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Funded Injury Control Research Centers (ICRCs)

Emory Center for Injury Control (ECIC)

FOA Number: CE 09 001
Project Period: 08/01/09-7/31/14
Application/Grant Number: 1 R49 CE001494-01
Principal Investigator: Debra Houry
Emory University
Emergency Medicine
49 Jesse Hill Dr. #114
Atlanta, GA 30303
Ph. 404-616-3181
Email dhoury@emory.edu

Abstract

Since its inception in 1993, Emory University's Center for Injury Control (ECIC) has produced high quality, high impact research on a wide range of issues. Key to our success has been strong partnerships with allied academic and community-based organizations throughout metropolitan Atlanta and the state of Georgia. With NCIPC support, we will build on this track record of success, and create an Injury Control Research Center of significant scope and impact. To accomplish this goal, we propose a nationally unique, multi-institutional consortium that will transcend the boundaries of Emory University to catalyze and shape injury prevention throughout Georgia and ultimately, have major impacts throughout the region and the nation. The ECIC will achieve its objectives by conducting critical research directed towards discovering and validating practical and actionable approaches to injury prevention and control. We will also train the next generation of injury prevention leaders, researchers, and practitioners. Although our ICRC will be administratively managed at Emory it will truly function as a 'center without walls or silos', engaging eight of Georgia's other top colleges and universities in this effort. Our consortium includes Georgia's three largest public institutions as well as three of Georgia's historically Black colleges and universities. The spirit of this collaboration is reflected in every aspect of our proposal, including the fact that three of our proposed research projects are submitted by partner universities and three of the Associate Directors proposed for our ICRC are based at institutions other than Emory. During our first 5 years of operation as a CDC funded ICRC, the Emory Center for Injury Control will address the following aims: Expand and enhance the ECIC's existing administrative core; Connect, mobilize and inform the local and state injury prevention research and practice communities; Develop effective mechanisms to foster and conduct translational research; Conduct multi- and interdisciplinary injury prevention training for public health practitioners, clinicians, and researchers-in-training; Conduct outreach activities that ensure that the ECIC is addressing local concerns and priorities; serve as a local and state information resource for injury prevention and research activities; and Conduct multidisciplinary, multi-institutional injury research.

Large Research Project: Preventive Intervention for Victims of School-Based Bullying

There is limited research about (1) effective interventions to prevent and/or reduce the impact of bullying and victimization, (2) the efficacy of the discrete components of comprehensive, universal primary bullying prevention programs, (3) selective interventions targeting particular groups of children at risk of negative outcomes from bullying, and (4) student bystanders (e.g. characteristics, reasons why they do/do not intervene, how they can be encouraged to actively prevent bullying). Deficit models have primarily been used to explain negative consequences of bullying rather than considering positive variables such as resilience. Only a small number of studies have used an experimental design with a control group, evaluated long term effects using longitudinal designs, or used environmental change strategies. This research project will investigate two related components of a school-based bullying preventive intervention program designed to nurture healthy development by cultivating resiliency, self-efficacy and coping skills. The study population is an urban school district in metro-Atlanta with one upper-elementary school serving all (331) 4th and 5th grade students and one middle school with all (498) 6th - 8th grade students in the district. The population is about 46% African American, 47% Caucasian, 4% multi-racial, 2% other and 1% Hispanic; 35% qualify for free/reduced lunch.

Small Research Project: Acute Care Early Intervention in the Emergency Department

Despite the prevalence of PTSD in the U.S. and the advancing knowledge of the neurobiology of fear, there currently are no accepted interventions for the early intervention and prevention of PTSD in the immediate aftermath of trauma. The existing evidence suggests that 1) the debriefing literature is equivocal at best with some studies indicating it can cause harm; 2) there are no good candidates for immediate intervention; 3) the animal evidence suggests that some immediate extinction training can result in decreases in spontaneous recovery and renewal and reinstatement; 4) the animal evidence suggests that incomplete extinction training may cause sensitization, and finally; 5) the timing of extinction training after exposure/conditioning is crucial. Given this evidence, the overall aim of this small research project is to gather pilot data to begin to determine which schedule for the timing and dose of exposure therapy in the immediate aftermath of trauma is the most effective for preventing the development of PTSD. The long term goals are to establish psychotherapeutic interventions at the most appropriate points in the aftermath of trauma to reduce the likelihood of developing a durable fear response such as PTSD. The specific aim of the study is to determine if the use of prolonged imaginal exposure therapy (PE) in recent trauma survivors will significantly reduce the severity of PTSD symptoms at four and 12 weeks post-trauma. The hypothesis is that patients who receive PE in the hours and weeks following trauma exposure will have reduced severity of PTSD symptoms at four and 12 weeks post-trauma compared to patients who were repeatedly assessed without receiving PE. To examine this aim, 75 eligible participants presenting at the ED will be randomly assigned to one of two groups: (1) Immediate Treatment Group, which includes immediate prolonged exposure therapy (PE) in the ED plus two sessions of delayed PE delivered one and two weeks after the initial ED visit (three sessions total) (n=50); or (2) Assessment Only Group with no PE intervention (n=25). Participants in the study will receive reimbursement for their time for each study visit. The intervention sessions will use a modification and abbreviation of the Prolonged Exposure (PE) procedure that has been used extensively in diverse populations and consists of brief education about trauma reactions and an overall rationale for the treatment program, delivered both verbally and in writing. Patients assigned to receive PE will receive three 60-minute sessions focused on imaginal reliving and processing the experience. The proposed Research Coordinator for the study is Feea Leifker, MPH, the study coordinator for Dr. Rothbaum's other clinical trials. A master's level graduate will be hired as the half-time Study Therapist to deliver the PE therapy in the ED and subsequent visits and perform assessments. The hypothesis will be tested by comparing the mean PTSD and depressive symptoms in the groups that received therapy and the control group (assessment only). For a secondary predictive outcome analysis, the researchers will examine predictors for response and will assess demographic 25 and psychological measures in the ED. They will then assess PTSD symptoms at four and 12 weeks post-trauma. Feasibility indicators will be examined overall and across trauma types to determine if a future efficacy study should target a specific population of trauma victims and to identify any roadblocks for successful completion of a definitive efficacy study. Rates of dropout and refusal will be compared using chi-square tests to determine if any specific types of trauma are associated with refusal or dropout more than others.

Small Research Project: Valuing Child Maltreatment Outcomes for Use in Economic Evaluations

The selection of educational programs and interventions to reduce the incidence of child maltreatment can be informed by results from economic evaluations, particularly cost-effectiveness analyses (CEAs), which are tools to compare an intervention's costs to its outcomes44. The outcome measure typically used in a CEA is a composite measure of health that includes life expectancy and health-related quality of life (HRQoL), combined together in a quality-adjusted life year (QALY). While outcome measures for use in economic evaluations are readily available for many acute and chronic conditions, the child maltreatment field is woefully behind in valuing outcomes for use in economic evaluations and for conducting economic evaluations of child maltreatment interventions in general. The cost effectiveness of child maltreatment prevention/intervention programs also becomes essential in attempting to disseminate programs. Little is known about cost-effective programs and what it takes to "scaleup" programs for wide-scale dissemination. Only when economic analysis is included as an integral part of program effectiveness evaluation and in policy, funding or national recommendation decisions can widespread implementation of child maltreatment interventions be considered fiscally responsible. In this exploratory qualitative data analysis, the researchers propose to extend recent work conducted in conjunction with researchers from the Division of Violence Prevention at CDC in the area of economic evaluation. The two aims of this CIC small research project are: (1) to develop appropriate descriptions of child maltreatment outcomes, in terms of identifying relevant dimensions of health-related quality of life (HRQoL); and (2) to test the descriptive validity of available instruments to measure preference based HRQoL in children and adolescents who are victims of violence, for use in cost-effectiveness analyses of interventions to prevent child maltreatment. The development of reliable descriptions of health states associated with child maltreatment by type of abuse and age of abuse, and the identification and validation of attributes and domains of health for victims of child maltreatment are expanding into relatively unexplored areas in the field of health-related quality of life (HRQoL) assessment, particularly for HRQoL measures that are preference-based. Victims of child maltreatment experience losses in quality of life49 in the long-term, and some estimates of these losses can now be used in economic 32 evaluations. It is not known how child maltreatment impacts HRQoL in the acute phase of the abuse. The proposed project is one of the first studies to explore this phenomenon. The researcher and two research assistants (RAs) will conduct 10 focus groups to identify domains/attributes and to understand the relative value of each potential domain/attribute in terms of type of maltreatment and age of victimization (Aim 1), and to determine which of the best available instruments is most appropriate for measuring short-term impacts of child maltreatment on HRQoL (Aim 2). Each focus group will have 5-8 members who are self-reported adult survivors of child maltreatment in Georgia. Identified through newspaper advertisements and flyers posted in non-profit agencies committed to violence prevention in Georgia, participants will be of varying age, race and socioeconomic status if possible, and stratified by gender and the type of maltreatment experienced (physical or sexual abuse). Descriptive statistics will be conducted for all demographic, abuse data and current health status collected from study participants. All focus groups will be audio-taped and transcribed verbatim. Audiotapes will be separately transcribed by one RA and the PI and reliability checks of the transcribed data will be conducted. Thematic analysis for domains and attributes of HRQoL will be performed separately by the RA and the PI on the translated transcripts. The PI and RA will develop a codebook using a standard iterative process developed by MacQueen et al. , and as outlined in Guest et al.,51. An initial content-based coding scheme for each set of the 10 focus groups will be created. The PI will then map domains/attributes to existing instruments available to assess HRQoL in children, including the PedsQL (www.pedsql.org), the Health Utilities Index-Mark II (www.healthutilities.com), and the Euroqol-5 Dimension Scale (www.euroqol.org), and compare to focus groups responses as to the applicability of the scales. Analyses from this exploratory study will be used in the design of a larger, more comprehensive study of HRQoL in victims of child maltreatment across the country. In addition to publishing the preliminary results in public health and preventive medicine journals, knowledge gained will be shared with faculty in the ECIC to incorporate the instruments identified as the best measures of child maltreatment HRQoL in future studies that assess the effectiveness of interventions to prevent child maltreatment.

Small Research Project: Do the Benefits of Georgia's Teenage Adult Driver Responsibility Act (TADRA) Continue into Adulthood

To reduce fatal crashes involving teenage drivers, many states have adopted graduated drivers licensing (GDI) systems, but they vary widely by the elements they incorporate and the strictness of their provisions. Published evaluations have found equally varying levels of effect. Responding to a public outcry about fatal crashes involving teenaged drivers, the Georgia General Assembly enacted a package of laws called the Teenage and Adult Driver Responsibility Act (TADRA). TADRA contained provisions aimed at reducing crashes among the youngest drivers including graduated licensing, zero tolerance, and license revocation for various traffic violations, particularly excessive speeding. The zero tolerance and automatic license revocation for various traffic violations provisions apply to all drivers under age 21. The law was strengthened in 2001 to extend curfew hours and restrict passenger numbers and 2007 to include requirements for a driver's education course and supervised driving experience. A comprehensive evaluation of TADRA conducted by the ECIC with funding provided by the National Highway Traffic Safety Administration (NHTSA) demonstrated that fatal crashes involving 16 year old drivers declined by 37% during the first five and a half years after TADRA was implemented. Notably, the fatal crash rate of the first cohort of drivers to reach age 21 in the era of TADRA was markedly lower than the fatal crash rate of 21year old drivers in the year that TADRA took effect. The follow up period of this evaluation was too short to determine if this effect was lasting or a statistical fluke. For this small research project, researchers will conduct a comprehensive study to compare fatal crashes by drivers aged 16-24 during the five years before and 10 years following TADRA. The researches will confirm if the benefits of the law have been sustained over its first decade of enactment, if drivers who have reached age 21 36 in the era of TADRA are driving more safely than those who reached age 21 prior to the law, and whether TADRA has differential effects in various regions of the state or by road conditions. The specific aims of project are: (1) Using NHTSA's Fatality Analysis Reporting System (FARS), calculate the aggregate fatal crash rates of Georgia drivers aged 16-24 who passed through the Georgia GDL System during three time intervals – the five years prior to and two five-year periods (1-5 years and 6-10 years) following implementation of TADRA. (2) Compare and contrast driver fatal crashes during each of these time periods by driver age and gender, with specific attention to driver history of previous crashes, citations, suspensions and revocations, and to crash contributing factors such as illegal speed and the type of crash, including single vehicle and rollover crashes. (3) Using the three time intervals described above, determine if the fatal crash rate experienced by Georgia drivers who reached age 21 prior to implementation of TADRA (1992-1996) differs from the fatal crash rate of drivers who turned 21 during the first five years of TADRA's existence (1997-2001) and the subsequent cohort who learned to drive under TADRA's restrictions and reached age 21 in the TADRA era (2002- 2007). (4) Compare fatal crash rates for young Georgia drivers aged 16-24 during the 5 years before and two 5-year intervals years following enactment of TADRA in urban, suburban and rural regions of the state. (5) Using the CDC's Youth Risk Behavior Survey (YRBS), compare risky driving behaviors for youth in school in Georgia to youth in school in neighboring states during three time periods: the years before TADRA was enacted (1991, 1993,1995), the year TADRA was enacted (1997), and the years after TADRA was enacted (1999, 2001, 2003, 2005, 2007).

Small Research Project: Preclinical Assessment of Progesterone Treatment for Pediatric Traumatic Brain Injury

Pre-clinical and clinical research demonstrates that the hormone progesterone (PROG) is a potent neurosteroid that, acutely administered, can dramatically reduce cerebral edema, inflammation, tissue necrosis and programmed cell death52. On the strength of these findings, Emory's Department of Emergency Medicine and other clinical departments recently completed a National Institutes of Health-supported (National Institute of Neurological Disorders and Stroke) Phase II clinical trial using PROG as a treatment in the first few hours after blunt force TBI in adults. These researchers reported in the Annals of Emergency Medicine31 that the death rate among patients given the study drug was less than half that of patients who did not receive the drug but were otherwise managed with state-of-the-art care. Behavioral testing at 30 days post-survival revealed significantly better functional outcomes in patients who received PROG compared to patients given placebo. The researchers have well-established, published techniques to examine the pro-and anti-inflammatory factors regulated by PROG administration. Through this ECIC small research project, they will determine whether the hormone will enhance the resolution of edema in pediatric TBI and promote functional recovery as well as it does in adults and examine any iatrogenic effects. The study objective is to conduct the animal experiments needed to provide data to support planning for clinical studies on the safety and benefits of PROG for the treatment of acute TBI in children. The hypothesis is that PROG will be as safe and effective in a pediatric population as it has been demonstrated to be in adult and aged populations. However, the researchers acknowledge that in the context of neuroprotective treatments for TBI, children with TBI are not just like little adults. Injury mechanisms, pathology, physiology and functional outcomes associated with pediatric TBI are not the same as in adults . From a drug-testing perspective, this project will break completely new ground. The study aim is to characterize the short- and long-term behavioral deficits following TBI in post-natal male and female rats and determine the efficacy of PROG in promoting morphological and functional recovery. It is important to characterize in greater detail the time course and behavioral deficit attenuation by PROG after TBI in neonatal male and female rats because as the animals continue to develop, the parameters of dose, timing and duration of treatment may be very different from those observed in older subjects with TBI. To assess functional outcomes at both the pre-clinical and clinical phases of testing, it is critically important to have a panel of reliable biomarkers whose changes after neurosteroid treatment reflect functional recovery. Because of the researchers' extensive work with adult TBI subjects, they have already determined the most effective biomarkers for inflammation, necrosis, apoptosis, neuronal protection, and regenerative response to injury. To manipulate the dosage, timing and duration of PROG treatments in a pediatric population of brain injured patients, researchers need to know whether the regulation and control of these various biomarkers in pediatric injury differ from the responses to injury and treatments seen in adults. PROG's substantive effects in reducing cerebral edema in adults are due to its pleiotropic effects on a number of injury/repair parameters and may be exactly what is needed to enhance repair in the pediatric brain. However, the hormone's anti-inflammatory, growth-promoting and neuronal guidance effects may prove to be even more important during development of the nervous system.

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