BACKGROUND: We previously reported a case of subacute combined degeneration of the spinal cord in a 37-year-old man due to recreational use of nitrous oxide (N2O). The man presented with a 3-week history of gait ataxia and paraesthesia of the hands and feet. He had been inhaling N2O every day for 6 months. His serum vitamin B12 was low and Schilling's test was normal. All his symptoms resolved with vitamin B12 replacement and cessation of inhalation. N2O binds irreversibly to vitamin B12, resulting in B12 deficiency. Cases of N2O toxicity presenting as subacute combined degeneration of the spinal cord have been described previously, usually by dentists and medical and nursing staff. However, new methods to access N2O gas have led to spinal-cord disease in non-medical recreational users.
METHODS: We distributed 1782 questionnaires to all undergraduate students attending selected lectures on the day of the survey. These students were from a target population of 2222 enrolled in first-year engineering, law, and health science papers at the University of Auckland, during the latter part of the first semester, 2002. Compulsory lectures for each course were targeted and the lectures were selected to keep duplication of responses to a minimum. Questionnaires were distributed as students entered the lecture theatres and gathered as they left the class, with a preset explanation given before class, with time at the end for clarification. The survey was done over 1 month, with collections done at around 1000 h and 1400 h. The 440 students who did not attend prescribed lectures were not surveyed. We piloted the survey on 15 students, and repeated questions with slightly different wording to screen for inconsistent responses.
FINDINGS: 1374 (77%) of the 1782 questionnaires were completed, 14 (1%) of which we discarded due to inconsistent or incomplete replies. 780 students (57.1%; 95% CI 54.4-59.7) were aware that N2O is used as a recreational drug. Students were classified as users or non-users on the basis of saying yes or no to the question "Have you ever inhaled nitrous oxide for recreational purposes". 96 (15%) of 652 men were users compared with 61 (9%) of 708 women (p=0.0005). Users had a median age of 20 years (range 17-48) compared with 19 years (16-50) for non-users (Mann Whitney U test p=0.02). Users were more likely to be white (99 [16%] of 608) than Asian (32 [7%] of 491) or Polynesian (ten [9%] of 116) (p<0.0001). The usual amount of N2O inhaled in one session was 2-5 bulbs, although seven (5%) regular users used more than ten bulbs per session. Sources of N2O were given as local corner stores, hardware stores, or supermarkets (in the form of cream-whipping bulbs), and a few from an on-campus nitrous club. Compared with non-users, people who used N2O were more than five times as likely to think N2O was safe; more than ten times as likely to have used use at least one other inhalant or recreational drug such as marijuana, cocaine, and hallucinogens; and more than eight times as likely to have seen friends use N2O. Questions about side-effects included neurological and urological sequelae and death from hypoxia.
DISCUSSION: Written surveys have difficulties with sample size, response rate, and respondent bias. Our survey was restricted to students from the law, health science, and engineering faculties. We also did not survey students who did not attend the lectures, perhaps biasing the sample slightly. The university population may not accurately reflect use of nitrous oxide in the wider community. Finally, we did not assess the extent of harm in this population.
Our results show a previously unrecognised high prevalence of recreational N2O use in first-year university students at Auckland University. Generally, few students were aware of the potential acute or chronic ill effects from use of this substance. N2O is not included routinely in drug education programmes. Moreover, with an increasing proportion of vegetarianism, many young people have a higher risk of nutritional deficiencies, further increasing their risk of subacute combined degeneration of the spinal cord. The high prevalence of such use should alert physicians to the possibility of N2O use in young people who present with subacute myelopathy, but are otherwise healthy.
Ephedra--Scientific Evidence Versus Money/Politics.
Although clear evidence of the dangers of ephedra-containing dietary supplements exists, the U.S. Food and Drug Administration has failed to use its legal authority to ban them. This is in the face of bans from the U.S. Army and Air Force commissaries and U.S. sports organizations and a recall from the Canadian government. The author of this Policy Forum urges an FDA ban on ephedra products, which he says has been blocked by lobbying and campaign contributions from Metabolife and other dietary supplement makers. Recently, several companies have reformulated their products without ephedra as the main ingredient, an unsatisfactory "regulatory" alternative to an FDA ban.
Correspondence: Daniel S. Moran, Institute of Military Physiology, Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer 52621, ISRAEL; (email: dmoran@sheba.health.gov.il).
BACKGROUND: Cold weather has been recognized in the Israel Defense Forces (IDF) as a potential medical and operational threat to the soldier. Although regulations have been issued to cope with this situation, every year about 20 cases of hypothermia (T(core) < 35 degrees C) and peripheral cold injuries are reported.
METHODS: This study was aimed at following cold weather injuries (CI) in the IDF in the period 1994-2001. 136 cases were reported to our institute during this period. All patients were from the general population of young (20 +/- 2 yr), male soldiers in the IDF. All were classified a priori as healthy, active subjects.
FINDINGS: Of these patients, 51% were diagnosed with mild hypothermia and 49% with peripheral CI. Among those soldiers who suffered from peripheral CI, less than 5% were diagnosed with frostbite. Most of the cases (76%) occurred in the winter months; however, 10% occurred in the spring, 13% in autumn, and 2 cases (1%) were reported in the summer. The majority of all CI cases occurred during routine scheduled training (51%), and 15% occurred during routine duties. Of the cases, 34% occurred during combat operations (mainly ambushing and surveillance).
DISCUSSION: The present study provides data on CI cases in an army where the awareness of the hazards involved in hostile environments is extensive, and in which detailed regulations aimed to prevent these injuries are common.
Unintentional injuries among children aged 1-4 years at home.
Chaveepojnkamjorn W, Pichainarong N, Pooltawee S. Southeast Asian J Trop Med Public Health. 2002; 33(3): 642-646.
Correspondence: W. Chaveepojnkamjorn, Department of Epidemiology, Faculty of Public Health, Mahidol University, Bangkok, THAILAND; (email: unavailable).
A hospital based case-control study was performed to determine causes of unintentional injuries among children aged 1-4 years at home. Data were obtained by interviewing parents and guardians of 242 children at Lerdsin Hospital in Bangkok, from August to October 1999. The results showed that falls were the most common type of injuries (54.6%). The age of 2 years comprised the major group (28.9%). The study subjects were injured within the home (60.7%). Sunday and Saturday were the most frequent days of injuries (18.2% and 16.5% respectively). The proportion of cases involving playing with others was 71.1%. Most of the injuries occurred in the period 16.00-19.00 hours (32.2%). Head and neck were the main injured area (45.5%). The multivariate model showed that children who had previous injuries were 19.22 times more likely to be injured again than those who had not previously been injured. Children with vigorous physical activities also had a higher risk (OR = 19.73, 95% CI 6.11-63.74). Outdoor working mothers were at higher risk than houseworking mothers (OR = 4.14, 95% CI 1.57-10.93) of having children affects. Children who spent most of the daytime at their relatives' houses had a higher risk than those who stayed at their home (OR = 3.48, 95% CI 1.02-11.81), while, 37.9% of children injured at their relatives' houses and 50.8% of all injured children were without supervision.
Occupational injuries treated in an emergency room
Concei o PS, Nascimento IB, Oliveira PS, Cerqueira MR. Cad Saude Publica 2003; 19(1): 111-117.
Correspondence: Paulo Sergio de Andrade Conceicao, Centro de Estudos da Sa de do Trabalhador, Secretaria da Sa de do Estado da Bahia, Salvador, BA, 40110-050, BRAZIL; (email: unavailable).
In Brazil, work-related injuries are only reported to the National Social Security data system. Therefore, records are limited to formally hired workers, who represent less than half of the active work force. In this cross-sectional study, cases of work-related injuries were identified and interviewed in an emergency room in the city of Salvador, capital of Bahia State, Brazil, to estimate their frequency and characteristics. Work-related injuries accounted for 31.6% of all injuries from external causes (n = 215). Only 36.8% of these patients reported having a formal job contract, and of these, fewer than half (45.5%) had their injuries reported to the Social Security data system, which indicates extensive underreporting of such important work-related health events, even in the formal sector of the economy. Medical records from emergency rooms can be an important source of information on work-related accidents, and health surveillance needs to be enforced in such health care services. This can also be an important step in obtaining a more complete picture of the occurrence of work-related accidents in Brazil.
Analysis of injuries among pilots killed in fatal helicopter accidents.
Correspondence: Douglas Wiegmann, Aviation Human Factors Division, Institute of Aviation, University of Illinois at Urbana-Champaign, USA; (email: dwiegman@uiuc.edu).
BACKGROUND: Despite advancements in the crashworthiness of helicopters, both the rate and severity of injuries sustained in helicopter accidents remain a cause for concern. The mechanism and pattern of injuries sustained in aircraft accidents can provide vital information for improving survivability. The purpose of this study was to analyze patterns of injuries sustained by pilots involved in fatal helicopter accidents.
METHOD: Detailed information on the pattern and nature of injuries was retrieved from the Federal Aviation Administration's autopsy database for pilots involved in fatal helicopter accidents from 1993 to 1999.
FINDINGS: A review of 84 autopsies revealed that blunt trauma was cited as the primary cause of death in 88.1% of these cases. The most commonly occurring bony injuries were fractures of the ribs (73.8%), skull (51.2%), facial bones (47.6%), tibia (34.5%), thorax (32.1%), and pelvis (31.0%). Common organ/visceral injuries included injury to the brain (61.9%), lung (60.7%), liver (47.6%), heart (41.7%), aorta (38.1/), and spleen (32.1%). Injury patterns did not appear to be related to the age of the pilot or the phase of flight. The use of a shoulder harness afforded protection to the occupant against certain injuries.
DISCUSSION: The findings and their significance are explained in the overall context of crash survivability and have implications for the design of crashworthy aircraft and making helicopter accidents more survivable.
Correspondence: Sallie E. Davis Kirsch, Family and Child Nursing, School of Nursing, University of Washington, Box 357262, Seattle, WA 98195-7262, USA; (email: skirsch@u.washington.edu).
Of the 500,000 children in the United States who are injured in bicycle crashes annually, 252 die - 97% of whom were no wearing a helmet. Although many intervention programs promote the use of helmets by children, a paucity of school-based evaluation studies exist that report students' knowledge retention or behavioral changes. The purposes of this study were to identify associations between student-reported knowledge of safety-related behaviors, reports of current safety-related practices, and students' participation in the Safety Central program while in the 4th grade. The samples consisted of 284 students currently enrolled in 5th and 6th grades. Findings showed a statistically significant association between participation in the Safety Central program and retention of knowledge and enactment of safety messages after a 1- and 2-year period. Motivators and barriers for helmet use were also identified. Implications for modifications to the content and delivery of the program and future evaluations are addressed.
Position sense has been found to decay as a function of the time delay the limb remains in a static position prior to movement onset. Position sense has also been found to deteriorate as a function of aging, with increased reliance on vision by the elderly. This study investigated whether the pointing kinematics of elderly adults were differentially affected by delay compared to young adults, and whether visual information could compensate for the effects of delay. Young and elderly adults kept the limb in a static position for 1, 6, or 10 s prior to movement onset, both with and without vision of the limb, initial position, and the movement trajectory. Across groups, delay resulted in increased overall movement duration, decreased peak velocity including a shorter relative time to peak velocity, with decreased distance and duration of the primary submovement. Delay and lack of vision differentially decreased distance of the primary submovement for elderly adults. Vision was able to compensate to some degree for the effects of delay across age groups. The findings provide evidence that decays in position sense as a function of time create difficulties in incorporating the initial limb position in motor planning process in elderly adults.
Carbon monoxide (CO) is a dangerous exogenous poison and an essential endogenous neurotransmitter. This gas when inhaled has an anaesthetic effect, which is poorly understood, but which may be fatal if compensatory mechanisms are exhausted, if cardiac oxygen (O(2)) needs exceed myocardial oxygenation and/or if apnoea or asphyxia onsets. Although there is considerable evidence that hypoxia occurs late in CO poisoning, both the treatment of acutely poisoned people and environmental exposure limits are largely based on a hypoxic theory of toxicity. The significance of recent demonstrations of increased endogenous CO and NO production in neurons of animals exposed to exogenous CO, and of a related sequestration of leucocytes along the endothelium and subsequent diapedesis is also not fully understood, but may in part explain both acute and delayed deleterious effects of a CO exposure. Delayed brain injuries due to a CO exposure may be preventable by hyperbaric O(2). However, the ideal dose of O(2) in this context, if any, is unknown and other potential treatments need to be tested.
Damore DT, Metzl JD, Ramundo M, Pan S, Van Amerongen R. Pediatr Emerg Care 2003; 19(2): 65-67.
Correspondence: Dorothy T. Damore, Department of Pediatric Emergency Medicine, New York- Presbyterian Hospital, New York, New York, USA; (email: DJY2001@med.cornell.edu).
OBJECTIVE: The purpose of this epidemiologic study is twofold: first, to determine the relative frequency of sports-related injuries compared with all musculoskeletal injuries in patients 5 to 21 years of age presenting to the emergency department (ED), and second, to evaluate the sports-specific and anatomic site-specific nature of these injuries.
METHODS: Patterns of injury in patients 5 to 21 years of age presenting to four pediatric EDs with musculoskeletal injuries in October 1999 and April 2000 were prospectively studied. Information collected included age, sex, injury type, anatomical injury site, and cause of injury (sports-related or otherwise). Information about patient outcome and disposition was also obtained.
FINDINGS: There were a total of 1421 injuries in 1275 patients. Musculoskeletal injuries were more common in male patients (790/62%) than in female patients. The mean age of the patients was 12.2 years (95% CI, 12.0-12.4). Sprains, contusions, and fractures were the most common injury types (34, 30, and 25%, respectively). Female patients experienced a greater percentage of sprains (44% vs 36%) and contusions (37% vs 33%) and fewer fractures (22% vs 31%) than male patients. Sports injuries accounted for 41% (521) of all musculoskeletal injuries and were responsible for 8% (495/6173) of all ED visits. Head, forearm, and wrist injuries were most commonly seen in biking, hand injuries in football and basketball, knee injuries in soccer, and ankle and foot injuries in basketball.
DISCUSSION: Sports injuries in children and adolescents were by far the most common cause of musculoskeletal injuries treated in the ED, accounting for 41% of all musculoskeletal injuries. This represents the highest percentage of sports-related musculoskeletal injuries per ED visit reported in children to date. As children and adolescents participate in sports in record numbers nationwide, sports injury research and prevention will become increasingly more important.
BACKGROUND: This study on traumatic brain injury (TBI) is based on prospective and retrospective population based data from a head injury register in Boras.
METHODS: Data was collected from the hospital emergency unit, the discharge register, the regional neurosurgical clinic and the coroner's records during 1 year. This district is mixed urban and rural with a population of 138 000.
FINDINGS: The 753 cases identified represent an incidence of 546 per 100 000 which includes deaths (0.7%), hospital admissions (67%) and attendance at the emergency department in patients not admitted (32%). Males (644 per 100 000), had 1.46 higher overall rate than females (442 per 100 000). The external causes were dominated by fall from same level (31%) and fall from different level (27%) followed by traffic accidents (16%) and persons hit by objects (15%).
DISCUSSION: The incidence of TBI found in this study is high but well in accordance with earlier published Swedish studies.
Correspondence: Tonja R. Nansel, Department of Health and Human Services, National Institute of Child Health and Human Development, Division of Epidemiology, Statistics, and Prevention Research, Bethesda, MD 20892, USA; (email: nanselt@mail.nih.gov).
OBJECTIVE: To determine the extent to which bullying and being bullied, both in and away from school, is associated with involvement in violent behavior.
DESIGN, SETTING, and PARTICIPANTS: A US representative cross-sectional sample of 15,686 students in grades 6 through 10 in public and private schools completed the World Health Organization's Health Behaviour in School-aged Children survey in 1998.
MAIN OUTCOME MEASURES: Self-report of weapon carrying, weapon carrying in school, physical fighting, and being injured in a physical fight.
FINDINGS: Involvement in each of the violence-related behaviors ranged from 13% to 23% of boys and 4% to 11% of girls. Bullying others and being bullied were consistently related to each violence-related behavior for both boys and girls. Greater odds of involvement occurred with bullying others than being bullied,and greater odds of involvement occurred with bullying that took place away from school than that occurring in school. For example, the adjusted odds ratio for weapon carrying associated with being bullied in school weekly was 1.5, for bullying others in school 2.6, for being bullied away from school 4.1, and for bullying others away from school 5.9.
DISCUSSION: Bullying should not be considered a normative aspect of youth development, but rather a marker for more serious violent behaviors, including weapon carrying, frequent fighting, and fighting-related injury.
Correspondence: Anne Maria Moller-Leimkuhler, Department of Psychiatry, Ludwig-Maximilians-University,Nussbaumstr. 7, 80336 Munich, GERMANY; (email: amoeller@psy.med.uni-muenchen.de).
Suicide and premature death due to coronary heart disease, violence, accidents, drug or alcohol abuse are strikingly male phenomena, particularly in the young and middle-aged groups. Rates of offending behaviour, conduct disorders, suicide and depression are even rising, and give evidence to a high gender-related vulnerability of young men. In explaining this vulnerability, the gender perspective offers an analytical tool to integrate structural and cultural factors. It is shown that traditional masculinity is a key risk factor for male vulnerability promoting maladaptive coping strategies such as emotional unexpressiveness, reluctance to seek help, or alcohol abuse. This basic male disposition is shown to increase psychosocial stress due to different societal conditions: to changes in male gender-role, to postmodern individualism and to rapid social change in Eastern Europe and Russia. Relying on empirical data and theoretical explanations, a gender model of male vulnerability is proposed. It is concluded that the gender gap in suicide and premature death can most likely be explained by perceived reduction in social role opportunities leading to social exclusion.
Suicidal ideation and suicide attempts in homeless mentally ill persons: Age-specific risks of substance abuse.
Correspondence: Holly G. Prigerson , VISN 1 Mental Illness Research, Education and Clinical Center, and the Northeast Program Evaluation Center, Veterans Affairs Medical Center (182), West Haven, CT, USA; (email: unavailable).
BACKGROUND: Despite reports of high rates of suicidal behavior among mentally ill homeless persons,it remains unknown whether the well-established suicide risks of increased age and comorbid psychiatric and substance abuse disorders ("dual diagnosis") documented in the general population are also markers for increased suicide risk among homeless persons.
METHODS: Data from a multi-site outreach program (ACCESS) (N = 7,224) were used to investigate whether rates of serious suicidal ideation and recent suicide attempts varied with the age and substance abuse diagnosis(es) (drug abuse and/or alcohol abuse disorders) among homeless mentally ill clients.
FINDINGS: The prevalence of 30-day suicidal ideation and suicide attempts (37.5 % and 7.9 %, respectively) was extremely high. Although the risk of serious suicidal ideation and suicide attempts was greater among the younger compared with the older homeless mentally ill clients, risks were not significantly increased by co-morbid alcohol and/or drug abuse. However, a significant interaction between age and co-morbid substance abuse was observed showing that among older clients but not younger clients, those with drug and alcohol abuse were at significantly greater risk of suicidal ideation than those without substance use problems, controlling for confounding factors.
DISCUSSION: Efforts to prevent suicide should recognize that among homeless people with mental illness, young-middle-aged (30- to 39-year-old) clients are at greatest risk of suicidal behavior. Among older clients the presence of both drug and alcohol abuse significantly increases suicide risk. These patterns are of special importance because they are quite different from those that are well documented in non-homeless populations.
Addressing hopelessness in people with suicidal ideation: building upon the therapeutic relationship utilizing a cognitive behavioural approach.
This article reports on how the therapeutic relationship can be enhanced by utilizing a cognitive behavioural approach when dealing with hopelessness in suicidal people. A rationale is presented regarding why this topic is deemed important. Following a brief overview of the concept of hope, the theoretical and empirical literature relating to hopelessness are examined. This literature indicates that, given the inextricable link between suicide and a sense of pervasive hopelessness, it is necessary for the practitioner to understand the methods and theoretical underpinnings of hope inspiration. Two case studies, drawn from clinical practice, are described in order to elucidate the key elements/interventions (which include the therapeutic relationship and specific cognitive behavioural techniques that the nurse therapist may utilize when attempting to ameliorate the client's sense of hopelessness). These key elements/interventions are further elaborated upon. Whilst cognitive behavioural techniques are shown to be beneficial when dealing with hopelessness, it is advocated that the therapeutic relationship is a prerequisite for successful therapy.
Child and adolescent suicide : epidemiology, risk factors, and approaches to prevention.
Pelkonen M, Marttunen M. Paediatr Drugs 2003; 5(4): 243-265.
Correspondence: M. Pelkonen, Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, FINLAND; (email: unavailable).
Suicide is rare in childhood and early adolescence, and becomes more frequent with increasing age. The latest mean worldwide annual rates of suicide per 100 000 were 0.5 for females and 0.9 for males among 5-14-year-olds, and 12.0 for females and 14.2 for males among 15-24-year-olds, respectively. In most countries, males outnumber females in youth suicide statistics. Although the rates vary between countries, suicide is one of the commonest causes of death among young people. Due to the growing risk for suicide with increasing age, adolescents are the main target of suicide prevention. Reportedly, less than half of young people who have committed suicide had received psychiatric care, and thus broad prevention strategies are needed in healthcare and social services. Primary care clinicians are key professionals in recognizing youth at risk for suicide.This article reviews recent population-based psychological autopsy studies of youth suicides and selected follow-up studies of clinical populations and suicide attempters, analyzing risk factors for youth suicides. As youth suicides are rare, research on risk factors for youth suicidal ideation and attempted suicide is also briefly reviewed.The relationship between psychiatric disorders and adolescent suicide is now well established. Mood disorders, substance abuse and prior suicide attempts are strongly related with youth suicides. Factors related to family adversity, social alienation and precipitating problems also contribute to the risk of suicide. The main target of effective prevention of youth suicide is to reduce suicide risk factors. Recognition and effective treatment of psychiatric disorders, e.g. depression, are essential in preventing child and adolescent suicides. Research on the treatment of diagnosed depressive disorders and of those with suicidal behavior is reviewed.In the treatment of youth depression, psychosocial treatments have proved to be useful and efficacious. Although studies on the effectiveness of selective serotonin reuptake inhibitors are limited in number, evidence supports their use as first-line antidepressant medication in youth depression. Available evidence suggests that various treatment modalities are useful in the treatment of suicidal youths, e.g. cognitive behavioral therapy and specialized emergency room interventions. Much of the decrease in suicide ideation and suicide attempts seems to be attributable to nonspecific elements in treatment. For high-risk youth, providing continuity of care is a challenge, since they are often noncompliant and commonly drop out or terminate their treatment prematurely. Developing efficacious treatments for suicidal children and adolescents would offer better possibilities to prevent suicides.
The influence of gender on risk factors for child and adolescent suicidal behavior
Geva K, Zalsman G, Apter A. Harefuah 2003; 142(3): 203-207.
Correspondence: K. Geva, Adolescent Inpatient Department, Geha Mental Health Center, Tel Aviv University, Tel Aviv, ISRAEL; (email: unavailable).
Suicide is the second leading cause of death among youths in many countries, and is a serious concern for public health. There are significant epidemiological differences between females and males--the "gender paradox". On the one hand, females report suicidal ideation more frequently, and attempt suicide more often. On the other, boys exceed females in the rates of suicidal deaths. Although many studies have been conducted to identify the risk factors for suicidal behavior, these have not focused on gender differences. In this review we examine the differences between suicidal females and males, in childhood and adolescence, as well as in adults. We review the gender differences concerning risk factors that have been linked to suicidal behavior. We also relate to the gender dependent social attitude toward suicidal behavior. Identifying the risk factors for suicidal behavior for each gender separately will help us understand, why girls try to commit suicide more often, but are relatively protected from dying from such acts, and the opposite is relevant for boys. This discussion is vital for the development of suicide prevention programs.
The influences of place of birth and socioeconomic factors on attempted suicide in a defined population of 4.5 million people.
Westman J, Hasselstrom J, Johansson SE, Sundquist J. Arch Gen Psychiatry 2003; 60(4): 409-414.
Correspondence: Jeanette Westman, Karolinska Institutet, MigraMed, Family Medicine Stockholm, Stockholm, SWEDEN; (email: unavailable).
BACKGROUND: Our knowledge of the influence of place of birth and socioeconomic status on attempted suicide in a defined national population is limited.
METHODS: The study population at baseline in 1993 included approximately 4.5 million Swedish persons aged 25 to 64 years, of whom 570 000 had been born abroad. Each individual was tracked until attempted suicide, remigration, death, or the end of the study on December 31, 1998. The Cox regression was used in the analysis.
FINDINGS: Labor migrants from Finland and other OECD (Organisation for Economic Cooperation and Development) countries and refugees from Poland and Iran had higher hazard ratios of attempted suicide than Swedish-born control subjects. Women born in Latin America, Asia, and Eastern Europe had significantly higher hazard ratios of attempted suicide than Swedish-born women. In contrast, men born in southern Europe and Asia had significantly lower hazard ratios of attempted suicide. The hazard ratios of attempted suicide among women from Iran, Asia, southern Europe, Latin America, and eastern Europe considerably exceeded those of men from the same country of origin. When socioeconomic status was included in the final model, the hazard ratios remained high for women, while the risk of attempted suicide among men declined sharply with increased income.
DISCUSSION: Place of birth, socioeconomic status, and sex are associated with attempted suicide. Socioeconomic status explains only part of the association between place of birth and attempted suicide.
Obstructive sleep apnoea is associated with an increased risk of sleep-related motor vehicle accidents. Seven recent legal cases of fatal motor vehicle accidents on NSW roads are presented, where the driver who caused the accident was suffering from an unrecognised or under-treated sleep disorder. The legal outcomes in these cases were variable: some of the drivers have been acquitted and others have been jailed. All remained licensed to drive immediately after their accidents. In some of the cases, the driver was cleared of any culpable driving offence because of a defence of sleepiness or a sleep attack without warning ("Jiminez defence"). This appears at odds with current medical research and legal opinion in other countries. More research is needed to understand the relation between sleep disorders and awareness of sleepiness. Medical practitioners need to be aware of current advice and guidelines with respect to obstructive sleep apnoea and driving.
What are the most effective ways of improving population health through transport interventions? Evidence from systematic reviews.
Correspondence: David S. Morrison, Greater Glasgow NHS Board, Glasgow, UK MRC Social and Public Health Sciences Unit, Glasgow, UK; (email:david.morrison@gch.glasgow.gov.uk).
OBJECTIVE: To review systematic review literature that describes the effectiveness of transport interventions in improving population health.
METHODS: Systematic review methodology was used to evaluate published and unpublished systematic reviews in any language that described the measured health effects of any mode of transport intervention.
FINDINGS: 28 systematic reviews were identified. The highest quality reviews indicate that the most effective transport interventions to improve health are health promotion campaigns (to prevent childhood injuries, to increase bicycle and motorcycle helmet use, and to promote children's car seat and seatbelt use), traffic calming, and specific legislation against drink driving. Driver improvement and education courses are associated with increases in crash involvement and violations.
DISCUSSION: Systematic reviews are able to provide evidence about effective ways of improving health through transport related interventions and also identify well intentioned but harmful interventions. Valuable additional information may exist in primary studies and systematic reviews have a role in evaluating and synthesising their findings.
The development and efficacy of a theory-based educational curriculum to promote self-regulation among high risk older drivers.
Knowledge Enhances Your Safety (KEYS) is a curriculum developed for older drivers who maintain driving privileges while coping with visual limitations that increase crash risk. KEYS' goal is to promote safe driving through self-awareness of vision impairment and adopting self-regulatory strategies. We discuss KEYS' theoretical framework based on the tenants of the Social Cognitive Theory, Health Belief and Transtheoretical Models, and Principles of Self-Regulation and Regulatory Self-Efficacy. Baseline and 6-month post test evaluations tested its efficacy in terms of theoretical construct outcomes. KEYS' participants improved self-perceptions of vision impairment, perceived a greater number of benefits in the performance of self-regulatory behaviors, and moved closer to the preparation and action / maintenance stages of change. Results indicate that high-risk older drivers benefit from educational interventions that promote self-awareness and self-regulation of driving. Future work will evaluate KEYS' efficacy for high-risk older drivers in promoting driver behavior changes and its impact on crash involvement.
Correspondence: Alan F. Williams, Insurance Institute for Highway Safety, Suite 800, 1005 North Glebe Road, Arlington, VA 22201, USA; (email: awilliams@iihs.org).
OBJECTIVE: To determine patterns of risk among teenage drivers.
METHODS: Review and synthesis of the literature.
FINDINGS: On most measures, crash rates during the teenage years are higher than at any other age, for both males and females. Risk among teenagers varies greatly by driving situation; it is particularly low in some situations (e.g., the learner period) and particularly high in others (e.g., right after licensure, late at night, with passengers present). In some of these high-risk driving situations, risk is elevated for drivers of all ages (e.g., late night driving), in others risk is elevated more for teens than adults (e.g., driving after consuming alcohol), and in others the risk is unique to teen drivers (e.g., having passengers)
DISCUSSION: These varying patterns of risk form the basis for graduated licensing systems, which are designed to promote low-risk and discourage high-risk driving.
This study compares risk factors for intimate partner violence related injury across two national data sources on violence against women, the Canadian Violence Against Women Survey and the National Violence Against Women Survey in the United States. After equating the data sets as much as possible on the types of violence experienced and risk factors, the authors determined which risk factors in each data source predicted injury and compared the magnitudes of associations between risk factors and injury across the data sets. The article presents results on bivariate and multivariate findings, model fit across the data sets, and statistical comparisons of findings across the data sets. Obtaining convergent findings across data sources on risk factors for injury will allow public health practitioners to intervene more effectively with women at risk for experiencing violence-related injuries perpetrated by spouses.
Correspondence: Tamera Coyne-Beasley, Department of Pediatrics, Division of Community Pediatrics, School of Medicine, the Injury Prevention Research Center, University of North Carolina at Chapel Hill, 27599, USA; (email: coybea@med.unc.edu).
BACKGROUND: Homicide is the third leading cause of deaths for girls aged 11 to 14 years and the second leading cause of death for girls aged 15 to 18 years. However, few studies examine the contextual issues of adolescent femicide, especially among 11- to 14-year-old victims.
OBJECTIVES: To obtain quantitative and contextual information about adolescent femicide, and to compare the context of femicide in younger vs older adolescents.
METHODS: Data from the North Carolina medical examiner were analyzed for all 11- to 18-year-old female homicide victims during 1990 to 1995. Police interviews were conducted for 1993 to 1995 cases to determine context, the relationship of victim and perpetrator, and criminal histories.
FINDINGS: There were 90 victims; 63 were aged 15 to 18 years, 55 were killed with firearms, and 40 were behind in school. Of 37 femicides for which law enforcement interviews were conducted, the most common contexts were altercation (n = 9), broken or desired relationship (n = 8), reckless behavior with a firearm (n = 6),retaliation (n = 5), and drug related (n = 3). Most perpetrators were men (89%; n = 33), were older than their victims (mean age difference, 8 years), and had criminal records (59%; n = 21). Seventy-eight percent of victims (n = 29) were killed by an acquaintance or intimate partner.
DISCUSSION: Femicide contexts differed by age. Younger adolescents (aged 11-14 years) were more likely to be killed by a family member in the context of an argument than by an intimate partner or acquaintance in the context of a broken relationship or reckless behavior with a firearm. Many victims were engaged in high-risk behaviors, including dropping out of school, running away from home,using drugs, and dating much older men with criminal records. Intervention specialists targeting high-risk female adolescents should be aware that this population may also be at increased risk of femicide.
Intimate partner abuse and high-risk behavior in adolescents.
Correspondence: Timothy A. Roberts, Division of Adolescent Medicine, Department of Pediatrics, Strong Children's Research Center, Golisano Children's Hospital at Strong, University of Rochester School of Medicine, Rochester,NY, USA; (email: unavailable).
OBJECTIVES: To determine the associations between abuse by an intimate partner and risk behaviors among adolescents and to determine whether these associations vary by gender.
DESIGN AND PARTICIPANTS: Ordinal and linear regression analyses of 1996 cross-sectional data from 4,347 adolescents surveyed for wave 2 of the National Longitudinal Study of Adolescent Health public use data set.
MAIN OUTCOME MEASURES: A 5-point scale was used to measure whether the adolescent had been the victim of any of the following behaviors by an intimate partner: insulted in public, sworn at, threatened with violence, or had something thrown at them. Risk behavior involvement was determined using 5 measures: substance use, antisocial behavior, violent behavior, suicidal behavior, and depressed mood.
FINDINGS: There was no significant difference in the frequency of abuse by an intimate partner for males (21.0%) vs females (22.1%). In females, after adjusting for sociodemographic factors and number of intimate partners, a history of abuse was significantly associated with substance use (values given as beta, 99% confidence interval) (0.87, 0.51-1.23), antisocial behavior (0.15, 0.10-0.20), violent behavior (0.06, 0.01-0.11), depressed mood (1.82, 1.21-2.43), and suicidal behavior (odds ratio, 1.37, 1.14-1.63). In males, abuse was independently associated with antisocial behavior (0.11, 0.03-0.19), violent behavior (0.09, 0.04-0.14), and depressed mood (1.29, 0.53-2.06). Abuse by an intimate partner had a significantly stronger association with substance use in females (0.87, 0.51-1.23) vs males (0.34, -0.09 to 0.77).
DISCUSSION: Abuse by an intimate partner is common among adolescents and has strong associations with risk behaviors among male and female victims of abuse.
