22 April 2002
Drugs and firearm deaths in new york city, 1990-1998.
- Galea S, Ahern J, Tardiff K, Leon AC, Vlahov D. J Urban Health 2002; 79(1): 70-86.
Correspondence: Sandro Galea, MD, MPH, Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029. (email: sgalea@nyam.org).
Firearm deaths remain among the leading causes of mortality in the United States. Changing law enforcement activities, incarceration, drug use, and socioeconomic conditions may have played roles in the declining rates of firearm deaths during the 1990s. Using records from the Office of the Chief Medical Examiner, we analyzed the role of drugs in firearm deaths in New York City between 1990 and 1998. Positive drug toxicology was present in over half of all firearm death victims during this time. Cocaine, cannabis, opiates, and alcohol accounted for almost all of these deaths with drug-positive toxicology. There were decreases in cocaine- and alcohol-positive toxicology for firearm deaths in New York City starting in the early 1990s; there was a more gradual decrease in heroin-positive toxicology for firearm deaths. Cannabis-positive toxicology for firearm deaths increased in the early part of the 1990s and then decreased starting in the mid-1990s. Although the disparities between minority and white firearm death rates narrowed during this time, minorities remained about three times more likely to be victims of fatal firearm violence than whites in 1998. The highest firearm death rates were among African American and Latino male decedents, with a larger proportion of Latinos testing cocaine or opiate positive, while a larger proportion of African Americans tested cannabis positive. These results suggest a complex role of drugs in firearm-related deaths.
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Heat waves in Madrid 1986-1997: effects on the health of the elderly.
- Diaz J, Jordan A, Garcia R, Lopez C, Alberdi JC, Hernandez E, Otero A. Int Arch Occup Environ Health 2002; 75(3): 163-70.
Correspondence: Julio Diaz, Centro Universitario de Salud Publica de Madrid, SPAIN (email: julio.diaz@uam.es).
OBJECTIVE: The objective of this paper is to analyse and quantify the effects exerted on summer mortality by extremes of heat, particularly among persons aged 65-74 and 75 years and over, groups in which mortality is higher.
METHODS: The study included the period from 1 January 1986 to 31 December 1997, for all people aged over 65 years resident in Madrid, based on mortality due to all causes except accidents (ICD-9 codes 1-799), and circulatory (390-459) and respiratory (460-487) causes. Meteorological variables analysed were: daily maximum temperature, daily minimum temperature and relative humidity. To control the effect of air pollution on mortality we considered the daily mean values of sulphur dioxide (SO2), total suspended particulate (TSP), nitric oxides (NOx), nitrogen dioxide (NO2) and tropospheric ozone (O3). Univariate and multivariate ARIMA models were used. Box-Jenkins pre-whitening was performed.
RESULTS: The results yielded by this study indicate a mortality increase up to 28.4% for every degree the temperature rises above 36.5 degrees C, with particular effect in women over the age of 75 years and circulatory-cause mortality. The first heat wave that leads to the greatest effects on mortality, due to the higher number of susceptible people and the duration of the heat wave, show an exponential growth in mortality. Furthermore, low relative humidity enhances the effects of high temperature, linking dryness to air pollutants, ozone in particular.
CONCLUSIONS: Since a warmer climate is predicted in the future, the incidence of heat wave should increase, and more comprehensive measures, both medical and social, should be adopted to prevent the effects of extreme heat on the population, particularly the elderly.
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Unintentional gun injuries, firearm design, and prevention: what we know, what we need to know, and what can be done.
- Frattaroli S, Webster DW, Teret SP. J Urban Health 2002; 79(1): 49-59.
Correspondence: Correspondence: Shannon Frattaroli, PhD, MPH, Assistant Scientist, The Johns Hopkins School of Public Health, 624 North Broadway, Baltimore, MD 21205. (email: Sfrattar@jhsph.edu).
The public health community has long recognized unintentional gun injuries as a public health issue. In 1998 in the United States, 866 people died from unintentional gunshot wounds, resulting in a crude death rate of 0.32 per 100,000. Unintentional gun deaths have been declining since at least 1920, yet the reasons for this downward trend are not understood. Possible explanations, such as changes in gun ownership and demography, changes in access to guns among population subgroups, safety practices, and artifactual influences are discussed. Intervention strategies for reducing the risk of unintentional gun injury are also discussed.
Accidents in Patients with Insulin-Treated Diabetes: Increased Risk of Low-Impact Falls but Not Motor Vehicle Crashes-A Prospective Register-Based Study.
Kennedy RL, Henry J, Chapman AJ, Nayar R, Grant P, Morris AD. J Trauma 2002; 52(4): 660-666.
Correspondence: R.L. Kennedy, University of Sunderland, Sunderland, United Kingdom.
BACKGROUND: Patients with diabetes mellitus may be at increased risk of accidents, mainly because of hypoglycemia. A variety of approaches have been adopted in an attempt to quantify this risk, but there has not been, to date, a systematic study using a national trauma register. In this study, we report findings from the Scottish Trauma Audit Group database.
METHODS: The database includes all patients admitted to hospital for 3 or more days, or who died in hospital as a result of their accident. The study includes 11,244 cases aged 15 years or over entered into the database between July 1996 and June 1998. This included 151 patients with insulin-treated diabetes. Using detailed prescribing information from one representative region, we have calculated the rates of different types of accidents for patients treated with insulin and compared this with the control population. We have analyzed information on the mechanism and severity of injury, outcome, and length of hospital stay.
RESULTS: Overall, the rate of accidents for insulin-treated patients was estimated at 291.2 per 100,000 population per year compared with 148.4 for the control population (p < 0.001; relative risk, 1.97; 95% confidence interval, 1.68-2.32). Insulin-treated patients were, on average, older (p < 0.005), more likely to be women (p < 0.02), and had longer stay in hospital (p < 0.001). The major excess of injuries related to low falls (< 2 m), which accounted for 62.3% of the injuries in the insulin-treated group compared with 47.1% in the remainder (p < 0.01). Low falls in the insulin-treated group (n = 94) were examined in detail: compared with the control population, there was no difference in age and sex, Injury Severity Score, Revised Trauma Score (a measure of the severity of physiologic disturbance), or calculated probability of survival (TRISS). Length of inpatient stay was higher in the insulin-treated low-fall patients (10 vs. 7 days, p < 0.01). Of the 151 catalogued injuries, the vast majority were fractures at peripheral sites. Only 23 insulin-treated individuals were admitted after a motor vehicle crash during the study period. This represents a slight but not significant increase above the rate for the background population.
CONCLUSION: This study confirms that patients taking insulin are at increased risk of accidents. Among the different types of injury, only low-impact falls were significantly increased. This is most likely related to an increased tendency for insulin-treated patients to fall during a hypoglycemic episode. However, patients with diabetes may also be at higher risk of sustaining a fracture after a fall. The number of car crashes involving drivers with insulin-dependent diabetes is small, and the rate is not significantly greater than that of the background population. Further study of the causes and consequences of falls in diabetic patients is warranted.
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Injury prevention and emergency medical services: the "Accidents Aren't" program.
- Yancey AH 2nd, Martinez R, Kellermann AL. Prehosp Emerg Care 2002; 6(2):204-209.
Correspondence: A.H. Yancy, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, USA (email: iyancey@emory.edu).
This report describes the rationale, purpose, structure, and content of the emergency medical services (EMS) injury prevention program "Accidents Aren't." The program is introduced with a review of injuries' toll professionally, epidemiologically, and economically in terms of the demand on medical care resources and the expense of care. With recognition that most EMS resources are expended on clinical care of non-critical but potentially catastrophic injuries, "Accidents Aren't" was designed to offer a more cost-effective means of care for this population and more efficient utilization of finite resources. The report describes the program's formulation process, its modular design, the instructor guidelines, the core training tool, the STARR mnemonic, and five clinical cases involving a wide array of injury mechanisms to which the mnemonic is applicable. Physician involvement in teaching and implementing the program is discussed. The relationship of the program to the future of EMS concludes the report.
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Epidemiology of pediatric injury-related primary care office visits in the United States.
- Hambidge SJ, Davidson AJ, Gonzales R, Steiner JF. Pediatrics 2002; 109(4):559-565.
Correspondence: Simon J. Hambidge, Denver Health Medical Center, 777 Bannock St, Mailcode 0132, Denver, Colorado, 80204 USA (email: shambidg@dhha.org).
OBJECTIVES: Unintentional injuries are a major cause of childhood mortality and morbidity in the United States. However, there is little epidemiologic information about pediatric injuries seen in primary care settings. The objective of this study was to characterize types and external causes of childhood injuries seen by primary care physicians and to compare the demographic and visit characteristics of children with injury-related visits (IRVs) and non-IRVs.
METHODS: A stratified random sample survey of office-based practicing physicians in the National Ambulatory Medical Care Survey (1997 and 1998) was conducted. Injury-related primary care office visits were measured for patients who were <19 years (number of patient visits = 6358).
RESULTS: Visits for childhood injuries composed >10 million primary care office visits per year (a rate of 13.8 visits per 100 person-years). The most common diagnoses assigned to these injuries were open wounds, sprains and strains, contusions, and superficial injuries such as abrasions and splinters. Leading external causes of these injuries were sports and overexertion, accidental falls, natural factors such as bites and stings, and cutting instruments. The single most common cause of pediatric injuries was sports/overexertion. Children who had IRVs were more likely to be older (odds ratio [OR]: 1.10/year of age; 95% confidence interval [CI]: 1.08-1.12), to be male (OR: 1.5; 95% CI: 1.2-1.9), and to reside in the West (OR: 1.9; 95% CI: 1.4-2.6) or in a rural area (OR: 1.4; 95% CI: 1.1-1.9). They were less likely to be Asian (OR: 0.2; 95% CI: 0.1-0.5) or Hispanic (OR: 0.5; 95% CI: 0.3-0.8). At the visit, children with IRVs were more likely to see a physician who was not their primary care physician (OR: 1.8; 95% CI: 1.4-2.3) and to see a family physician rather than a pediatrician (OR: 2.3; 95% CI: 1.8-2.9).
CONCLUSIONS: IRVs account for a significant portion of primary care for children in the United States. Identifying potentially preventable external causes of injury and characteristics of children who are more likely to be injured is important both for injury prevention programs and for the education of physicians who care for children.
Changes in injury mortality by intent and mechanism in Taiwan, 1975-98.
- Lu TH. Injury Prev 2002; 8(1):70-73.
Correspondence: Tsung-Hsueh Lu, Department of Public Health, Chung Shan Medical University, No 110, Sec 1, Chien Kuo Road, Taichung 402, TAIWAN (email: robertlu@ms1.hinet.net).
BACKGROUND: Most official mortality publications do not present the mechanism of injury (for example, cut/pierce, drowning, fall, poisoning, or suffocation) for intentional injuries (for example, suicide or homicide).
OBJECTIVES: To determine if the presentation of mechanism of injury for intentional injuries had different mechanism profiles.
METHODS: Age adjusted injury mortality rates by intent and mechanism of injury for Taiwan were calculated for the years 1975 to 1998. The International Classification of Disease codes for the matrix by intent and mechanism groupings were based on recommendations of the US Centers for Disease Control and Prevention.
RESULTS: If rates for both groups (intentional and unintentional) are combined, the importance of poisoning and suffocation increase relative to their contribution for unintentional injuries alone. Given the same mechanism of injury, different intents showed different patterns of change during the study period and given the same intent, the changes over time differed for different mechanisms of injury.
CONCLUSIONS: It is important to include the mechanism of injury within intentional injuries because it provides different profiles of injury problems. Thus the simultaneous tabulation of injury mortality data by both intent and mechanism is a necessary step for identifying and prioritizing injury problems. The argument that good preventive measures could prevent both unintentional and intentional injuries was also confirmed.
The New Zealand blood donors' health study: baseline findings of a large prospective cohort study of injury.
- Ameratunga SN, Norton RN, Whitlock G, Macmahon S, Coggan C, Jackson RT, Langley JD, Parag V, Smith D, Woodfield DG. Injury Prev 2002; 8(1):66-69.
Shanthi Ameratunga, Division of Community Health, Faculty of Medicine and Health Sciences, University of Auckland, NEW ZEALAND (email: s.ameratunga@auckland.ac.nz).
BACKGROUND: Cohort studies have contributed important scientific knowledge regarding the determinants of chronic diseases. Despite the need for etiologic investigations, this design has been infrequently used in injury prevention research.
OBJECTIVES: To describe the baseline findings of the New Zealand Blood Donors' Health Study, a large prospective study designed to investigate relationships between lifestyle, psychosocial factors, and serious injury due to road crashes, falls, self harm, assault, work, sport, and recreation.
METHODS: Participants were recruited from fixed and mobile collection sites of a voluntary non-profit blood donor program. Baseline exposure data (for example risk taking behaviors, alcohol and marijuana use, sleep habits, and depression) were collected using a self administered questionnaire. Outcome data regarding serious injury will be collected prospectively through computerized record linkage of participants' unique identifiers to national morbidity and mortality databases.
RESULTS: In total, 22 389 participants enrolled in the study (81% response rate). The diverse study population included 36% aged 16-24 years, 20% rural residents, and large variability in exposures of interest. For example, in the 12 months before recruitment, 21% had driven a motor vehicle when they considered themselves over the legal limit for alcohol, and 11% had been convicted of traffic violations (excluding parking infringements). Twelve per cent had seriously considered attempting suicide sometime in their life.
CONCLUSIONS: This is the first, large scale cohort study investigating determinants of serious injury in New Zealand and among the largest worldwide. Preliminary findings from prospective analyses that can inform injury prevention policy are expected within five years.
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The Epidemiology of Firearm Suicide in the United States.
- Romero MP, Wintemute GJ. J Urban Health 2002; 79(1): 39-48.
Correspondence: Correspondence: Michael P. Romero, Violence Prevention Research Program, UC Davis Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817. (E-mail: mpromero@ucdavis.edu).
BACKGROUND: In 1998, firearms were the leading method of committing suicide for both men and women, responsible for three times the number of suicides compared to the next leading method. Understanding the epidemiology of firearm suicide will increase awareness of firearm suicide as a major public health problem.
RESULTS: Rates of firearm suicide have changed little over the past two decades and have consistently exceeded rates of firearm homicide. The firearm suicide rate among men is approximately six times that of women. While firearm suicide rates are highest among the elderly, the majority (66%) of firearm suicides are among persons under 55 years of age. Firearm suicide rates among women of all ages have dropped modestly, while rates among elderly men have risen considerably. Whites have roughly twice the rate of firearm suicide as do blacks and other race/ethnicity groups. Individual-level empirical studies have consistently indicated that keeping firearms in the home is associated with an increased risk of suicide.
CONCLUSIONS: For suicide prevention to be effective, the availability and use of firearms in suicides must be addressed.
See report under Violence
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Traffic injury data, policy, and public health: lessons from Boston Chinatown.
- Brugge D, Lai Z, Hill C, Rand W. J Urban Health 2002; 79(1): 87-103.
Correspondence: Doug Brugge, Department of Family Medicine and Community Health, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111. (email: dbrugge@aol.com).
We note that long-standing land use and transportation policy are critical factors in creating traffic conditions and will have to play a role in reducing injuries. We present the historical progression of events that created current traffic conditions in Boston Chinatown and an analysis of traffic-related injuries at the community level for the years 1996-1998. Injuries were found to be as likely on weekends as on weekdays and frequently occurred late at night. Nighttime occupant injuries were found to be more likely on Friday, Saturday, and Sunday nights (relative risk = 2.26; confidence interval = 1.35-3.78, P =.0014). Injuries varied significantly by location for occupant (P = < .001) and for pedestrian injuries (P =.039). There were no peaks of injuries at traditionally defined commuter hours, which have been the standard time for assessing "worst case" traffic impacts by developers and government agencies. There was, however, a strong association between injuries and vehicle volume at 9 intersections with simple configurations for AM and PM commuter hours (R(2) = 0.589, P =.010), resulting in a calculated increase of 3-5 injuries per year for each increase of 1,000 vehicles. There was no such association at 10 intersections with complex configurations (R(2) = 0.104, P =.397). The 24-hour weekend patterns of vehicle volumes showed that traffic abated only between 3 and 7 AM, and the patterns appeared qualitatively to mirror the 24-hour pattern of injuries, suggesting that they were also indicative of injury risk. We suggest that there is a need for both long-term changes in policy and more immediate interventions. We also conclude that researchers should be cautious about assuming that traffic patterns conform to naive expectations such as rush hour peaks.
Review: Drugs and traffic collisions.
- Vingilis E, Macdonald S. Traffic Inj Prev 2002; 3(1): 1-11.
Correspondence: Scott Macdonald, Centre for Addiction and Mental Health, 100 Collip Circle, Suite 200, London, Ontario N6G 4X8, CANADA (email: scotm@uwo.ca).
Three categories of drugs, and specific commonly used drug subcategories are examined in this paper: depressants (benzodiazepines, methadone), stimulants (cocaine), and hallucinogens (cannabis). Descriptive, epidemiological studies on the incidence of drugs in driving populations show that cannabis or benzodiazepines are the most common drugs detected in most industrialized countries. The large number of experimental studies on the impact of various drugs on psychomotor performance show that the effects of the three categories of drugs and specific drugs with each category vary considerably. Some psychoactive drugs within these three categories have the potential to alter the skills required for driving.
Analytic epidemiological studies, where comparison groups are utilized, provide the best information on the role of drugs in traffic crashes. The most rigorous epidemiological studies have been conducted on benzodiazepines and traffic crashes. Generally, benzodiazepine users are up to 6 times more likely to be in crashes than non-users, depending on the study; however, the effects can be mitigated by altering the mode and type of prescriptions. In terms of the other types of drugs, the research is less rigorous and has not clearly shown they are associated with increased rates of traffic crashes.
The effect of rest-schedule orientation on sleep quality of commercial drivers.
- Filiatrault DD, Vavrik J, Kuzeljevic B, Cooper PJ. Traffic Inj Prev 2002; 3(1): 13-18.
Daniel D. Filiatrault, Insurance Corporation British Columbia, 151 W. Esplanade, North Vancouver, British Columbia, CANADA (email: daniel.filiatrault@icbc.com).
A study was conducted to examine the relationship between sleep quality and how commercial drivers balance conflict between the need for rest and tight delivery schedules. Face-to-face interviews were conducted with 188 commercial drivers to collect physiological data and self-reported measures. Multivariate linear regression models were developed to analyze relationships between sleep quantity, sleep quality, symptoms of obstructive sleep apnea, and how schedule-based priorities were established. A significant correlation was found between sleep quality and preference given by subjects, when symptoms of fatigue were detected, to elect whether to rest or comply with a real or perceived duty to maintain externally imposed schedule demands.
Fatal childhood vascular injuries associated with seat belt use.
- Riches KJ, James RA, Gilbert JD, Byard RW. Am J Forensic Med Pathol 2002; 23(1):45-47.
Correspondence: Roger W. Byard, Forensic Science Center, 21 Divett Place, Adelaide 5000, AUSTRALIA (email: byard.roger@saugov.sa.gov.au).
The deaths of two children who were passengers in motor vehicles involved in accidents were directly attributable to vascular injuries derived from seat belts. In the first case, a 10-year-old boy died as a result of abdominal aortic transection by a lap seat belt, and in the second case a 15-year-old boy died as a result of transection of his common carotid artery by a lap-shoulder seat belt. Although these cases demonstrate rare fatalities associated with seat belt use, there is no doubt that seat belts have significantly reduced mortality and morbidity from traffic accidents. Although it is possible that a fatal outcome might have occurred in each of these cases from other injuries that might have been sustained had seat belts not been worn, appropriate positioning and size of seat belt harnesses might have avoided the lethal injuries.
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Firearm availability and suicide, homicide, and unintentional firearm deaths among women.
- Miller M, Azrael D, Hemenway D. J Urban Health 2002; 79(1): 26-38.
Correspondence: Matthew Miller, Department of Health Policy and management, 677 Huntington Ave., Boston, MA 02115 USA (email: mmiller@hsph.harvard.edu).
BACKGROUND: In the United States, more than 45,000 women died from gun violence over the last decade.
OBJECTIVE: To determine whether measures of firearm availability are related to rates of suicide, homicide, and unintentional firearm deaths among women in the United States.
DESIGN: Pooled cross-sectional time series data on suicide, homicide, and unintentional firearm deaths (1988-1997) were used to estimate the association between the rate of violent death among women and four proxies of firearm availability. Two proxies came from survey reports of household firearm ownership rates; two were derived from mortality statistics. SETTING: United States, 1988-1997.
RESULTS: The increased rate of suicide and homicide in states with high gun levels was accounted for primarily by significantly elevated firearm suicide and firearm homicide rates. Unintentional firearm death rates were also increased in states with more guns. At the regional level, qualitatively similar results were obtained.
CONCLUSION: Between 1988 and 1997, the suicide, homicide, and unintentional firearm death rates among women were disproportionately higher in states where guns were more prevalent. The elevated rates of violent death in states with more guns was not entirely explained by a state's poverty or urbanization and was driven primarily by lethal firearm violence, not by lethal nonfirearm violence.
How delinquent youths acquire guns: initial versus most recent gun acquisitions.
- Webster DW, Freed LH, Frattaroli S, Wilson MH. J Urban Health 2002; 79(1): 60-69.
Correspondence: Daniel W. Webster, Center for Injury Research and Policy, Johns Hopkins University, 624 North Broadway, Room 593, Baltimore, MD 21205-1996 USA (email: dwebster@jhsph.edu).
BACKGROUND: Access to firearms among delinquent youths poses significant risks to community safety. The purpose of the study was to describe how a group of criminally involved youths obtained guns.
METHODS: Youths were randomly selected from a juvenile justice facility to participate in a semistructured, anonymous interview. Transcripts were coded and analyzed with the aid of textual analysis software.
RESULTS: Of the 45 participants, 30 had acquired at least 1 gun prior to their most recent incarceration, and 22 had acquired multiple guns. About half of the first gun acquisitions were gifts or finds. The first guns youths acquired were usually obtained from friends or family. The most recent acquisitions were often new, high-caliber guns, and they came from acquaintances or drug addicts. New guns often came from high-volume traffickers. Gun acquisitions from strangers or through "straw purchases" were rare. Though few obtained guns directly through theft, some youths believed their supplier had stolen guns. Youths rarely left their community to obtain a gun.
CONCLUSIONS: Guns were readily available to this sample of criminally involved youths through their social networks. Efforts to curtail high-volume, illegal gun traffickers and to recover discarded guns from areas in which illicit drug sales take place could potentially reduce gun availability to high-risk youth.
Effects of Maryland's law banning "Saturday night special" handguns on homicides.
- Webster DW, Vernick JS, Hepburn LM. Am J Epidemiol 2002; 155(5):406-412.
Correspondence: Daniel W. Webster, Center for Injury Research and Policy, Johns Hopkins University, 624 North Broadway, Room 593, Baltimore, MD 21205-1996. (email: dwebster@jhsph.edu).
Small, inexpensive, often poorly made handguns known as "Saturday night specials" are disproportionately involved in crime. Maryland banned the sale of Saturday night specials effective January 1, 1990. During the 2 years between the law's passage in 1988 and its effective date, legal handgun sales in Maryland were 34% higher than expected (p = 0.09). Interrupted time-series analysis of age-adjusted homicide rates for 1975-1998 with statistical controls for trends in two neighboring states, social and economic variables, and temporal patterns in Maryland's homicide rates was used to assess the effect of the law. Estimates of the Saturday night special ban effects depended on the assumption made about the timing of the law's effects. Models that assumed a delayed or gradual effect of the Saturday night special ban produced estimates indicating that firearm homicide rates were 6.8-11.5% lower than would have been expected without the Saturday night special ban (p < or =0.05). The model that assumed an immediate, constant change in response to the law showed no law effect, unless an outlier was excluded from the analysis. Excluding this outlier, the model estimated a 15% increase in firearm homicides associated with the Saturday night special ban. None of the models revealed significant law effects on nonfirearm homicides.
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