Alcohol affects executive cognitive functioning differentially on the ascending versus descending limb of the blood alcohol concentration curve.
- Pihl RO, Paylan SS, Gentes-Hawn A, Hoaken PN. Alcohol Clin Exp Res 2003; 27(5): 773-779.
Robert O. Pihl, Department of Psychology and Psychiatry, McGill University, Stewart Biological Sciences Bldg., 1205 Doctor Penfield Ave., Montreal, QC, H3A 1B1, CANADA; (email: czrp@musica.mcgill.ca).
CONTEXT: Executive cognitive functioning (ECF), a construct that includes cognitive abilities such as planning, abstract reasoning, and the capacity to govern self-directed behavior, has been recently researched as an antecedent to many forms of psychopathology and has been implicated in alcohol-related aggression.
OBJECTIVES: This study was designed to examine whether differential ECF impairments can be noted on the ascending versus the descending limbs of the blood alcohol concentration curve.
METHODS: Forty-one male university students participated in this study. Twenty-one subjects were given 1.32 ml of 95% alcohol per kilogram of body weight, mixed with orange juice, and the remaining 20 were given a placebo. Participants were randomly assigned to either an ascending or descending blood alcohol group and were tested on six tests of ECF on their assigned limb. Subjective mood data were also collected.
FINDINGS: Intoxicated participants on both limbs demonstrated ECF impairment; the descending-limb group showed greater impairment than their ascending-limb counterparts. Intoxicated subjects were significantly more anxious at baseline than placebo subjects. The introduction of this covariate nullified any significant differences in subjective mood found on either limb of the blood alcohol concentration curve, but ECF impairments remained robust.
DISCUSSION: Our results support the conclusion that alcohol negatively affects cognitive performance and has a differential effect on the descending versus the ascending limb of the blood alcohol concentration curve. The latter finding may have important ramifications relating to the detrimental consequences of alcohol intoxication.
Are Opioid-Dependent/Tolerant Patients Impaired in Driving-Related Skills? A Structured Evidence-Based Review.
CONTEXT: Previous reviewers have concluded that opioids cause dose-related impairment in opioid-naive volunteers on psychomotor skills related to driving. Data relating to opioid-dependent/tolerant patients have not yet been reviewed.
OBJECTIVES: To determine what evidence, if any, exists for or against opioid-related driving skill impairment in opioid-dependent/tolerant patients, we performed a structured evidence-based review of all available studies addressing the issue of whether opioid-dependent/tolerant patients are impaired in driving-related skills. A computer and manual literature search for studies relating to opioid-dependent/tolerant patients and driving-related skills produced 48 relevant reports. These references were reviewed in detail, sorted, and placed into tabular form according to the following subject areas: (1) psychomotor abilities studies; (2) cognitive function studies; (3) effect of opioid dosing on psychomotor abilities studies; (4) motor vehicle driving violations and motor vehicle accident studies; and (5) driving impairment as measured in driving simulators and off/on road driving studies. For each topic area, each study was categorized for the type of study it represented according to guidelines developed by the Agency for Health Care Policy Research (AHCPR). The strength and consistency of the evidence in each subject area also then was categorized according to AHCPR guidelines and a quantitative method.
FINDINGS: This evidence-based review indicated the following: (1) There was moderate, generally consistent evidence for no impairment of psychomotor abilities of opioid-maintained patients; (2) There was inconclusive evidence on multiple studies for no impairment on cognitive function of opioid- maintained patients; (3) There was strong consistent evidence on multiple studies for no impairment of psychomotor abilities immediately after being given doses of opioids; (4) There was strong, consistent evidence for no greater incidence in motor vehicle violations/motor vehicle accidents versus comparable controls of opioid-maintained patients; and (5) There was consistent evidence for no impairment as measured in driving simulators off/on road driving of opioid-maintained patients.
DISCUSSION: Based on the above results, it can be concluded that the majority of the reviewed studies appeared to indicate that opioids do not impair driving-related skills in opioid-dependent/tolerant patients. This evidence was consistent in four out of five research areas investigated, but inconclusive in one. As such, additional controlled studies are required. Until more data are available, however, physicians may wish to consider the approach to this problem recommended in this review.
OBJECTIVES: To determine whether fatigue and need for recovery are risk factors for being injured in an occupational accident.
METHODS: These associations were investigated within the Maastricht Cohort Study of "Fatigue at Work", a prospective cohort study of employees from a wide range of companies and organisations. For 7051 employees information was available on fatigue as measured with the Checklist Individual Strength (CIS), need for recovery as measured with the VBBA, and possible confounding factors such as age, smoking, alcohol consumption, educational level, shift work, and work environment. Information on the risk factors was collected in May 1999 and January 2000, before the occurrence of the occupational accidents. The incidence of being injured in an occupational accident was inventoried over the year 2000. A total of 108 employees reported having been injured in an occupational accident in 2000.
FINDINGS: For the highest CIS fatigue score tertile a for age, gender, educational level, smoking, shift work, and work environment, adjusted relative risk for being injured in an occupational accident of 1.29 (95% CI: 1.03 to 2.78) was found compared to the lowest tertile, and for the highest tertile of need for recovery a relative risk of 2.28 (95% CI: 1.41 to 3.66) was found.
DISCUSSION: Fatigue and need for recovery were found to be independent risk factors for being injured in an occupational accident. This means that in the push back of occupational accidents, fatigue, and even more importantly need for recovery, need special attention.
Falls from trucks: A descriptive study based on a workers compensation database.
- Jones D, Switzer-McIntyre S. Work 2003; 20(3): 179-184.
Correspondence: Derek Jones, Workplace Safety and Insurance Board of Ontario, Ont., CANADA; (email: swyejone@pathcom.com ).
CONTEXT: Falls from heights, including falls from nonmoving trucks, are a known cause of serious workplace injuries. Subsequent to the Workplace Safety and Insurance Board (WSIB) of Ontario implementing an industry sector management approach for service delivery the principle author noted a number of serious injuries as a consequence of falls from trucks or truck trailers. A literature search revealed limited articles, specifically relating to injuries sustained in falls from trucks or truck trailers. It was therefore decided to further investigate the scope of the problem.
METHODS: A search of the Province of Ontario, Workplace Safety & Insurance Board (WSIB) database for the year 1997 was conducted to identify all claims, within the Transportation Sector, where a reported accident had been classified as a fall from a non-moving vehicle. The data extracted from identified claims constitutes the basis of this study. There were 1026 claims initially identified. Each identified claim was reviewed to determine if the study entry criteria; (1) a fall occurred and (2) the fall originated from a truck, its trailer or the cargo, were met. Of the identified claims 352 met the study inclusion criteria. A retrospective file review was conducted on each claim entered into the study and the study variables recorded on a predefined data sheet.
FINDINGS: The most frequent sites of falls were the back of the truck or trailer, the truck step and the cargo being transported. More than one injury was sustained by 23.6% of the study population. The major injuries identified included; 214 strains/sprains, 117 contusions and 101 fractures. One year post accident 89.4% of the study population had returned to work, of these 84.9% were on full duties and the remaining 4.5% were on modified duties. The total costs associated with the 352 injured workers included in this study amounted to $5,313,901.27.
DISCUSSION: Falls from trucks often result in significant injuries with considerable periods of disability and related costs. As falls from three specific locations i.e. the back of trucks/trailer, the cargo and the truck step made up 83% of the total falls efforts at prevention might best be directed to further investigate causal factors involved in the falls from these high frequency areas. A prospective study, including a detailed interview, with workers suffering a fall from a truck would assist in understanding factors that contribute to falls from trucks or truck trailers.
OBJECTIVES: To describe the pedestrian population, their use of an overpass, and to assess pedestrian perceptions and responses to the risk of traffic crashes, determine pedestrian injuries in relation to traffic flow, and compare traffic crash and pedestrian injury rates before and after the overpass construction.
SETTING: The study was conducted in Nakawa trading center approximately six kilometers from the center of Kampala city on a major highway. The trading center has a busy market, small retail shops, industries, a sports stadium, offices, low cost housing estates, schools, and an estimated population of 6,226 residents, 15.1% of them students1.
METHODS: Pedestrian road behavior and traffic patterns were observed, and police traffic crash records reviewed, one year before and one year after overpass construction. A convenient sample of overpass and non-overpass users was interviewed to assess their perceptions of risk.
FINDINGS: A total of 13,064 pedestrians were observed (male: female ratio= 2.2:1). The overall prevalence of pedestrian overpass use was 35.4%. A bigger proportion of females (49.1%) crossed on the overpass compared to males (29.2%). More children (79.7%) than adults (27.3%) used the overpass. The majority of pedestrians (77.9%) were worried about their safety in traffic but only 6.6% thought of the overpass as an appropriate means to avoid traffic accidents. Traffic was not segregated by vehicle type. Mean traffic flow varied from 41.5 vehicles per minute between 0730-0830 hours, to 39.3 vehicles per minute between 1030-1130 hours and 37.7 vehicles per minute between 1730-1830 hours. The proportion of heavy vehicles (lorries, trailers, tankers, and tractors) increased from 3.3% of total vehicle volume in the morning to 5.4% in the evening (t = 2.847, p < 0.05); 44.0% of the collisions occurred in the evening with 35 pedestrian casualties before and 70 after the overpass intervention.
DISCUSSION: The prevalence of pedestrian overpass use was low with adult males least likely to use it. Pedestrians had a high perception of risk, which did not seem to influence overpass use. Pedestrians were more likely to be injured during slow traffic flows. There were more traffic crashes, and pedestrian injuries, but fewer fatalities after the construction of the overpass.
National multicentre study of acute intoxication in emergency departments of Spain.
- Burillo-Putze G, Munne P, Duenas A, Pinillos MA, Naveiro JM, Cobo J, Alonso J; The Clinical Toxicology Working Group, Spanish Society of Emergency Medicine (SEMESTOX). Eur J Emerg Med 2003; 10(2): 101-104.
Guillermo Burillo-Putze, Emergency Department, Hospital Universitario de Canarias, Ofra, S/N, La Laguna, Tenerife 38320, SPAIN; (email: gburillop@medynet.com).
OBJECTIVES: No studies have been published on global acute intoxication in Spanish emergency departments. We therefore designed a multicentre study to identify the epidemiology and management of intoxicated patients in Spain.
METHODS: We prospectively recorded cases from 14 emergency departments during 14 randomized days between February and April 2000. We included all age groups and all kinds of acute intoxication patients (including alcohol), except food-related cases, inert foreign bodies and deaths before arrival at the emergency department. Phone calls to poison control centres and inpatients were not followed.
FINDINGS: A total of 419 cases were recorded, 0.66% of emergency department visits. The incidence of intoxication was higher at weekends and on Mondays (P < 0.001). The mean age was 33 years (STD+/-18.10); males represented 56%, and 34.2% of patients arrived at the emergency department within the first 2 h. A total of 80% of patients were treated as outpatients, 3.7% were admitted to the intensive care unit, 6.7% were hospitalized, and 0.2% died.
DISCUSSION: We recorded a slightly lower incidence than other European countries with the same epidemiological profile, except for a low incidence of acetaminophen cases. If we apply the European Association of Poisons Centres and Clinical Toxicologists gastric lavage criteria, there were an important number of unnecessary gut decontamination techniques in drug poisoning. Most patients were treated in emergency departments, without hospital admission.
Correspondence: Kim M Yates, Emergency Care Centre, North Shore Hospital, Private Bag 93503, Takapuna Auckland, NEW ZEALAND; (email: Kim.Yates@WaitemataDHB.govt.nz).
OBJECTIVE: To examine mortality and morbidity associated with accidental poisoning in New Zealand for the period of 1993-97, and make comparisons with international trends.
METHODS: Poison Centre call data, and mortality and public hospital discharge data from the New Zealand Health Information Service were examined. Mortality and hospitalization rates were calculated. Statistical trends were examined using Poisson regression.
FINDINGS: Poison Centre calls regarding household agents and therapeutics were most frequent. Accidental poisoning with analgesics, antipyretics and antirheumatics (18%) was a common cause of hospitalization. Children under 5 years had the highest hospitalization rates, but were less at risk of death by accidental poisoning than other age groups. Common causes of death from accidental poisoning included utility gas/carbon monoxide (16%), psychotropic agents (16%), and analgesics, etc. (15%). Mortality rates varied between 0.54 and 0.72/100 000 population.
DISCUSSION: Mortality rates in New Zealand are lower than in many countries, but hospitalization rates are higher. Possible explanations and prevention implications are discussed.
Injury Risk in Men's Canada West University Football.
- Hagel BE, Fick GH, Meeuwisse WH. Am J Epidemiol 2003; 157(9): 825-833.
Correspondence: Willem H. Meeuwisse, University of Calgary Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, CANADA; (email: meeuwiss@ucalgary.ca).
Injury and participation information was collected over 5 years (1993-1997) on varsity men's football players in the Canada West Universities Athletic Association. The locations of acute time-loss injuries or neurologic injures were coded as head and neck, upper extremity (shoulder to hand), or lower extremity (hip to foot). Poisson regression-based generalized estimating equations were used to estimate rate ratios and 95% confidence intervals. Injury rates were higher during games as compared with practice periods (for the head and neck, rate ratio (RR) = 9.75 (95% confidence interval (CI): 7.50, 12.67); for upper extremities, RR = 5.76 (95% CI: 4.46, 7.45); and for lower extremities, RR = 7.06 (95% CI: 6.03, 8.25)). In dry-field game situations, head and neck injury rates were 1.59 times higher on artificial turf than on natural grass (95% CI: 1.04, 2.42). Lower extremity game injury rates were higher on artificial turf than on natural grass under both dry (RR = 1.83, 95% CI: 1.35, 2.48) and wet (RR = 2.31, 95% CI: 1.18, 4.52) field conditions. Injury rates increased with every additional year of participation. Past injury increased the rate of subsequent injury. The effect of an artificial field surface may be related to infrequent use. Risk factors for injury included participation in a game, playing on artificial turf, being a veteran player, and having a past injury.
Epidemiological considerations of concussions among intercollegiate athletes.
The purpose of this study was to examine epidemiological trends of concussions among 15 different intercollegiate sports during the 1997-1998, 1998-1999, and 1999-2000 seasons. Data were collected using the National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS). For the 15 sports studied during the 3 academic years, the NCAA ISS documented 3,535 team-seasons, 40,547 reportable injuries, 5,566,924 practice athlete exposures (AEs), and 1,090,298 game AEs. Concussions accounted for 6.2% of all reported injuries during this 3-year study. Of all the reported injuries, women lacrosse players (13.9%) reported the highest percentage of suffering a concussion during a game followed by women's soccer (11.4%), men's ice hockey (10.3%), men's lacrosse (10.1%), football (8.8%), women's basketball, (8.5%), field hockey (7.2%), men's soccer (7.0%), wrestling (6.6%), men's basketball (5.0%), baseball (4.2%), and women's volleyball (4.1%). Female athletes from all 7 sports were found to be at a lower risk for suffering concussions during practice sessions than the 8 male sports. However, female athletes were found to be at a greater risk for suffering concussions during games compared to male athletes. Injury trends over the 3- year period indicate concussions continue to be on the rise for athletes participating in collegiate football, men's soccer, and women's and men's basketball.
Rates and Risks of Injury during Intercollegiate Basketball.
- Meeuwisse WH, Sellmer R, Hagel BE. Am J Sports Med 2003; 31(3): 379-385.
Correspondence: Willem H. Meeuwisse, University of Calgary Sport Medicine Centre, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, CANADA; (email: unavailable).
BACKGROUND: Previous studies of basketball injury have not been able to assess injury incidence and risk.
OBJECTIVES: To determine rates and risks of injury in Canadian intercollegiate basketball.
STUDY DESIGN: Prospective cohort study.
METHODS: Standardized data were collected with a validated instrument from 98.1% of the 318 athletes on the eight men's basketball teams in the Canada West Division of the Canadian Intercollegiate Athletic Union.
METHODS: A total of 142 athletes sustained 215 injuries (44.7% of players injured) over the 2-year study period. The greatest number of injuries resulting in more than seven sessions of time loss involved the knee, whereas the most common injuries causing fewer than seven sessions of time loss involved the ankle. The most common mechanism of injury was contact with another player, especially in the "key". Injuries occurred 3.7 times more often in games than during practice. Centers had the highest rate of injury, followed by guards, and then forwards. The relative risk of reinjury was significantly increased by previous injuries to the elbow, shoulder, knee, hand, lower spine or pelvis, and by concussions.
DISCUSSION: Risk factors for injury were previous injury, games as opposed to practice, player position, player contact, and court location.
Effect of experience on rodeo injury.
- Butterwick DJ, Meeuwisse WH. Clin J Sport Med 2002; 12(1): 30-5.
Correspondence: Dale J. Butterwick, The University of Calgary Sport Medicine Center, Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4 CANADA; (email: Butterwi@ucalgary.ca).
OBJECTIVES: To document injury rates, severity, and relative risk during five competitive seasons of Canadian professional rodeo, between experienced (saddle bronc [SB], bareback [BB], and bull riders [BR]) and inexperienced (novice saddle bronc [NSB], novice bareback [NBB], and boys' steer riders [BSR]) rough stock competitors. DESIGN: Prospective cohort study.
SETTING: Canadian professional rodeo competition. SUBJECTS: Experienced competitors included professional cowboys from Australia, Brazil, New Zealand, the United States, and Canada. Inexperienced competitors included cowboys from Canada and the United States.
METHODS: Data was gathered prospectively at 63 of 323 professional rodeos in Canada from 1995 to 1999, constituting 30.8% of all professional rodeo performances during this time period. Injury data (severity and body part affected) was included when the injury occurred to a registered contestant, at a Canadian professional rodeo, at which the Canadian Professional Rodeo Sport Medicine Team was officially present and providing services. Data were collected by certified athletic therapists.
FINDINGS: Inexperienced rough stock competitors had a lower overall rate of injury in comparison to experienced competitors. In addition, inexperienced rough stock competitors had a lower injury rate of severe injuries, and a lower rate of injury to most body parts when compared with experienced competitors. Inexperienced competitors had a high rate of injury to the hand, wrist, and forearm. Most of these injuries to inexperienced contestants occurred to NBB (46%) and BSRs (31%). The relative risk of injury to inexperienced competitors did not differ from experienced competitors in the horse riding events (NSB vs. SB, NBB vs. BB), but the relative risk of injury to BSRs was one-half that of BR (0.49).
DISCUSSION: Inexperienced competitors in rodeo rough stock events do not have increased rates of severe injury, or of injury to specific body parts (in general). Inexperienced competitors do have a greater rate of injury to the arm, hand, and wrist. The relative risk of BSR is one-half the risk of BR.
Football incident analysis: a new video based method to describe injury mechanisms in professional football.
- Andersen TE, Larsen O, Tenga A, Engebretsen L, Bahr R. Br J Sports Med 2003; 37(3): 226-232.
Correspondence: Andersen, Oslo Sports Trauma Research Center, Norwegian University of Sport and Physical Education, PO Box 4014 Ullev�l Stadion, 0806 Oslo, NORWAY; (email: thor.einar.andersen@nih.no).
OBJECTIVES: To develop and test a new video based method for match analysis that combines football specific and medical information to achieve a better understanding of the injury mechanisms and events leading up to high risk situations.
METHODS: Football incident analysis (FIA) is a video based method describing incidents that may result in an injury using 19 variables and categories modified from match analysis. Videos from 35 of 76 (46%) official Norwegian under 21 matches played from 1994 to 1998 were analysed. Two football experts classified each incident on the basis of predetermined criteria, and their results were compared using interobserver and intraobserver reliability tests.
FINDINGSS: kappa correlation coefficients for interobserver and intraobserver agreement were very good for 63% and 95% and good for 37% and 5% of the variables respectively. Fifty two incidents were recorded (1.6 incidents per team per match or 94 per 1000 player hours), and 16 (31%) led to injuries (0.5 injuries per match or 29 injuries per 1000 player hours). FIA results showed that 28 incidents occurred while attacking in midfield zone 2 or the attacking zone, and 24 took place while defending in the defensive zone or midfield zone 1. Midfielders were exposed in 67% of the incidents, mainly in breakdown attacks or during long attacks by the opposing team. Of the 28 incidents during offence, only one was classified as having great potential to score a goal. Most incidents (70%) were the result of tackling duels both in the offensive and defensive playing phases. Of the 21 offensive incidents resulting from tackling duels, in 19 cases the exposed player was unaware of the tackling (passive duellist).
DISCUSSION: This study shows that football incident analysis is a potentially valuable tool for understanding the events leading up to injuries in football.
Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age.
- Agran PF, Anderson C, Winn D, Trent R, Walton-Haynes L, Thayer S. Pediatrics 2003; 111(6 Pt 1): E683-92.
Correspondence: Phyllis F. Agran, University of California, Center for Health Policy and Research, Pediatric Injury Prevention Research Group, 100 Theory, Ste 110, Irvine, CA 92697-5800, USA; (email: pagran@uci.edu).
CONTEXT: Mortality and morbidity data on childhood injury are used to construct developmentally appropriate intervention strategies and to guide pediatric anticipatory counseling on injury prevention topics. Effective anticipatory guidance depends on detailed injury data showing how risks change as children develop. Conventional age groupings may be too broad to show the relationship between children's development and their risk of various causes of injury. Previous studies revealed differences in overall rates and specific causes of injury by year of age. However, single year of age rates for children younger than 4 years may not reflect the variations in risk as a result of rapid developmental changes.
OBJECTIVE: This study was designed to analyze injury rates for children younger than 4 years by quarter-year intervals to determine more specifically the age period of highest risk for injury and for specific causes.
METHODS: We used data from 1996-1998 California hospital discharges and death certificates to identify day of age and external cause of injury (E-code) for children younger than 4 years. The number of California residents for each day of age was estimated from US Census of estimates of California's population by year of age for the midpoints (1996-1998). Rates were calculated by 3-month intervals. We grouped the E-codes into major categories that would be particularly relevant for developmentally related risks of injury specific to young children. The categorization took into account physical, motor, behavioral, and cognitive developmental milestones of children 0 to 3 years.
FINDINGS: There were a total of 23 173 injuries; 636 resulted in death. The overall annual rate for children aged 0 to 3 years was 371/100 000. Beginning at age 3 to 5 months, the overall rate of injury rapidly increased with increased age, peaking at 15 to 17 months. The mean injury rate calculated for each single year of age did not reflect the variation and the highest rate of injury by quarter year of age for children younger than 1 year, 1 year, and 2 years. The leading major causes of injury in descending order were falls, poisoning, transportation, foreign body, and fires/burns. The overall rate of the major category of falls exceeded poisoning, the second leading cause of injury, by a factor of 2. Age-related differences were detected within each major cause of injury. For children 0 to 12 months of age, there was a different leading cause of specific injury for each 3-month period: other falls from height (0-2 months), battering (3-5 months), falls from furniture (6-8 months), and nonairway foreign body (9-11 months). Hot liquid and vapor injuries were the leading specific causes for children 12 to 17 months. Poisoning by medication was the leading specific cause of injury for all age groups from 18 to 35 months and exceeded poisoning by other substances. Pedestrian injury was the leading specific cause of injury for all age groups from 36 to 47 months. Fall from furniture has the highest rates of specific causes of falls from age 3 to 47 months. Fall from stairs peaked at age 6 to 8 months and 9 to 11 months. Fall from buildings was highest at 24 to 26 months. Poisoning by medication peaked at age 21 to 23 months, but poisoning by other substances peaked at 15 to 17 months. The motor vehicle occupant injury rates were fairly stable over the age span of this study. The pedestrian injury rate increased beginning at age 12 to 14 months and by 15 to 17 months was double that of the motor vehicle occupant. Foreign body had a marked peak at age 9 to 11 months. Both battering and neglect rates were highest among infants 0 to 2 and 3 to 5 months. Bathtub submersions had a narrow peak at age 6 to 11 months. Other submersions peaked at 12 to 14 months and remained high until 33 to 35 months.
DISCUSSION: We departed from usual groupings of E-codes and devised groupings that would be reflective of age-related developmental characteristics. Differences in rates by narrow age groups for young children can be related to developmental achievements, w can be related to developmental achievements, which place the child at risk for specific causes of injury. We found marked variability in both rates and leading causes of injury by 3-month interval age groupings that were masked by year of age analyses. Children aged 15 to 17 months had the highest overall injury rate before age 15 years. This coincides with developmental achievements such as independent mobility, exploratory behavior, and hand-to-mouth activity. The child is able to access hazards but has not yet developed cognitive hazard awareness and avoidance skills. A remarkable finding was the high rate of battering injury among infants 0 to 5 months, suggesting the need to address potential child maltreatment in the perinatal period. Poisoning was the second major leading cause of injury; more than two thirds were medication. Cultural factors may influence views of medications, storage practices, use of poison control system telephone advice, and risk of toddler poisoning. The pedestrian injury rate doubled between 12 and 14 months and 15 and 17 months and exceeded motor vehicle occupant injury rates for each 3-month interval from 15 to 47 months. Pedestrian injury has not received sufficient attention in general and certainly not in injury prevention counseling for children younger than 4 years. Anticipatory guidance for pedestrian injury should be incorporated before 1 year of age. Effective strategies must be based on the epidemiology of childhood injury. Pediatricians and other pediatric health care providers are in a unique position to render injury prevention services to their patients. Integrating injury prevention messages in the context of developmental assessments of the child is 1 strategy. These data can also be used for complementary childhood injury prevention strategies such as early intervention programs for high-risk families for child abuse and neglect, media and advocacy campaigns, public policies, and environmental and product design.
Children with attention deficit hyperactivity disorder and attendance at hospital.
Correspondence: Thomas Beattie, A & E Department, Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh EH9 1LF, Scotland, UK; (email: louise.cowan@luht.scot.nhs.uk).
The aim of this study was to identify the risk of injury for children with attention deficit hyperactivity disorder. Children with attention deficit hyperactivity disorder were matched with controls and attendances at the Accident and Emergency department and injury rates were compared. Children with attention deficit hyperactivity disorder are at a greater risk of injury and also attend the Accident and Emergency department more frequently. The pattern and causation of injury is also different. This paper identifies attention deficit hyperactivity disorder as a predisposing cause of injury.
Flammable liquid burns in children.
- Henderson P, Mc Conville H, Hohlriegel N, Fraser JF, Kimble RM. Burns 2003; 29(4): 349-52.
Roy M. Kimble, Department of Paediatrics and Child Health, University of Queensland, Third Floor, Foundation Building, Royal Children's Hospital, Herston Road Herston, Queensland 4029, AUSTRALIA; (email: royk@uq.edu.au).
OBJECTIVES: To document and describe the effects of flammable liquid burns in children. To identify the "at risk" population in order to tailor a burns prevention programme.
DESIGN, PATIENTS AND SETTING: Retrospective study with information obtained from the departmental database of children treated at the burns centre at The Royal Children's Hospital, Brisbane between August 1997 and October 2002.
MAIN OUTCOME MEASURES: Number and ages of children burned, risk factors contributing to the accident, injuries sustained, treatment required and long-term sequelae.
FINDINGS: Fifty-nine children sustained flammable liquid burns (median age 10.5 years), with a clear preponderance of males (95%). The median total body surface area burned was 8% (range 0.5-70%). Twenty-seven (46%) of the patients required debridement and grafting. Hypertrophic scars occurred in 56% of the children and contractures in 14%, of which all of the latter required surgical release. Petrol was the causative liquid in the majority (83%) of cases.
DISCUSSION: The study identified the population most at risk of sustaining flammable liquid burns were young adolescent males. In the majority of cases these injuries were deemed preventable.
- Shields LB, Hunsaker DM, Hunsaker III JC, Humbert KA. Am J Forensic Med Pathol 2003; 24(2): 107-113.
Correspondence: Donna M. Hunsaker, Office of the Chief Medical Examiner, Urban Government Center, 810 Barret Avenue, Louisville, Kentucky 40204, USA; (email: stinknLex@aol.com).
Suicidal deaths involving explosives unconnected to terrorism are rare. The investigation of deaths from explosive devices requires a multidisciplinary collaborative effort, as demonstrated in this study. Reported are 2 cases of nonterrorist suicidal explosive-related deaths with massive craniocerebral destruction. The first case involves a 20-year-old man who was discovered in the basement apartment of his father's home seconds after an explosion. At the scene investigators recovered illegal improvised power-technique explosive devices, specifically M-100s, together with the victim's handwritten suicide note. The victim exhibited extensive craniofacial injuries, which medicolegal officials attributed to the decedent's intentionally placing one of these devices in his mouth. The second case involves a 46-year-old man who was found by his wife at his home. In the victim's facial wound, investigators recovered portions of a detonator blasting cap attached to electrical lead wires extending to his right hand. A suicide note was discovered at the scene. The appropriate collection of physical evidence at the scene of the explosion and a detailed examination of the victim's history is as important as documentation of injury patterns and recovery of trace evidence at autopsy. A basic understanding of the variety of explosive devices is also necessary. This investigatory approach greatly enhances the medicolegal death investigator's ability to reconstruct the fatal event as a means of separating accidental and homicidal explosive-related deaths from this uncommon form of suicide.
Factors Associated With Suicide Attempts in 648 Patients With Bipolar Disorder in the Stanley Foundation Bipolar Network.
Correspondence: Gabriele S. Leverich, Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health, Biological Psychiatry Branch, Bethesda, MD, USA; (email: gl12u@nih.gov)
CONTEXT: Clinical factors related to suicide and suicide attempts have been studied much more extensively in unipolar depression compared with bipolar disorder. We investigated demographic and course-of-illness variables to better understand the incidence and potential clinical correlates of serious suicide attempts in 648 outpatients with bipolar disorder.
METHODS: Patients with bipolar I or II disorder (DSM-IV criteria) diagnosed with structured interviews were evaluated using self-rated and clinician-rated questionnaires to assess incidence and correlates of serious suicide attempts prior to study entry. Clinician prospective ratings of illness severity were compared for patients with and without a history of suicide attempt.
FINDINGS: The 34% of patients with a history of suicide attempts, compared with those without such a history, had a greater positive family history of drug abuse and suicide (or attempts); a greater personal history of early traumatic stressors and more stressors both at illness onset and for the most recent episode; more hospitalizations for depression; a course of increasing severity of mania; more Axis I, II, and III comorbidities; and more time ill on prospective follow-up. In a hierarchical logistic regression, a history of sexual abuse, lack of confidant prior to illness onset, more prior hospitalizations for depression, suicidal thoughts when depressed, and cluster B personality disorder remained significantly associated with a serious suicide attempt.
DISCUSSION: Our retrospective findings, supplemented by prospective follow-up, indicate that a history of suicide attempts is associated with a more difficult course of bipolar disorder and the occurrence of more psychosocial stressors at many different time domains. Greater attention to recognizing those at highest risk for suicide attempts and therapeutic efforts aimed at some of the correlates identified here could have an impact on bipolar illness-related morbidity and mortality.
Correspondence: Dennis R. Durbin, Children's Hospital of Philadelphia, Division of Emergency Medicine, 34th St and Civic Center Blvd, Philadelphia, PA 19104, USA; (email: durbind@e-mail.chop.edu).
CONTEXT: Although more than a dozen states have ratified laws that require booster seats for children older than 4 years, most states continue to have child restraint laws that only cover children through age 4 years. Lack of booster seat effectiveness data may be a barrier to passage of stronger child restraint laws.
OBJECTIVES: To quantify the association of belt-positioning booster seats compared with seat belts alone and risk of injury among 4- to 7-year-old children and to assess patterns of injury among children in booster seats vs seat belts.
DESIGN, SETTING, AND POPULATION: Cross-sectional study of children aged 4 to 7 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 3616 crashes involving 4243 children, weighted to represent 56 593 children in 48 257 crashes was collected between December 1, 1998, and May 31, 2002.
MAIN OUTCOME MEASURE: Parent report of clinically significant injuries.
FINDINGS: Injuries occurred among 1.81% of all 4- to 7-year-olds, including 1.95% of those in seat belts and 0.77% of those in belt-positioning booster seats. The odds of injury, adjusting for child, driver, crash, and vehicle characteristics, were 59% lower for children aged 4 to 7 years in belt-positioning boosters than in seat belts (odds ratio, 0.41; 95% confidence interval, 0.20-0.86). Children in belt-positioning booster seats had no injuries to the abdomen, neck/spine/back, or lower extremities, while children in seat belts alone had injuries to all body regions.
DISCUSSION: Belt-positioning booster seats were associated with added safety benefits compared with seat belts to children through age 7 years, including reduction of injuries classically associated with improper seat belt fit in children.
Motorcycle casualties sustained during Daytona Beach Bike Week 2000: lessons learned.
- Kanny D, Schieber RA, Jones BH, Ryan GW, Sorensen BJ. Ann Emerg Med 2003; 41(6): 792-797.
Correspondence: Dafna Kanny, Georgia Division of Public Health, 2 Peachtree Street, Suite 14-493, Atlanta, GA 30303, USA; (email: dkanny@dhr.state.ga.us).
CONTEXT: In March 2000, an estimated 500,000 people attended an annual motorcycle rally in Daytona Beach, FL, where approximately 64,000 residents live year-round. The media reported 15 deaths during this 10-day event.
OBJECTIVES: To more comprehensively assess the extent of trauma and need for emergency medical care, we investigated all motorcycle crashes, regardless of outcome.
METHODS: Motorcycle-related crash data from local medical examiner, hospital, emergency medical services (EMS), and police sources were linked. Frequencies of crashes, injuries, hospitalizations, and deaths were determined, and EMS use data were analyzed.
FINDINGS: During Bike Week 2000, 570 people were involved in 281 motorcycle-related crashes. Two hundred thirty (40%) people were injured, of which 147 (64%) sought treatment in emergency departments, 72 (31%) were hospitalized, and 11 (5%) died. In crashes between motorcycles and passenger cars, individuals exposed as motorcycle occupants were 8.7 times more likely to be injured than car occupants (95% confidence limit 1.7, 15.7). Of 205 EMS dispatches for motorcycle-related crashes, two thirds resulted in transport to an ED. Data needed to assess known risk factors (eg, alcohol use, speed, lack of helmet use) were not routinely ascertained at either the crash site or ED.
DISCUSSION: Although fatalities first called attention to the problem, nonfatal injuries outnumbered deaths 20:1. The manpower resources of civil service and health resources could become overwhelmed or exhausted in circumstances in which many people are injured or killed throughout a relatively long period. The situation deserves future study. Better risk factor surveillance is needed to help prevent crashes.
Factors associated with severity of motorcycle injuries among young adult riders.
- Lin MR, Chang SH, Huang W, Hwang HF, Pai L. Ann Emerg Med 2003; 41(6): 783-791.
Mau-Roung Lin, PhD, Institute of Injury Prevention and Control, Taipei Medical University, 250 Wu-Hsing Street, Taipei 110, Taiwan, ROC; (email: mrlin@tmu.edu.tw).
OBJECTIVES: A cohort of 4,729 junior college students in Taiwan was studied to determine risk factors for increased severity of motorcycle injuries.
METHODS: Crash characteristics were collected by using self-administered questionnaires soon after a student was involved in a motorcycle crash. The proportional odds model with generalized estimating equations, with correlated ordinal responses for collisions categorized into not injured, mildly injured, and severely injured categories, was used to determine the odds of injury severity.
FINDINGS: A total of 1,889 motorcycle crashes involving 1,284 persons occurred over a 20-month period from November 1994 to June 1996. There were 1,339 noninjuries, 474 mild injuries, and 76 severe injuries. The adjusted odds ratio (OR) of rural to urban roads having a greater level of injury severity was 1.64. Compared with noncollisions, collisions with a moving car (adjusted OR=1.76), a parked car (adjusted OR 1.90), or another stationary object (adjusted OR=2.31) increased the odds for a greater level of injury severity. Riders using Sanyang (adjusted OR=1.63) and Yamaha (adjusted OR=1.39) motorcycles had greater odds of being involved in a crash with a greater level of injury compared with those riding Kymco motorcycles. Darkness (adjusted OR=1.65) and greater speeds (adjusted OR=1.63 to 4.69) also increased the odds of greater injury severity.
DISCUSSION: At the time of motorcycle crashes, factors such as being on rural roads, collisions with a heavier object, some motorcycle makes, darkness, and greater speeds increased the severity of motorcycle injuries among these young adult riders.
Age, flight experience, and risk of crash involvement in a cohort of professional pilots.
- Li G, Baker SP, Grabowski JG, Qiang Y, McCarthy ML, Rebok GW. Am J Epidemiol 2003; 157(10): 874-880.
Correspondence: Guohua Li, Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21205, USA; (email: ghli@jhmi.edu).
Federal aviation regulations prohibit airline pilots from flying beyond the age of 60 years. However, the relation between pilot age and flight safety has not been rigorously assessed using empirical data. From 1987 to 1997, the authors followed a cohort of 3,306 commuter air carrier and air taxi pilots who were aged 45-54 years in 1987. During the follow-up period, the pilots accumulated a total of 12.9 million flight hours and 66 aviation crashes, yielding a rate of 5.1 crashes per million pilot flight hours. Crash risk remained fairly stable as the pilots aged from their late forties to their late fifties. Flight experience, as measured by total flight time at baseline, showed a significant protective effect against the risk of crash involvement. With adjustment for age, pilots who had 5,000-9,999 hours of total flight time at baseline had a 57% lower risk of a crash than their less experienced counterparts (relative risk = 0.43, 95% confidence interval: 0.21, 0.87). The protective effect of flight experience leveled off after total flight time reached 10,000 hours. The lack of an association between pilot age and crash risk may reflect a strong "healthy worker effect" stemming from the rigorous medical standards and periodic physical examinations required for professional pilots.
Psychosocial health among young victims and offenders of direct and indirect bullying.
- van der Wal MF, de Wit CA, Hirasing RA. Pediatrics 2003; 111(6 Pt 1): 1312-1317.
Correspondence: Marcel F. van der Wal, Department of Epidemiology and Health Promotion, Institute for Research in Extramural Medicine, Amsterdam, NETHERLANDS (email: mvdwal@gggd.amsterdam.nl).
OBJECTIVE: To assess the association between bullying (both directly and indirectly) and indicators of psychosocial health for boys and girls separately.
STUDY DESIGN: A school-based questionnaire survey of bullying, depression, suicidal ideation, and delinquent behavior.
SETTING: Primary schools in Amsterdam, The Netherlands.
PARTICIPANTS: A total of 4811 children aged 9 to 13.
FINDINGS: Depression and suicidal ideation are common outcomes of being bullied in both boys and girls. These associations are stronger for indirect than direct bullying. After correction, direct bullying had a significant effect on depression and suicidal ideation in girls, but not in boys. Boy and girl offenders of bullying far more often reported delinquent behavior. Bullying others directly is a much greater risk factor for delinquent behavior than bullying others indirectly. This was true for both boys and girls. Boy and girl offenders of bullying also more often reported depressive symptoms and suicidal ideation. However, after correction for both sexes only a significant association still existed between bullying others directly and suicidal ideation.
DISCUSSION: The association between bullying and psychosocial health differs notably between girls and boys as well as between direct and indirect forms of bullying. Interventions to stop bullying must pay attention to these differences to enhance effectiveness.
