injury, inadequate management of the airways, and poor management of the transfer between hospitals. IMPLICATIONS--Regions should revise urgently their guidelines for optimal management and indications for neurosurgical referral to include children with severe head injuries and audit their systems of care for all patients with head injuries.     

The Epidemiology and Prevention of Traffic Accidents Involving Child Pedestrians

A study of 713 motor vehicle accidents involving 749 children in the city of Vancouver is reported. A control group of 110 children who did not have accidents was included in the concurrent study. Factors investigated were the driver, the vehicle, the weather, the time of day, the day of week, the month, the width of roadway, the location of the accident, the child''s age, sex, personality, school record, and family background, the type of injury, and the ambulance and hospital service received. Boys were more commonly involved than girls, and most accidents occurred in the 3 to 7 year age group. Head injuries prevailed in the younger age groups and decreased steadily with the age of the child. Specific epidemic areas in the city were identified and selective enforcement was suggested as a possible countermeasure. Hospital records seldom provided a detailed history of the events leading up to the accident. In order to apply the preventive techniques of education and enforcement it was suggested that in each pedestrian traffic accident the driver should be required to accompany the victim to the site of medical care.     

Accidents in the home among children under 5: ethnic differences or social disadvantage?

Accidents in the home to children under 5 in a multiracial population with a high level of social disadvantage were studied by interviewing at home the parents of 402 children attending the accident department of a west London hospital during one year. The parents'' country of birth, whether they were employed, and their housing conditions were recorded using the definitions of the 1981 census. Four ethnic groups (British (183 children), Asian (127), Caribbean (61), and other (31)) were identified. Though attendance rates based on the populations of electoral wards at the census and standardised for distance from the hospital showed no significant differences among the ethnic groups, there was a strong gradient by social class and strong associations with unemployment of the mother (although not of the father), overcrowding, and tenure of housing.Social disadvantage seems to be more important than ethnicity as a determinant of accidents to children in the home.     

Bicycle-related injuries: a survey in a pediatric emergency department.

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children''s Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child''s home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.     

Effectiveness of bicycle helmets in preventing head injury in children: case-control study.

OBJECTIVE--To examine the risk of injury to the head and the effect of wearing helmets in bicycle accidents among children. DESIGN--Case-control study by questionnaire completed by the children and their carers. SETTING--Two large children''s hospitals in Brisbane, Australia. SUBJECT--445 children presenting with bicycle related injuries during 15 April 1991 to 30 June 1992. The cases comprised 102 children who had sustained injury to the upper head including the skull, forehead and scalp or loss of consciousness. The controls were 278 cyclists presenting with injuries other than to the head or face. A further 65 children with injuries to the face were considered as an extra comparison group. MAIN OUTCOME MEASURES--Cause and type of injury, wearing of helmet. RESULTS--Most children (230) were injured after losing control and falling from their bicycle. Only 31 had contact with another moving vehicle. Children with head injury were significantly more likely to have made contact with a moving vehicle than control children (19 (19%) v 12 (4%), P < 0.001). Head injuries were more likely to occur on paved surfaces than on grass, gravel, or dirt. Wearing a helmet reduced the risk of head injury by 63% (95% confidence interval 34% to 80%) and of loss of consciousness by 86% (62% to 95%). CONCLUSIONS--The risk of head injury in bicycle accidents is reduced among children wearing a helmet. Current helmet design maximises protection in the type of accident most commonly occurring in this study. Legislation enforcing helmet use among children should be considered.     

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey.

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.     

Head Injuries in Children

Two-hundred children with head injury admitted consecutively to paediatric wards in the two main hospitals in Newcastle upon Tyne have been studied. Eight children required neurosurgical operation. There were two deaths. Details of the cause and consequences of the accidents have been analysed and an attempt has been made to identify psychological or physical factors that may predispose to injury. There was a slightly higher proportion of children with what are regarded as adverse personality factors among the head injuries than in a control group and there were more left-handed children than would be expected in the general population. The results suggest that the modern “high-rise” bicycle may carry a special risk of head injury.     

Insulin dependent diabetes in childhood and material deprivation in northern England, 1977-86.

OBJECTIVE--To determine the incidence of insulin dependent diabetes in the Northern region of England in children less than 16 years old in the period 1977 to 1986 and to relate the incidence data to an index of deprivation. DESIGN--Retrospective analysis of hospital case records identified from the regional health authority''s computer; validation of the primary source with hospital clinic registers and community paediatric registers. SETTING--Northern region, excluding South Cumbria District Health Authority (659,300 children under 16 in 1981). PATIENTS--All children diagnosed with insulin dependent diabetes before the age of 16 and resident in the region at time of diagnosis. MAIN OUTCOME MEASURES--Incidence rates for the 10 year period and analysis of incidence rates within categories of deprivation. RESULTS--919 incident cases were identified. The validation procedure covered 54% of all cases identified and gave 95% completeness of ascertainment. The average annual incidence over the 10 year period was 14.8/100,000 for girls and 13.4/100,000 for boys. The annual incidence for the most and least deprived areas of the region was 18.7/100,000 (95% confidence interval 16.2 to 21.5) for boys and 7/100,000 (5.6 to 8.8) for girls. There was a highly significant trend (p less than 0.001) of decreasing incidence with decreasing level of deprivation. CONCLUSIONS--In the north of England the incidence of childhood diabetes is related to material deprivation.     

Unemployment rates: an alternative to the Jarman index?

OBJECTIVE--To compare the Jarman index with alternative deprivation measures with regard to its usefulness to district health authorities as an indicator of need at small area level. DESIGN--The Jarman index (UPA (8)), Townsend''s index of material deprivation, the Scottish Development Department''s index, the Department of the Environment''s basic index, and unemployment rates were compared in respect of their correlation with measures of morbidity by electoral ward in a typical English district health authority. Measures of morbidity comprised standardised mortality ratios, admission rates (standardised and non-standardised), and permanent sickness rates. Spearman rank correlation coefficients were calculated for each combination of measures and were then ranked for each of the deprivation indices. SETTING--The 59 electoral wards of the Central Nottinghamshire Health Authority. RESULTS--The Jarman index consistently ranked lower in respect of its correlation with measures of morbidity than did the other deprivation measures. Current unemployment rates correlated well with morbidity measures, in particular with hospital admission rates, with correlations ranging from 0.669 to 0.830 for average and standardised all age admission rates. CONCLUSIONS--The Jarman index seems to be the least appropriate of these indices for health authority use. Unemployment rate merits further consideration as a simple, up to date marker for deprivation and consequent need for health service provision.     

Head injuries in childhood: a 2-year survey.

A retrospective study was conducted of the 880 children with head injuries consecutively admitted to the Children''s Hospital of Eastern Ontario in Ottawa from July 1976 to June 1978. It confirmed a boy:girl ratio of about 2:1, with a peak of 3.5:1 around 7 years of age. The largest number of head injuries was in children under 1 year of age. Injuries were most common in summer and spring, and most were caused by falls. The most common place for head injuries was in the home, but the single most common cause of injuries was bicycle accidents, which were responsible for 12% of all the head injuries. Skull fractures were found in 30% of all the patients. Of the 34 patients with severe head injuries 8 (24%) died, 9 (26%) had a moderate residual disability and 17 (50%) made a good recovery. There were no other deaths, so the mortality for the entire group of 880 patients was 0.9%.     

Injury patterns in cyclists attending an accident and emergency department: a comparison of helmet wearers and non-wearers.

OBJECTIVES--To study circumstances of bicycle accidents and nature of injuries sustained and to determine effect of safety helmets on pattern of injuries. DESIGN--Prospective study of patients with cycle related injuries. SETTING--Accident and emergency department of teaching hospital. SUBJECTS--1040 patients with complete data presenting to the department in one year with cycle related injuries, of whom 114 had worn cycle helmets when accident occurred. MAIN OUTCOME MEASURES--Type of accident and nature and distribution of injuries among patients with and without safety helmets. RESULTS--There were no significant differences between the two groups with respect to type of accident or nature and distribution of injuries other than those to the head. Head injury was sustained by 4/114 (4%) of helmet wearers compared with 100/928 (11%) of non-wearers (P = 0.023). Significantly more children wore helmets (50/309 (16%)) than did adults (64/731 (9%)) (P < 0.001). The incidence of head injuries sustained in accidents involving motor vehicles (52/288 (18%)) was significantly higher than in those not involving motor vehicles (52/754 (7%)) (chi 2 = 28.9, P < 0.0001). Multiple logistic regression analysis of probability of sustaining a head injury showed that only two variables were significant: helmet use and involvement of a motor vehicle. Mutually adjusted odds ratios showed a risk factor of 2.95 (95% confidence interval 1.95 to 4.47, P < 0.0001) for accidents involving a motor vehicle and a protective factor of 3.25 (1.17 to 9.06, P = 0.024) for wearing a helmet. CONCLUSION--The findings suggest an increased risk of sustaining head injury in a bicycle accident when a motor vehicle is involved and confirm protective effect of helmet wearing for any bicycle accident.     

Some features of traffic accidents

Some aspects of urban and rural traffic accidents have been studied at the scene of some accidents in Birmingham and the county of Worcestershire. Accidents to pedestrians are essentially an urban problem, occur mainly at low speed, and most of the serious injury comes from the initial contact with the vehicle, rather than from secondary impacts with the road surface. The characteristics of motor-cycle accidents are more varied; in urban areas there are many side impacts, with consequent injury to the lower limbs, while rural collisions are predominantly front on, with a high incidence of head injury. Accidents to car occupants vary according to the environment.     

Injuries to pedestrians in road traffic accidents.

Although there have been many reports on injuries to occupants of cars in road traffic accidents, there have been few prospective studies of injuries to pedestrians in such accidents. For this reason a two year prospective study of pedestrians in road traffic accidents in the Oxford region was carried out. The incidence of death in pedestrians was significantly higher than in car occupants or motorcyclists. The principal determinant of death was the weight of the vehicle concerned. The most common site of injury was the head because of a high incidence of brief concussion, but the most common site of serious injuries was the leg. Injuries to all regions of the body increased with age and with the weight of the vehicle in the collision. Accidents most often concerned young children or the elderly.     

Drowning and near drowning in children in the United Kingdom: lessons for prevention.

OBJECTIVES--To determine the pattern of drowning and near drowning of children in Britain and identify means of prevention. DESIGN--Study of drowned and nearly drowned children under 15 years old. SETTING--United Kingdom, 1988 and 1989. SUBJECTS--Children under 15 years either drowning or admitted to hospital after a submersion incident. MAIN OUTCOME MEASURES--Number of nearly drowned children, obtained from consultant paediatricians returning monthly notification cards through the British Paediatric Surveillance Unit. Number of drowned children notified by the Office of Population Censuses and Surveys and other national epidemiological offices; information from coroners. RESULTS--306 children had confirmed submersion incidents: 149 died and 157 survived after near drowning. The annual incidence in England and Wales was 1.5/100,000, and mortality 0.7/100,000. Mortality was lowest in public pools 6% (2/32) and highest in rivers, canals, and lakes (78%, 56/73). Most of the children (263, 83%) were unsupervised at the time of the accident. 208 (68%) children were under 5 years old. CONCLUSIONS--Drowning and near drowning of children are problems in the British Isles. Appropriate supervision and safety barriers seem important for preventing such accidents. Improving information on dangers of drowning given to parents through the child surveillance programmes, encouraging fencing or draining of garden ponds and domestic swimming pools, and increasing supervision of swimming in lakes, rivers, and beaches should reduce the number of accidents.     

CHILD PEDESTRIAN FATALITIES IN LOS ANGELES

In an analysis of information concerning 81 child pedestrians killed in traffic accidents in the city of Los Angeles during a recent five-year period it was observed that the majority of children were preschoolers playing near their residences but without adult supervision. In most instances the action of the child and not the driver of the vehicle was responsible for the accident. Among school age child fatalities, improper handling of a bicycle was commonly to blame.     

Biodynamics model for operator head injury in stand-up lift trucks

Biodynamics and injury potential of operators in stand-up rider lift truck accidents have been investigated with a special focus on head injury. An anthropomorphic test device (ATD) model was used as an operator surrogate in computer simulations of off-the-dock (OTD) and tip-over (TO) accidents. The biomechanical model representing the ATD was developed based on rigid body segments, and then combined with a rigid body truck model in the accident simulations. The operator compartment of the truck model was enclosed with a rear door. The computed kinematics are in agreement with the results of previous experimental testing. A 2D finite element model of the head was created to compute head impact decelerations in the sagittal plane. Values of the head injury criterion for the TO cases were computed from the model and shown to compare favourably with experimental values. The results advance the state of knowledge concerning injury potential in TO and OTD accidents and simulation models for such accidents.     

Higher mortality in deprived areas: community or personal disadvantage?

OBJECTIVE--To investigate the association between level of social deprivation in electoral wards and premature mortality among residents, before and after allowing for levels of personal deprivation. DESIGN--Longitudinal study of the Office of Population Censuses and Surveys. SETTING--England. SUBJECTS--Random sample of nearly 300,000 people aged between 16 and 65 at the 1981 census and followed up for nearly nine years. MAIN OUTCOME MEASURE--Death from all causes between ages of 16 and 70. RESULTS--Without allowance for personal disadvantage, both sexes showed a clear, significant, and roughly linear positive relation between degree of deprivation of the ward of residence in 1981 and premature death before 1990. For men, this association was effectively explained away once allowance was made for individual socioeconomic circumstances. For women living in wards of above average deprivation, the association was also effectively removed, but the situation for other women was less clear. CONCLUSION--The excess mortality associated with residence in areas designated as deprived by census based indicators is wholly explained by the concentration in those areas of people with adverse personal or household socioeconomic factors. Health policy needs to target people as well as places.