SafetyLit Update: 16 December 2002

Other Information

Publications Available
On-Line from IPW Sites

16 December 2002

We are unable to provide photocopies of any the articles and reports abstracted below. Where possible, links have been provided to the publisher of the material and contact information for the corresponding author is listed. Many of the journals provide copies (usually for a fee) of reports online. Please consider asking your library to subscribe to the journals from which these abstracts have been gathered.

Recent contact with health and social services by drug misusers in Glasgow who died of a fatal overdose in 1999.

Jones R, Gruer L, Gilchrist G, Seymour A, Black M, Oliver J. Addiction 2002; 97(12): 1517-1522.

Correspondence: Russell D. Jones, Greater Glasgow NHS Board, Health Promotion Research and Evaluation, 350 St Vincent Street, Glasgow G3 8YY, UK; (email: russell.jones@gghb.scot.nhs.uk).

OBJECTIVES: To explore the recent contact with health and social services by drug misusers who died of a fatal overdose and identify opportunities for preventive intervention. DESIGN: Retrospective case analysis.

SUBJECTS: Eighty-seven residents of the Greater Glasgow area who died of a drug misuse-related overdose in 1999.

METHODS: Analysis of matched data from several sources: Strathclyde Police; University of Glasgow Department of Forensic Medicine and Science; the Scottish Prison Service; general practitioners' medical notes, including records of accident and emergency attendances and psychiatric assessments; and five specialist agencies for drug misusers or the homeless.

FINDINGS: Most of those who died of an overdose were males, long-standing heroin injectors and resident in a deprived area. Heroin caused most deaths, either alone or with other drugs. Twenty-three per cent died within 2 weeks of release from prison. For the 77 whose medical records were available, 90% had seen their general practitioner (32% in the month before death), 48% had attended accident and emergency services and 22% had received a psychiatric assessment in the year before death. Over 40% of the 87 used a drug agency in the year before death and 20% had used more than one agency.

CONCLUSIONS: Previous suicidal ideation, attempted suicide and depression were common among those who died of an overdose, as was recent release from prison. Almost all had been in contact with and several were receiving specific treatment from health or specialist addiction services in their last weeks or months. The findings highlight both the numerous opportunities for intervention and the challenge of using them to prevent death. (Copyright © 2002, Society for the Study of Addiction - Blackwell Publishing)

No reports this week

Foreign body aspiration in children.

Lima JA, Fischer GB. Paediatr Respir Rev 2002; 3(4): 303-307.

Correspondence: Joo A. B. Lima, Rua Henrique Scliar, 225, Porto Alegre, BRAZIL; (email: rsf7304@via-rs.net).

Foreign body aspiration is a common accident in children and represents an important cause of morbidity and mortality. Diagnosis of this condition demands a high degree of suspicion since physical examination and basic radiology exams have low sensitivity. It is more frequent in children younger than 3 years of age, predominantly boys. Food materials are most commonly involved, particularly peanuts, although this could change according to regional feeding habits. The right main bronchus is the site where foreign bodies are most commonly found. Radiographical findings are not diagnostic, but the presence of unilateral obstructive emphysema or atelectasis are important clues. A rigid endoscopy is indicated whenever there is a suggestive history, since delays in removing foreign bodies can lead to severe bronchial sequelae. In developing countries this type of accident may be more relevant due to the lack of resources and awareness, which can lead to late diagnosis and treatment. Routine preventive measures must be taught to caregivers in order to reduce the incidence. Health care professionals should also be made more aware of the prevalence of this condition. (Copyright © 2002 Harcourt International)
Population based study of hospitalised fall related injuries in older people.

Peel NM, Kassulke DJ, McClure RJ. Inj Prev 2002; 8(4): 280-283.

Correspondence: Roderick McClure, Injury Prevention and Control Ltd, School of Population Health, University of Queensland Medical School, Herston QLD 4006, AUSTRALIA; (email: r.mcclure@sph.uq.edu.au).
OBJECTIVE: This study aimed to identify the distribution of fall related injury in older people hospitalised for acute treatment of injury, in order to direct priorities for prevention.

SETTING: A follow up study was conducted in the Brisbane Metropolitan Region of Australia during 1998.

METHODS: Medical records of patients aged 65 years and over hospitalised with a fall related injury were reviewed. Demographic and injury data were analysed and injury rates calculated using census data as the denominator for the population at risk.

FINDINGS: From age 65, hospitalised fall related injury rates increased exponentially for both males and females, with age adjusted incidence rates twice as high in women than men. Fractures accounted for 89% of admissions, with over half being to the hip. Males were significantly more likely than females to have fractured their skull, face, or ribs (p < 0.01). While females were significantly more likely than males to have fractured their upper or lower limbs (p < 0.01), the difference between proportions of males and females fracturing their hip was not significant. Males were more likely than females (p < 0.01) to have fall related head injuries (13% of admissions). Compared with hip fractures, head injuries contributed significantly to the burden of injury in terms of severity, need for intensive care, and excess mortality.

DISCUSSION: The frequency and impact of hip fractures warrants continued emphasis in falls program interventions for both males and females to prevent this injury. However, interventions that go beyond measures to slow and protect against bone loss are also needed to prevent fall related head injuries. (Copyright © 2002, Injury Prevention - Published by BMJ Publishing Group)

Modelling border-line tolerated conditions of use (BTCU) and associated risks.

Polet P, Vanderhaegen F, Amalberti R. Saf Sci 2002; 41(2-3): 137-154.

Correspondence: Philippe Polet, LAMIH, University of Valenciennes, System Automation, UMR CNRS 8530, Le Mont Houy, Valenciennes cedex, F59313, FRANCE; (email: ppolet@univ-valenciennes.fr).

For the design of most technical systems a desirable safe field of use is calculated from systems technical constraints, and expectations of human capacities and limitations. Performance incursions outside the safe field are then limited by means of hard-protections, instructions, education, and regulations. However, once in service, the socio-technical conditions of work create conditions for performance to migrate and stabilise outside the expected safe field of use. The stabilisation of migration results from a compromise between global performance improvement, individual additional advantages, and apparent risk control. This paper proposes a double modelling approach to such migrations, first in terms of a cognitive model of the production of migrations, and second in terms of a mathematical safety analysis of severity and consequences. Both approaches lead to the emergence of methodologies in order to take BTCU into account during design. Conclusions highlight the impossibility of avoiding such in service migrations of use, and advocate for an early consideration of potential migrations in order to improve the robustness of safety analysis techniques. The field example chosen for demonstration is the design and use of a rotary press. (Copyright © 2002 Elsevier Science)
Integrating safety into the design process: elements and concepts relative to the working situation.

Hasan R, Bernarda A, Ciccotelli J, Martin P. Saf Sci 2002; 41(2-3):155-179.

Correspondence: Rad Hasan, CRAN (Research Centre for Automatic Control), University of Nancy I, Faculte des Sciences, BP 239, F54 506, Vandoeuvre les Nancy Cedex, FRANCE; (email: hasan@cran.uhp-nancy.fr).

The fact that the design of equipment and machines can no longer be separated from the concept of human safety has led to criteria linked to exploitation being taken into account during their design. This paper firstly looks at the problem of integrating safety into the design as early as possible, and goes on to review the state of the art and examine the work known to have been carried out in this respect. The area of application of our research is then presented. The production system analysed is an offset printing line. We present the results of an analysis of the design process employed in the design and integration company and of how safety is integrated into the design process. The ultimate aim is to provide designers the means of integrating the potential work context at the start of the design process. We propose a system model by defining the working situation and the elements characterising this situation as well as the concepts relative to these elements. Entity-relationship formalism is used to present the model, which is an extension of the generic model proposed by Harani (Harani, Y., 1997. Une approche Multi-Modles pour la capitalisation des connaissances dans le domaine de la conception. PhD Report, Institut National Polytechnique de Grenoble, Laboratoire de Gnie Industriel et de Production Mcanique, Grenoble, France). (Copyright © 2002, Elsevier Science)
Changing paradigms for professional engineering practice towards safe designan Australian perspective.

Toft Y, Howard P, Jorgensen D. Saf Sci 2002; 41(2-3): 263-276.

Correspondence: Yvonne Toft, School of Health and Human Performance, Building 77, Faculty of Arts, Health and Sciences, Central Queensland University, North Rockhampton, Queensland 4702, AUSTRALIA; (email: y.toft@cqu.edu.au).

Engineers have a duty of care to end users of the systems they design under current statutes and at common law. Considerations such as cognitive compatibility and usability of equipment and system design are becoming issues of increasing importance, as society becomes more reliant on information technology and automation. That engineers contribute to human error in these systems through latent design error and poor management decision-making is well documented. Therefore, the role of engineers can be considered integral to positive outcomes in workplace safety.

This research offers an opportunity to understand why engineering design work may be contributing to human error on part of the operator, and offers hope toward a future when engineers will embrace safe design principles. This cross sectional study examines the relationship between professional engineering education and ergonomics. This research specifically addresses the attitudes of engineers to the inclusion of ergonomic principles in engineering practice and in undergraduate engineering curriculum.

It was found that the surveyed members of the Australasian Association for Engineering Education (AAEE) had a positive attitude toward the inclusion of ergonomic principles in their design practice. The intensity of their attitude was more positive if they had some previous exposure to ergonomic training. At present few engineering faculties systematically include ergonomic principles in their design courses. The most encouraging finding was the overwhelming support for the inclusion of ergonomic principles in undergraduate engineering curriculum. This finding was complimented by current literature suggesting a changing engineering paradigm, one that would facilitate and embrace these concepts, encouraging promotion of sustainable engineering design well into the future. (Copyright © 2002, Elsevier Science)
Musculoskeletal injuries in female soldiers: analysis of cause and type of injury.

Strowbridge NF. J Royal Army Med Corps 2002; 148(3): 256-258.

Correspondence: N.F. Strowbridge, Medical Reception Station, Ypres Road, Colchester, Essex, CO2 7NL, UK; (email: nstrow@aol.com).

OBJECTIVES: To record and analyse those injuries and conditions requiring referral to a military sports injury and rehabilitation centre over a three year period, with special reference to gender, type and site of injury, and the cause of the injury.

METHODS: A prospective study in which data on the gender, diagnosis, and cause of injury, of all patients referred to the Colchester Garrison Sports Injury and Rehabilitation Centre was recorded. All subjects were trained, serving soldiers in the British Army referred via their General Practitioner.

FINDINGS: Low back pain (OR 2.71, p < 0.0001) and injuries to the hip, thigh and lower leg (OR 2.33, p < 0.0001) were more frequent in female soldiers. Military training (OR 4.62, p < 0.0001), work (OR 2.53, p < 0.0001), recreation (OR 2.39, p < 0.0001), and pre-existing conditions (OR 4.2, p < 0.0001) were the causes most commonly cited by female rather than male soldiers. There was no statistical gender difference for sport related or road traffic accident injuries.

DISCUSSION: Female soldiers are more likely to sustain an injury than their male counterparts. Specific injuries account for the majority of this difference. Military training, work, and recreation are more likely to be the cause of injury in the female soldier. Conditions existing prior to military service were also more common. There was no gender difference in the injuries caused by sport or road traffic accidents. These results may act as a basis for targeted intervention in order to reduce inequality without reducing overall training standards.

No reports this week

See item #1 under Alcohol & Other Drugs
Regional variation in the incidence of symptomatic pesticide exposures: applications of geographic information systems.

Sudakin DL, Horowitz Z, Giffin S. J Toxicol Clin Toxicol 2002; 40(6): 767-773.

Correspondence: Daniel L. Sudakin , Department of Environmental and Molecular Toxicology, Oregon State University, Corvallis, USA; (email: sudakind@ace.orst.edu).

OBJECTIVE: To evaluate the epidemiology of symptomatic human pesticide exposures using poison control center data and geographic information systems.

METHODS: All symptomatic human pesticide exposures reported to the poison center during the period from January 1 to December 31, 2000 were included for analysis using geographic information systems. A space-time scan statistic was utilized to evaluate for clustering of symptomatic human exposures.

FINDINGS: Of 322 symptomatic pesticide exposures, 297 (92%) contained spatial identifiers that could be further analyzed using geographic information systems. A spatial and temporal cluster of symptomatic pesticide exposures was identified during the periodfrom April 1 to August 31, 2000, covering a large geographic area of eastern and predominantly rural regions of the state. The relative risk of reporting a symptomatic pesticide exposure among individuals living within this geographic area was 1.8 (log likelihood ratio = 18.5, P = 0.0005).

DISCUSSION: Geographic information systems can be effectively utilized by poison control centers to study regional and temporal variation in the incidence of human pesticide exposures. With the collection of more specific spatial identifiers, geographic information systems may have many additional applications in the surveillance and prevention of pesticide and other sentinel event exposures.

No reports this week

A Bayesian hierarchical model for accident and injury surveillance.

MacNab YC. Accid Anal Prev 2003; 35(1): 91-102.

Correspondence: Ying C. MacNab, Division of Epidemiology and Biostatistics, Department of Health Care and Epidemiology, University of British Columbia, BC, V6H 3V4, Vancouver, CANADA; (email: ymacnab@cw.bc.ca).

This article presents a recent study which applies Bayesian hierarchical methodology to model and analyse accident and injury surveillance data. A hierarchical Poisson random effects spatio-temporal model is introduced and an analysis of inter-regional variations and regional trends in hospitalisations due to motor vehicle accident injuries to boys aged 0-24 in the province of British Columbia, Canada, is presented. The objective of this article is to illustrate how the modelling technique can be implemented as part of an accident and injury surveillance and prevention system where transportation and/or health authorities may routinely examine accidents, injuries, and hospitalisations to target high-risk regions for prevention programs, to evaluate prevention strategies, and to assist in health planning and resource allocation. The innovation of the methodology is its ability to uncover and highlight important underlying structure of the data. Between 1987 and 1996, British Columbia hospital separation registry registered 10,599 motor vehicle traffic injury related hospitalisations among boys aged 0-24 who resided in British Columbia, of which majority (89%) of the injuries occurred to boys aged 15-24. The injuries were aggregated by three age groups (0-4, 5-14, and 15-24), 20 health regions (based of place-of-residence), and 10 calendar years (1987 to 1996) and the corresponding mid-year population estimates were used as 'at risk' population. An empirical Bayes inference technique using penalised quasi-likelihood estimation was implemented to model both rates and counts, with spline smoothing accommodating non-linear temporal effects. The results show that (a) crude rates and ratios at health region level are unstable, (b) the models with spline smoothing enable us to explore possible shapes of injury trends at both the provincial level and the regional level, and (c) the fitted models provide a wealth of information about the patterns (both over space and time) of the injury counts, rates and ratios. During the 10-year period, high injury risk ratios evolved from northeast to central-interior and the southwest. (Copyright © 2002, Elsevier Science)
The use of multilevel models for the prediction of road accident outcomes.

Jones AP, Jorgensen SH. Accid Anal Prev 2003; 35(1): 59-69.

Correspondence: Andrew P. Jones, School of Environmental Sciences, University of East Anglia, Norwich, NR4 7TJ, Norfolk, UK; (email: a.p.jones@uea.ac.uk

An important problem in road traffic accident research is the resolution of the magnitude by which individual accident characteristics affect the risk of fatality for each person involved. This article introduces the potential of a recently developed form of regression models, known as multilevel models, for quantifying the various influences on casualty outcomes. The application of multilevel models is illustrated by the analysis of the predictors of outcome amongst over 16,000 fatally and seriously injured casualties involved in accidents between 1985 and 1996 in Norway. Risk of fatality was found to be associated with casualty age and sex, as well as the type of vehicles involved, the characteristics of the impact, the attributes of the road section on which it took place, the time of day, and whether alcohol was suspected. After accounting for these factors, the multilevel analysis showed that 16% of unexplained variation in casualty outcomes was between accidents, whilst approximately 1% was associated with the area of Norway in which each incident occurred. The benefits of using multilevel models to analyse accident data are discussed along with the limitations of traditional regression modelling approaches. (Copyright © 2002 Elsevier Science)
Traps for the unwary in estimating person based injury incidence using hospital discharge data.

Langley J, Stephenson S, Cryer C, Borman B. Inj Prev 2002; 8(4): 332-337.

Correspondence: John Langley, Injury Prevention Research Unit, Dunedin School of Medicine, Dunedin, NEW ZEALAND; (email: john.langley@ipru.otago.ac.nz).

BACKGROUND: Injuries resulting in admission to hospital provide an important basis for determining priorities, emerging issues, and trends in injury. There are, however, a number of important issues to be considered in estimating person based injury incidence using such data. Failure to consider these could result in significant overestimates of incidence and incorrect conclusions about trends.

OBJECTIVES: To demonstrate the degree to which estimates of the incidence of person based injury requiring hospital inpatient treatment vary depending on how one operationally defines an injury, and whether or not day patients, readmissions, and injury due to medical procedures are included.

METHOD: The source of data for this study was New Zealand's National Minimum Dataset. The primary analyses were of a dataset of all 1989-98 discharges from public hospital who had an external cause of injury and poisoning code assigned to them.

FINDINGS: The results show that estimates of the incidence of person based injury vary significantly depending on how one operationally defines an injury, and whether day patients, readmissions, and injury due to medical procedures are included. Moreover the effects vary significantly by pathology and over time.

CONCLUSIONS: (1) Those using New Zealand hospital discharge data for determining the incidence of injury should: (a) select cases which meet the following criteria: principal diagnosis injury only cases, patients with day stay of one day or more, and first admissions only, (b) note in their reporting that the measure is an estimate and could be as high as a 3% overestimate. (2) Other countries with similar data should investigate the merit of adopting a similar approach. (3) That the International Collaborative Effort on Injury Statistics review all diagnoses within International Classification of Diseases 9th and 10th revisions with a view to reaching consensus on an operational definition of an injury. (Copyright © 2002, Injury Prevention - Published by BMJ Publishing Group)

Surveillance for Traumatic Brain Injury Deaths --- United States, 1989--1998.

Adekoya N, Thurman DJ, White DD, Webb KW. 2002; MMWR 51(SS10);1-16.

Correspondence: Nelson Adekoya, CDC National Center for Injury Prevention and Control, 4770 Buford Highway NE, Atlanta, GA 30341-3724, USA; (email: nba7@cdc.gov).

Available online: HERE.

BACKGROUND: Data indicate that approximately 50,000 U.S. residents die as a result of traumatic brain injury (TBI) annually. Survivors of TBI are often left with neuropsychologic impairments that result in disabilities affecting work or social activity. During 1979--1992, TBI-related death rates declined 22%, from 24.6 to 19.3 deaths/100,000 population. This report describes the epidemiology and trends in TBI-related mortality during 1989--1998.

REPORTING PERIOD: January 1, 1989--December 31, 1998.

DESCRIPTION OF SYSTEMS: The National Center for Health Statistics (NCHS) Multiple Cause of Death public use data were analyzed for this study.

FINDINGS: During 1989--1998, an annual average of 53,288 deaths (range: 51,848--54,501) among U.S. residents were associated with TBI. TBI-related death rates declined 11.4%, from 21.9 to 19.4/100,000 population. The major causes of TBI-related deaths were firearm-related (40%), motor-vehicle--related (34%), and fall-related (10%). The leading causes of TBI-related deaths differed among age groups. Among youths aged 0--19 years, motor-vehicle--related TBIs were the leading cause; among persons aged 20--74 years, firearm-related TBIs were the leading cause; and among persons aged >75 years, fall-related TBIs were the leading cause. Comparing rates in 1989 with rates in 1998, motor-vehicle--related causes declined by 22%; the majority of this decline occurred during the first 5 years of the period. During 1989--1998, firearm-related TBI-related deaths declined by 14%; approximately all of this decline occurred during the last 5 years of the period. In contrast, fall-related TBI-related death rates increased by 25% during the period.

CONCLUSION: This analysis of mortality data identifies recent trends in TBI-related deaths occurring during 1989--1998. Fall-related TBI death rates have increased throughout the period. Firearm-related TBI death rates, which were increasing in the early 1990s, declined. Motor-vehicle--related TBI death rates, which were decreasing until the mid-1990s, have since demonstrated only a limited change.

PUBLIC HEALTH ACTION: More current population-based epidemiologic studies of TBI are needed to assess recent trends of etiologic factors, provide additional guidance for public policy, and evaluate prevention strategies. Despite the decline in fatal TBI incidence, TBI morbidity and mortality remains a public health challenge. Public health, law enforcement, and transportation safety professionals can address these challenges by implementing effective interventions based on a thorough assessment of the factors that influence health-related behaviors.
Sex- and age- specific relations between economic development, economic inequality and homicide rates in people aged 0-24 years: a cross-sectional analysis.

Butchart A, Engstrom K. Bull World Health Organ 2002; 80(10): 797-805.

Correspondence: Alexander Butchart, Department of Injuries and Violence Prevention, World Health Organization, Geneva, SWITZERLAND.

Full text available online: HERE.

OBJECTIVE: To test whether relations between economic development, economic inequality, and child and youth homicide rates are sex- and age-specific, and whether a country's wealth modifies the impact of economic inequality on homicide rates.

METHODS: Outcome variables were homicide rates around 1994 in males and females in the age ranges 0-4, 5-9, 10-14, 15-19 and 20-24 years from 61 countries. Predictor variables were per capita gross domestic product (GDP), GINI coefficient, percentage change in per capita gross national product (GNP) and female economic activity as a percentage of male economic activity. Relations were analysed by ordinary least squares regression.

FINDINGS: All predictors explained significant variances in homicide rates in those aged 15-24. Associations were stronger for males than females and weak for children aged 0-9. Models that included female economic inequality and percentage change in GNP increased the effect in children aged 0-9 and the explained variance in females aged 20-24. For children aged 0-4, country clustering by income increased the explained variance for both sexes. For males aged 15-24, the association with economic inequality was strong in countries with low incomes and weak in those with high incomes.

DISCUSSION: Relations between economic factors and child and youth homicide rates varied with age and sex. Interventions to target economic factors would have the strongest impact on rates of homicide in young adults and late adolescent males. In societies with high economic inequality, redistributing wealth without increasing per capita GDP would reduce homicide rates less than redistributions linked with overall economic development.
Behavioral, Demographic, and Prior Morbidity Risk Factors for Accidental Death among Men: A Case-Control Study of Soldiers.

Garvey Wilson AL, Lange JL, Brundage JF, Frommelt RA. Prev Med 2003; 36(1): 124-130.

Correspondence: Abigail L. Garvey-Wilson, Army Medical Surveillance Activity, Building T-20, Room 213 (Attn: MCHB-TS-EDM), 6900 Georgia Avenue, N.W., Washington, DC, USA; (email: Abigail.Wilson@amedd.army.mil).

BACKGROUND: In the United States, the leading cause of death for young men is unintentional injury. The experience of the U.S. Army, because it comprises mostly young men, provides insights into factors associated with risk of accidental death. Between 1990 and 1998, accidents accounted for more than half of all deaths of men on active duty in the U.S. Army.

METHODS: All men on active duty in the U.S. Army who died in an accident between 1990 and 1998 were included in the study. For each accidental death case, four randomly selected controls were also included, matched on gender and contemporaneous military service.

FINDINGS: In multivariate analyses, accidental death victims were more likely to be unmarried, limited to a high school education, in combat-specific occupations, veterans of a recent deployment, and previously hospitalized for an "injury/poisoning," "mental disorder," or "sign/symptom/ill-defined condition." Of behaviors reported on routine health risk assessments, the strongest predictor of a subsequent fatal accident was motorcycle use while the most excess deaths were attributable to consuming more than five alcoholic drinks per week.

DISCUSSION: There are characteristics, experiences, and behaviors that predict accidental death risk. The findings may inform safety and health promotion programs aimed at young adults.
Motor vehicle and fall related deaths among older Americans 1990-98: sex, race, and ethnic disparities.

Stevens JA, Dellinger AM. Inj Prev 2002; 8(4): 272-275.

Correspondence: Judy A Stevens, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop K-63, Atlanta, GA 30341, USA; (email: jas2@cdc.gov).

OBJECTIVES: To examine differences in motor vehicle and fall related death rates among older adults by sex, race, and ethnicity.

METHODS: Annual mortality tapes for 1990-98 provided demographic data including race and ethnicity, date, and cause of death. Trend analyses were conducted using Poisson regression.

FINDINGS: From 1990-98, overall motor vehicle related death rates remained stable while death rates from unintentional falls increased. Motor vehicle and fall related death rates were higher among men. Motor vehicle related death rates were higher among people of color while fall related death rates were higher among whites. Among whites, fall death rates increased significantly during the study period, with an annual relative increase of 3.6% for men and 3.2% for women.

DISCUSSION: The risk of death from motor vehicle and fall related injuries among older adults differed by sex, race and ethnicity, results obscured by simple age and sex specific death rates. This study found important patterns and disparities in these death rates by race and ethnicity useful for identifying high risk groups and guiding prevention strategies.
Injuries among older adults: the challenge of optimizing safety and minimizing unintended consequences.

Binder S. Inj Prev 2002; 8:(Suppl 4): IV2-IV4.

Correspondence: Suzanne Binder, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), K-02, 4770 Buford Highway, NE, Atlanta, GA 30341, USA; (email: scb1@cdc.gov).

OBJECTIVES: To describe the problem of falls, motor vehicle related injuries, and suicide among older adults, and issues related to their prevention.

METHODS: Summary and synthesis of selected literature.

FINDINGS: About 39 000 adults aged 65 and older die each year in the United States from injuries; worldwide this annual toll is about 946 000 persons. The top three causes of injury related death in this age goup in the United State are falls, those related to motor vehicle crashes, and suicide. Effective strategies exist for preventing fall related injuries and deaths. Preventing injuries and deaths from motor vehicles and suicide may be more difficult because of the nature of these problems.

DISCUSSION: As the number and percentage of older adults continues to rise in the United States and globally, new approaches to preventing injuries will be critical. Interventions will need to operate at multiple levels-directed at the individual, at interpersonal relationships, and at the community level.
The negative impact of the repeal of the arkansas motorcycle helmet law.

Bledsoe GH, Schexnayder SM, Carey MJ, Dobbins WN, Gibson WD, Hindman JW, Collins T, Wallace BH, Cone JB, Ferrer TJ. J Trauma 2002; 53(6): 1078-1087.

Thomas J. Ferrer, MD, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 520-1, Little Rock, AR 72205; email: ferrerthomasj@uams.edu.

BACKGROUND: On July 1, 1997, Arkansas became the first state in 14 years to repeal their adult helmet law. We examined the clinical and financial impact of this repeal.

METHODS: A 6-year retrospective review was conducted of the University of Arkansas for Medical Sciences trauma registry including the 3 years before and the 3 years after the repeal of the helmet law. A head and neck Abbreviated Injury Scale (AIS) score >/= 3 was considered severe. All patients admitted to the hospital or who died in the emergency department were included in the study. The database of the Arkansas Highway and Transportation Department was also used to determine the number of crashes and fatalities occurring statewide (1995-1999).

FINDINGS: Although total and fatal crashes in Arkansas were not significantly different (1995-1996 vs. 1998-1999), nonhelmeted deaths at the scene of a crash significantly increased from 19 of 48 (39.6%) (1995-1996) to 40 of 53 (75.5%) (1998-1999) ( < 0.0001). Before repeal, 25% of nonfatal crash admissions were nonhelmeted (18 of 73). This significantly increased to 54% (52 of 96, < 0.001) after repeal. Overall, patients who were nonhelmeted had significantly higher AIS scores for head and neck, significantly more severe head injuries (AIS score >/= 3), 47% (33 of 70) versus 20% (20 of 99), and significantly longer length of intensive care unit stay. Financially, patients without helmets had significantly higher unreimbursed charges compared with their helmeted counterparts, resulting in a total of $982,560 of additional potentially lost revenue over the length of the study.

DISCUSSION: Repeal of the mandatory helmet law was associated with an increase in the nonhelmeted crash scene fatality rate. After the repeal, there was a disproportionately higher admission rate for nonhelmeted motorcycle crash survivors. These patients had an increased use of hospital resources and poorer reimbursement of charges compared with their helmeted counterparts. This resulted in significantly higher unreimbursed charges. States considering repeal of their mandatory adult helmet laws should consider the potential negative financial impact on their health care system and the increased morbidity associated with nonhelmeted motorcycle riders involved in a crash. (Copyright © 2002, Lippincott Williams & Wilkins)

See abstract #1 under Poisoning

Trends in school violence.

Merrick J, Kessel S, Morad M. Int J Adolesc Med Health 2002; 14(1):77-80.

Correspondence: Joav Merrick, Schneider Children's Medical Center of Israel, Sackler School of Medicine, Tel Aviv University, Office of the Medical Director, Division for Mental Retardation, Ministry of Labour and Social Affairs, Jerusalem, ISRAEL; (email: jmerrick@aquanet.co.il).

School violence has been a new research area since the 1980s, when Scandinavian and British researchers first focused on the subject. This violence has sometimes even resulted in murder. Since the late 1980s the World Health Organization (WHO) has conducted cross-national studies every fourth year on Health Behavior in School Aged Children (HBSC). Today 37 countries participate under the guidance of the WHO-European Office. The HBSC school-based survey is conducted with a nationally representative sample of 11, 13 and 15 year old school children in each country using a standard self-administrated questionnaire. The subject of bullying at school has been part of the questionnaire. Results from these surveys and studies in the United States and Israel are presented and it is hoped that the recent public debate and initiatives by the various government agencies will result in reduced school violence in the future. (Copyright © 2002, Freund Publishing)

See item #1 under Alcohol & Other Drugs
Retrospective analysis of youth evaluated for suicide attempt or suicidal ideation in an emergency room setting.

Hagedorn J, Omar H. Int J Adolesc Med Health 2002; 14(1):55-60.

Correspondence: Julie Hagedorn, Section of Adolescent Medicine, Department of Pediatrics, University of Kentucky, Lexington, USA; (email: unavailable).

Suicide is the third leading cause of death in adolescents and a major contributor to morbidity in this age group. The objective of this study was to look at the demographics, major stressors and factors leading to attempting suicide as well as the methods of attempted suicide in adolescents admitted to two hospitals in a medium size city. Medical records were reviewed of adolescents admitted to two area hospitals for attempted suicide between 7/1/97-12/31/99. Coroner's data on completed suicide were also reviewed. In the study period a total of 287 persons aged 21 years or under were admitted for attempted suicide. Mean age was 16.9 years (range 7-21). 53.4% of the total were females and 46.6 were males with the majority of the total being Caucasians (75.6%). Interpersonal conflicts were the most common stressors preceding the attempt; fight with parents 20%, end of a relationship 12%, fight with a significant other 8%. Financial difficulties were the culprit in 10% of the cases. Abuse was not clearly recorded in 64% of cases. In cases where documentation was clear, 60% reported sexual and 67% physical abuse. Nearly half of the patients had a prior psychiatric diagnosis with prior suicide attempt and depression being most common at 27 and 18% respectively. Overdose was the most common method utilized. There were 20 completed adolescent suicides in the area with firearms as the method used in all of them. It is concluded that suicide continues to be a major problem in adolescents. Access to guns may be a detrimental factor in completing suicide. Health care providers may help identify those at risk by routinely screening all adolescents for depression and suicide. (Copyright © 2002, Freund Publishing)
Epidemiological, Forensic, Clinical, and Imaging Characteristics of Head Injuries Acquired in the Suicide Attempt with Captive Bolt Gun.

Gnjidic Z, Kubat M, Malenica M, Sajko T, Radic I I, Rumboldt Z. Acta Neurochir (Wien) 2002; 144(12): 1271-1277.

Correspondence: Z. Gnjidic, Department of Neurosurgery, University Hospital "Sestre Milosrdnice", Zagreb, CROTIA; (email: unavailable).

The captive bolt gun (slaughterer's gun) is a tool used in the meat industry for "humane killing" of animals. Used with the intent of suicide, the captive bolt gun causes very serious injuries.We analysed 19 self-inflicted head injuries with captive bolt gun during the past 20 years. Autopsy of 20 pigs killed by this method was also performed.All 19 cases were middle-aged men from rural areas, with low level of education, and without a previous psychiatric history. Five of them used the captive bolt gun daily in their professional activities, while the remaining 14 handled it only sometimes. In seven cases suicide was primarily successful, while in five patients, despite intensive medical care, serious craniocerebral injuries eventually resulted in death. Total mortality was 63.2%.The clinical appearance of the entrance wound and the imaging characteristics of the cranial trauma are very specific, and can be easily differentiated from firearm or other penetrating injuries. These wounds were always primarily infected with mixed bacterial flora from the skin. Therefore, besides radical primary wound care, especially of the wound canal with removal of foreign bodies, it is important to administer high doses of wide spectrum antibiotics. (Copyright © 2002, Springer Publishing)

Injuries and deaths from vehicular accidents in Calabar, Nigeria.

Archibong AE, Ikpatt OFR. Global J Med Sci 2002; 1(1): 61-64.

Correspondence: A.E. Archibong, Department of Surgery, College of Medical Sciences, University of Calabar Teaching Hospital, Calabar, NIGERIA; (email: unavailable).

Four thousand five hundred and sixty (4560) accident cases that were reported to the traffic section of the Nigerian Police in Calabar were studied. Of this number, 1051 (23%) were fatal and post mortem examinations were carried out at the University of Calabar, Teaching Hospital (UCTH). Six hundred and eighty-Two (682) were males while 369 were female victims. Head injury and ruptured abdominal viscera were the commonest causes of death.

Lack of good roads, indiscipline on the part of drivers/motorcycle riders and absence of good law enforcement measures by the relevant authorities all combine to render vehicular movements unsafe. It is hoped that the reinvigoration of the Federal Road Safety Commission and the reactivation of the Marine police will help reduce vehicular accident-related deaths.
Field relevance of a suite of rollover tests to real-world crashes and injuries.

Parenteau CS, Viano DC, Shah M, Gopal M, Davies J, Nichols D, Broden J. Accid Anal Prev 2003; 35(1): 103-110.

Correspondence: Chantal S. Parenteau, Delphi Automotive Systems, 1401 Crooks Road, 48084, Troy, MI, USA; (email: unavailable)

The objective of this study was to assess the distribution of rollover accidents occurring in the field and to compare the vehicle kinematics in the predominant field crash modes with available laboratory tests. For this purpose, US accident data were analyzed to identify types and circumstances for vehicle rollovers. Rollovers were most commonly induced when the lateral motion of the vehicle was suddenly slowed or stopped. This type of rollover mechanism is referred to as "trip-over". Trip-overs accounted for 57% of passenger car and 51% of light truck vehicle (LTV) rollovers. More than 90% of trip-overs were initiated by ground contact. Fall-overs were the second most common rollover type, accounting for 13% of passenger car and 15% of LTV rollovers. Bounce-overs only accounted for 8% of both passenger car and LTV rollovers.The FMVSS 208 dolly and the ADAC corkscrew rollover tests are well-known laboratory tests, but do not simulate many of the real-world rollovers. Three additional tests have been devised to more fully address the field relevant conditions identified in this study. To do so, assumptions were made and adding the new laboratory tests (soil-trip, curb-trip and ditch fall-over) increases representativeness to 83% of passenger car and 75% of LTV rollovers reported in the field. Accident data were also used to identify injuries in belted drivers so the information could later be used to better understand occupant kinematics in various roll conditions. The injury distribution for belted/non-ejected drivers was assessed for trip-over, fall-over and bounce-over accidents. Serious injuries (AIS 3+) were most common to the head and thorax, in particular for bounce-overs. Head injuries occurred from contact with the roof, pillar and the interior, while thoracic injuries resulted from contact with the interior and steering wheel assembly. Field data are useful in the development of laboratory test conditions for rollovers as it provides insights on the significance of various rollover types, understanding of injury biomechanics, guidance for future testing and inputs for mathematical modeling. (Copyright © 2002, Elsevier Science)
Ergonomics in product design: safety factor.

Sagot J-C, Gouin V, Gomes S. Saf Sci 2002; 41(2-3): 137-154.

Correspondence: Jean-Claude Sagot, quipe de Recherche en ERgonomie et COnception (ERCO), Universit de Technologie de Belfort-Montbliard, Belfort, Cedex 90010, FRANCE; (email: jean-claude.sagot@utbm.fr).

The aim of this paper is to give a number of methodological and theoretical indicators concerning the contribution of ergonomists to the execution of design projects of new products. Within the context of a design project, the present work therefore describes the studies and ergonomic analyses that can be undertaken during each phase of the design process from a design model based on concurrent engineering. Encompassing the design of the driving cabin of the new generation of high-speed trains (TGV-NG), this paper, through the ergonomic study of a number of technical sub-systems of this product, illustrates the advisory role of the ergonomist who, within the collective design process, ensures that the specific nature of the "human factor" is fully integrated into the design approach. Thus, throughout the design process, the ergonomist is called upon both to advise the designer on the characteristics of the target users and, on the basis of a "desirable future activities" approach, to help him or her assess the consequences of the design choices made. Ergonomics is described consequently, as an innovation and safety factor. (Copyright © 2002, Elsevier Science)
Association of seat belt use with death: a comparison of estimates based on data from police and estimates based on data from trained crash investigators.

Cummings P. Inj Prev 2002; 8(4): 338-341.

Correspondence: Dr Peter Cummings, Harborview Injury Prevention and Research Center, 325 Ninth Avenue, Box 359960, Seattle, WA 981042499, USA; (email: peterc@u.washington.edu).

OBJECTIVE: Estimates of any protective effect of seat belts could be exaggerated if some crash survivors falsely claimed to police that they were belted in order to avoid a fine. The aim of this study was to determine whether estimates of seat belt effectiveness differed when based on belt use as recorded by the police and belt use determined by trained crash investigators.

DESIGN: Matched cohort study.

SETTING: United States.

SUBJECTS: Adult driver-passenger pairs in the same vehicle with at least one death (n=1689) sampled from crashes during 1988-2000; data from the National Accident Sampling System Crashworthiness Data System.

MAIN OUTCOME MEASURE: Risk ratio for death among belted occupants compared with those not belted.

FINDINGS: Trained investigators determined post-crash seat belt use by vehicle inspections for 92% of the occupants, confidential interviews with survivors for 5%, and medical or autopsy reports for 3%. Using this information, the adjusted risk ratio for belted persons was 0.36 (95% confidence interval 0.29 to 0.46). The risk ratio was also 0.36 using police reported belt use for the same crashes.

DISCUSSION: Estimates of seat belt effects based upon police data were not substantially different from estimates which used data obtained by trained crash investigators who were not police officers. These results were from vehicles in which at least one front seat occupant died; these findings may not apply to estimates which use data from crashes without a death. (Copyright © 2002, Injury Prevention - Published by BMG Publishing Group)

Identification and characteristics of victims of violence identified by emergency physicians, triage nurses, and the police.

Howe A, Crilly M. Inj Prev 2002; 8(4): 321-323.

Correspondence: Andy Howe, East Lancashire Public Health Network, 33 Eagle Street, Accrington BB5 1LN, UK; (email: andyhowe@clara.co.uk).

OBJECTIVES: The objectives of the study were threefold-to evaluate the identification and characteristics of victims of assault who attend an accident and emergency (A & E) department; to compare the total number of assaults recorded in the A & E department with the number recorded by the police; and to assess a system for collecting the location and method of assault.

SETTING: The A & E department of Chorley and South Ribble Hospital Trust, Lancashire, England.

METHODS: A three month prospective study was performed. Victims of violence recorded on computer by doctors at discharge were compared with those identified at initial nurse triage. A comparison of police data with the A & E data relating to Chorley residents was performed. Additional information on the method and location of assault was also collected.

FINDINGS: During the period 305 (2.6%) of the patients attending A & E were identified as having been assaulted. Of the 305 individuals, 236 (77%) were identified by a doctor while 173 (57%) such patients were identified by a triage nurse. A & E identified twice the number of assaults involving Chorley residents as the police. Both men and women were most likely to have been injured on the street (44% and 37% respectively), although a greater proportion of women were injured at home (24%) than men (10%). The majority of injuries were sustained by blows from fists, feet, and heads (73%).

DISCUSSION: A & E doctors identify significantly more patients as the victims of violence than do nurses at triage. Using A & E data identifies assaulted individuals not identified by the police. Computer systems can be used in A & E to provide a more complete picture of the occurrence of violence in the community. (Copyright © 2002, Injury Prevention - Published by BMG Publishing Group)
Congressional voting behavior on firearm control legislation: 1993-2000.

Price JH, Dake JA, Thompson AJ. J Community Health 2002; 27(6): 419-432.

Correspondence: James H. Price, University of Toledo, Department of Public Health, Toledo, OH 43606, USA; (email: jprice@utnet.utoledo.edu)

Firearm morbidity and mortality place an enormous burden on the health care enterprise and society at large. Recent research has shown strong public support for strategies to regulate firearms yet effective federal legislation to control the types of firearms sold, conditions of sale and purchase, limitation in transportation and storage, and responsibility for use of personally owned firearms has been limited. Thus the purpose of this study was to evaluate the relationship between Congressional voting on firearm control legislation and the following: political affiliation, military service, geographic location of representation, education level, sex, and gun rights and gun control contributions. This was accomplished using a retrospective assessment of Congressional voting records from the 103rd-106th Congresses (1993-2000) regarding firearm control legislation. The study found that $6,270,553 was donated to members of Congress, $5,394,049 to members of the House and $876,504 to members of the Senate by groups concerned with firearm legislation. In the House, males (Odds Ratio [OR], 3.87), Republicans (OR, 13), those from the South (OR, 5), and those who received gun rights funds (OR, 13 to 203, depending on level of donations) were more likely to vote pro gun rights. In the Senate, support for gun rights occurred more often for those from the West (OR, 3.56), Republicans (OR, 130.50), or those who had received gun rights donations (OR, 28.00). This study has found a strong and consistent relationship between a Congressional member's position on firearm legislation and the amount of money received, political affiliation, and geographic location of representation. (Copyright © 2002, Kluwer Academic Publishers)
Screening for domestic violence in health care settings: Letters to the editor.

Available online HERE.

Many letters, multiple authors. All copyright © 2002 British Medical Journal.

Cultural shift is needed.

Jo Nurse, Health Policy Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (email: jo.nurse@lshtm.ac.uk).

EDITOR: The systematic review of Ramsay et al (SafetyLit Update 12 August 2002) makes a valuable contribution to the debate on whether to screen for domestic violence. This debate also needs to consider some of the wider cultural issues influencing the acceptability of the existence of domestic violence in society.

The taboo of recognising, acknowledging, and bringing into the open issues surrounding domestic violence has led to resistance by the health profession in dealing with what is increasingly becoming understood as an important influence on the health of women. Domestic violence is not unique: the recent history of the denial of the existence of child sexual abuse has undergone a major societal and cultural shift in the past 20 years, resulting in a heightening of awareness and recognition by health professionals and society at large.

A similar cultural shift is starting to take place in attitudes towards domestic violencefor example, with its inclusion within the community safety plans of local authorities. Although clear needs exist for research in determining the effectiveness of interventions for the prevention of domestic violence, part of the resistance towards screening for domestic violence seems to be related to negative attitudes held by health professionals.

To address this, more work needs to be done in assessing the training needs of health professionals in relation to domestic violence. Furthermore, the approach to dealing with domestic violence in the health sector may benefit from creating an environment whereby health professionals are seen not to support the use of violence as a means to deal with interpersonal conflict in any setting. A stronger emphasis needs to be placed on becoming a part of the cultural shift towards non-tolerance of violence in relationships in a similar way that health professionals have been able to contribute to the prevention of child abuse.

Screening for partner violence makes a difference and saves lives.

Samuel T Bauer, Kansas University Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA; (email: sbauer@kumc.edu) and Elizabeth M Shadigian, University of Michigan Hospitals and Health Centers, Obstetrics and Gynecology, Division of Women's Health, 1500 East Medical Center Drive, L 4000 Woman's 0276, Ann Arbor, MI 48109-0276, USA; (email: eshadig@umich.edu).

EDITOR: Ramsay et al say that implementation of screening programmes for domestic violence in healthcare settings cannot be justified, although such violence is common with major health consequences for women. Many healthcare organisations have professional statements on violence from intimate partners and support routine screening, including the American Medical Association, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, Family Violence Prevention Fund, and Physicians for a Violence-free Society. Partner violence continues to gain recognition by the healthcare community as one of the most prevalent current public health issues.

Screening for intimate partner violence in medical settings is effective in identifying victims and providing interventions. People are not offended when asked about current or past violence in their lives, 4 5 although research design is sometimes suboptimal.

The attitudinal surveys quoted by Ramsay et al are taken to mean that women do not favour screening. We calculated percentages by using the criteria provided by the authors, and when all four studies were combined 708 out of 1117 (63%) patients favoured screening. We therefore conclude that people favour screening.

Even if patients disliked screening, we do not accept the argument that it would be detrimental or possibly harmful to screen for partner violence. A comparison can be made historically with screening for cigarette use.

Many smokers do not favour screening. For years the harmful effects of cigarette smoking were not documented by observational studies. Now, well done, long term epidemiological research has documented multiple adverse outcomes associated with cigarette smoking and universal screening for cigarette use is standard.

Similarly, evidence of the poor physical and mental health outcomes of people exposed to violence continues to grow. Universal screening for violence must be taught as a healthcare imperative before millions more die from its adverse effects, as happened with smokers in the 1950s and 1960s.

Ramsay et al did not find any randomised controlled trials of interventions in healthcare settings to improve outcomes. In the absence of optimal research, we recommend universal screening. We challenge medical and sociological researchers everywhere to conduct government funded research to follow up people throughout their lifetimes so that the effects of screening, long term health consequences, and death rates from intimate partner violence can be brought to light.

Doctor's duty of confidentiality may not be in patient's or community's interest.

Peter Davies, Mixenden Stones Surgery, Halifax HX2 8RQ, UK; (email: npgdavies@doctors.org.uk).

EDITOR: With reference to the paper by Ramsay et al on screening for domestic violence, I cannot see that asking about domestic violence is a screening test as there is no agreement on effective subsequent intervention, even if there is a statement confirming domestic violence.

The difficulty in these cases is the conflict between the doctor's duty of confidentiality to the patient and the doctor's common law responsibility to report a crime that has been committed. Currently the duty of confidentiality is ranked far higher than the doctor's duty to society.

If we as a society are to tackle domestic violence it needs to move from being treated by doctors, the police, and legal services as a personal matter and instead be treated as seriously as any other crime. In particular the police and prosecuting authorities need to stop asking victims whether they want the prosecution to go ahead. If the crime has been committed the prosecution should go ahead anyway as a domestic crime strikes as much at society as it does at the immediate victim.

Perhaps it is time to look at whether the doctor's duty of confidentiality is really in the patient's (and the community's) interest in cases such as these. I do not necessarily know the answer to these questions, and I find these areas where law and medicine mix difficult territory to navigate. A clearer map would be useful.

Routine questioning of patients attending emergency departments may help in assessing local violence.

Mike Crilly, Department of Public Health, University of Aberdeen Medical School, Aberdeen AB25 2ZD, UK; (email: mike.crilly@abdn.ac.uk).

Andy Howe, East Lancashire Public Health Network, Accrington BB5 1LN, UK (email: andyhowe@clara.co.uk).

EDITOR: We agree with Ramsay et al that domestic violence is an important problem, with major health consequences for women. But the wider issue of violence in society (not just domestic violence) also deserves consideration, particularly since violent assault is most commonly directed against men.

Police data provide an incomplete picture of violent assault in a community, and public health action to reduce the levels of violence in society will require the use of health service data to identify priorities and monitor change. The routine questioning of patients attending hospital emergency departments is one option for assessing the levels of violence in a local community.

We have recently reported on the acceptability of the routine questioning of patients (both men and women) attending emergency departments in England. In our questionnaire survey of a representative sample of 281 adults, 67% (95% confidence interval 60% to 74%) supported routine questioning about violent assault, with similar levels of support from both men (66%, 59% to 73%) and women (68%, 59% to 76%). The proportion of respondents supporting routine questioning increased with age (52% of 16-24 year olds; 65% of 25-44 year olds; 85% of people older than 45). Overall 89% (85% to 93%) believed that healthcare staff should actively encourage victims of violence to inform the police, and 74% (68% to 80%) believed that health professionals should routinely inform the policeas is the case in some American states.

Patients attending emergency departments support a far more active approach from healthcare professionals in identifying victims of violence than is currently the case in the United Kingdom. But we agree with Ramsay et al that further evidence is required to assess the effectiveness of both population based and individual based interventions intended to reduce violence.

Balanced approach is needed.

Mary M Goodwin (mmg2@cdc.gov), Patricia Dietz (pad8@cdc.gov), Alison M Spitz (ams2@cdc.gov), Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mail Stop K-35, Atlanta, GA 30341 USA; Ileana Arias (iaa4@cdc.gov), Linda E Saltzman, (les1@cdc.gov), Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Mailstop K65, 4770 Buford Highway NE, Atlanta, GA 30341-3724, USA.

EDITOR: We agree with Ramsay et al that insufficient evidence exists to justify routine screening for violence in healthcare settings. The finding, however, seems to contradict current recommendations of numerous professional organisations in the United States that urge clinicians to screen routinely.

Such contradictions are not uncommon in prevention and intervention research. Recent summaries of evidence on routine screening for both breast and prostate cancer cite concerns that for some people the potential harm of mammography and prostate cancer screening could outweigh the benefits. Compared with these two widely used types of screening, the evidence base for violence screening in healthcare settings is far more tenuous.

Ramsay et al base their assessment on studies that do not include a single randomised controlled trial. The Centers for Disease Control and Prevention recently funded a randomised controlled trial to test screening and intervention in primary care settings. Research questions will address screening effectiveness. Do screening and identification decrease violence? Do women use referrals and find them helpful? No single trial, however, will provide all the answers; additional researchers and funders must design and support similar studies. Evaluation will require complicated and expensive methods and replication in diverse settings to gather rigorous scientific evidence.

Meanwhile, recommendations for routine screening will probably remain, and screening for violence will continue. Acceptance of screening may be more widespread in some settings than Ramsay et al's findings indicate. A recent survey of public family planning clinics in the United States reported that among 665 clinicians (75% nurses; 78% responding), 30% always conduct face to face screening for violence with new patients, and an additional 40% reported that another staff member screens new patients routinely (Centers for Disease Control, unpublished data).

Although these screening levels are unlikely to become widespread while scientific evidence is lacking, a balanced approach is needed towards the future. Routine screening should continue when appropriate systems are in place. Alternatively, some institutions and people will choose not to institute routine screening until stronger evidence exists.

Regardless of the approach, however, healthcare providers and institutions cannot ignore the problem of violence and must attempt to intervene whenever violence is disclosed or discovered. Scientific evaluation of screening and interventions must advance, and so must the critical need for institutions and healthcare providers to adopt the most appropriate responses and to receive the most complete training currently known.

Review is not an excuse for clinicians to ignore abuse.

Gene Feder, Barts and the London, Queen Mary's School of Medicine and Dentistry, London E1 4NS, UK; (email: g.s.feder@qmul.ac.uk).

NOTE: Dr. Feder is the corresponding author of the study to which the above letters responded.

EDITOR: From the responses to the review on screening of women for domestic violence, routine questioning of all women in healthcare settings about abuse is clearly still considered a justifiable strategy by many, but not all, correspondents. The interpretation of research evidence and use of public health criteria to judge effectiveness of routine questioning remains controversial.

The correspondence reflects a healthy debate on different public health models for addressing domestic violence. Consensus is strong on the importance of training healthcare professionals in responding appropriately to women who have been abused, with or without routine questioning. There is no disagreement on the urgent need for further research on interventions in healthcare settings.

We are dismayed that the review is being cited in the United Kingdom and the United States as a reason for health services not to develop projects or programmes for women experiencing abuse and as a reason for health professionals not to participate in existing projects. This is emphatically not the message of the paper, which argues that domestic violence is a crucial issue for healthcare professionals.

We believe that all acute and primary care organisations need to develop policies and procedures for responding to domestic violence. Evaluation of these programmes and robust research on interventions based in health services is a priority. We urge the health departments in the United Kingdom to show their commitment to improving the response of the health service to women experiencing abuse by commissioning research in this area.
Children and homicide.

Merrick J, Morad M. Int J Adolesc Med Health 2002; 14(3): 245-247.

Correspondence: J. Merrick, National Institute of Child Health and Human Development, Division of Community Health, Department of Family Medicine, Ben Gurion University, Beer-Sheva, ISRAEL; (email: jmerrick@aquanet.co.il).

Child homicide is as old as human history. It can be classified into intra- and extra familial child homicide. Different forms of homicide are discussed, and research findings show that in the age group 0-3 years the majority of cases were within the family. After age 12 years, it is primarily extra familial. With increased age of the child the phenomenon of child perpetrators is seen to be manifested in school homicide and juvenile crime. Risk factors are mentioned and pediatricians and family physicians should be aware of these in order to try preventive measures. (Copyright © 2002; Freund Publishing)

The criteria for selecting report for inclusion are simple. If the answer to any of the following questions is "yes", then the report is likely to be included: 1. Do the SafetyLit reviewers find the report interesting? 2. Are SafetyLit readers likely to hear of a report from a colleague? 3. Are SafetyLit readers likely to be questioned about the report from a member of the population they serve? 4. Does the report contain findings that are likely to be used by an adversary to oppose the actions or recommendations of a SafetyLit reader?

If you know of a journal article or a report that you believe should be included in a SafetyLit update, please: Send SafetyLit.org an E-mail Message.

Back to "New This Week" Menu

Rev. 15 Dec 2002