This report describes the investigation of parameters related to accidents in tunnels in the framework of the "Advanced Training System for Emergency Management" project A-TEAM. On this basis, the flow field is investigated within tunnels, and its effects on fire development and smoke concentration fields for these emergency cases are reconstructed. This is
achieved with the use of the Computational Fluids Dynamics (CFD) model CFX-5. This model has been applied for two tunnels in Switzerland: Belchen, a one-directional road tunnel,and Grauhotz, a bi-directional railway tunnel. The simulations identify the effects of the direction of trains/traffic on the resulting concentration fields, and show that at low ventilation areas, accident releases lead to increased concentration levels.
The time first-response fire fighters have to initiate care in a midsize city.
- Lerner EB, Billittier AJ, Moscati RM, Adolf JE. J Emerg Med 2003; 25(2): 171-174.
Correspondence: E.Brooke Lerner, Department of Emergency Medicine at the University of Rochester in Rochester, New York, USA; (email: unavailable).
The objective of this study was to determine whether simultaneously dispatched first-response firefighters (fire) arrive before transporting EMS providers (ambulance) and the amount of time fire has on scene to initiate care. Fire and ambulance dispatch records were obtained for all 9-1-1 responses from four 1-month intervals. Only incidents to which both agencies had been simultaneously dispatched were included. Response time for each agency was determined by subtracting the time of dispatch from the time of arrival. The difference between fire and ambulance response time was the time fire had to initiate care. Both agencies were simultaneously dispatched to 4752 incidents. Average response time for all incidents was 4.0 ± 2.6 min for fire and 5.3 ± 2.0 min for ambulance. Fire had 1.3 ± 3.2 min on average to initiate care. Fire arrived before ambulance for 69% (3262) of requests and for these calls had 2.8 ± 1.7 min on average to initiate care. Utilization of densely staged first-response fire apparatus in a midsize city may be appropriate because firefighters frequently arrive before ambulances and may have adequate time to initiate lifesaving interventions.
A conceptual model for analyzing the risks involved in the transportation of hazardous goods: implementation in a geographic information system.
The transportation of hazardous goods by road implies a risk for both humans and the environment, in that an accident involving a vehicle transporting this kind of material may cause extensive material and environmental damage and might even endanger lives. For this reason, both public and private entities (e.g., insurance companies) have a growing interest in studies that assess the risks associated with hazardous goods transportation.
This article describes a method for calculating these risks. The risk is determined on the basis of a calculation of the probability of the occurrence of an accident and the gravity of the damage, which is in turn a function of the potential damage inherent in the goods being transported taken with the vulnerability of the environmental medium in which the accident takes place. The mathematical model proposed is easily implemented in a geographical information system that will produce risk maps delimiting the more potentially conflictive stretches of roadway.
CONTEXT: In the decade between 1991 and 2000 there were 33,227 deaths from residential fires in the United States, of which 7,978 or 24% were in children less than 15 years of age. Children less than age 5 seem to be at particular risk, comprising 34% of children under 15, yet 61% of pediatric deaths. Fatalities from home fires are most common between the hours of 24:00 and
06:00, a time when the inhabitants are likely to be asleep.
Home fire alarms, responding to the presence of heat, smoke, or carbon monoxide, generally produce a pure tone of approximately 85 dB, which is sufficient to trigger an arousal in most sleeping adults. However, there are clear developmental variations in auditory arousal thresholds, and evidence that children may not arouse or awaken when presented with a pure tone signal of this amplitude.
OBJECTIVES: Underwriters Laboratories convened a panel with expertise in childhood sleep physiology and smoke alarm technology, to review current research and make recommendations for future areas of study.
METHODS: The panel members comprised a heterogeneous group of people, including some members with commercial interests in the topic of interest. Panel members reviewed the literature, including a computerized search of the National Library of Medicine's Medline database, supplemented with additional publications thought to be relevant.
This report is directed specifically towards school-aged children and adolescents. In infants producing an arousal will obviously be of no benefit, as they do not have the ability to rescue themselves. In very young children, producing an arousal may actually be counterproductive if it results in an inappropriate response (such as hiding in a closet). In this age group, the primary goal of a smoke alarm is to arouse the child's caregivers, who themselves need to have been educated to have made appropriate rescue plans in this eventuality. However, in older children smoke alarms have the potential to result in the child him/herself arousing and seeking safety.
FINDINGS: During sleep, most children less than ten years of age are developmentally incapable of arousing from a pure tone auditory stimulus of 85 dB to a level of wakefulness that can result in rapid performance of procedural tasks required to escape from fire/smoke hazards. Although adolescents are more likely to awaken to smoke alarms than younger children, evidence suggests that adolescents up to age 16 do not awaken consistently.
Pure tone auditory stimuli during sleep that do not cause full awakening may result in no response, confusional arousals or brief unsustained awakening. Objective, scientific data regarding arousal and/or awakening of children to other types of alerting stimuli are not available.
During sleep, an appropriate procedural response to a stimulus during a fire/smoke emergency requires sustained awakening with performance appropriate to extricate oneself from the hazard. Current data on the arousal threshold in children strongly support a lack of children's ability to wake to this level of alertness secondary to an auditory stimulus produced by commercially available smoke alarms. Furthermore, panic during emergency conditions may also adversely influence a child's behavior and performance.
COMMENTS: The majority of children between the ages of birth and five years are developmentally incapable of responding appropriately during fire/smoke emergencies. Caretaker rescue is the only reliable method to decrease morbidity and mortality in this age group. Children aged 5-16 years of age are unlikely to awaken fully to auditory stimuli currently produced by commercially available smoke alarms. There are no standardized scientific data exist regarding arousal and/or awakening to other types of non-biological stimuli in this age group. Therefore, pending further research, rescue is the only currently known reliable method to decrease morbidity and mortality in sleeping children when faced with a fire/smoke
emergency.
Prevention of drowning in infants, children, and adolescents.
Correspondence: R.A. Brenner, American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098, USA; (email: kidsdocs@aap.org).
Drowning is a leading cause of injury-related death in children. In 2000, more than 1400 US children younger than 20 years drowned. Most (91%) of these deaths were unintentional and were not related to boating. For each drowning death, it is estimated that at least 1 to 4 children suffer a serious nonfatal submersion event, many of which leave children with permanent disabilities. Environmental strategies, such as installation of 4-sided fences around swimming pools, and behavioral strategies, such as increased supervision of children while around water, are needed to prevent these tragedies.
Fatal occupational injuries among self-employed workers in North Carolina.
- Mirabelli MC, Loomis D, Richardson DB. Am J Ind Med 2003; 44(2): 182-190.
Correspondence:Maria C Mirabelli, Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; (email: mirabell@email.unc.edu).
CONTEXT: Research suggests that rates of occupational injury and death may be higher among self-employed workers than in the wage and salaried population.
OBJECTIVES: This analysis was conducted to describe the demographic and occupational characteristics, as well as injuries, activities, and occupations of self-employed workers who are fatally injured on the job.
METHODS: Characteristics of workers by type of employment were compared using data from the North Carolina Office of the Chief Medical Examiner, 1978-1994. Age-, activity-, and industry-specific fatality rates in self-employed workers (N = 395) were contrasted to those privately employed (N = 1,654).
FINDINGS: Highest fatal injury rates among the self-employed occurred in agriculture, retail, and transportation industries. Homicide deaths occurred more frequently among self-employed workers; deaths resulting from unintentional injuries occurred more frequently among non-self-employed workers.
COMMENTS: Elevated occupational fatality death rates among self-employed workers, especially in retail and transportation industries, provide justification for addressing work-related conditions of self-employed workers in North Carolina.
The role of distributed cognition in the causation of accidents.
The notion that, in many situations, cognition is distributed provides a significantly different perspective for understanding past failures in sociotechnical systems, and for reasoning about future risks. In this study a set of reports of accidents on offshore installations was analyzed in an attempt to discover how the distribution of cognition contributed to accident causation. The assumptions about the world implied in the various patterns of distribution were identified, and these were grouped in an attempt to say how distribution made systems vulnerable. A model was then developed to express some general observations: for example the fact that distribution was generally entrained in people's activity, not deliberately planned. A significant conclusion was that systems designers should use results of this kind in their risk analyses. In particular they should test how their systems are likely to respond to the kinds of flawed assumptions that were revealed in the study.
Wildland firefighter load carriage: effects on transit time and physiological responses during simulated escape to safety zone.
- Ruby BC, Ledbetter GW III, Armstrong DW, Gaskill SE. Int J Wildland Fire 2003; 12(1): 111-116.
Correspondence: Brent Ruby, Department of Health & Human Performance, University of Montana, 32 Campus Drive #4536, Missoula, MT 59812-4536, USA; (email: ruby@selway.umt.edu).
The purpose of this investigation was to determine the effects of load carriage on transit time during simulated escape route evacuation. Subjects (8 males, 5 females) completed two maximal field hikes in random order on two successive days (16 kg [35 lb] line gear pack trial and no pack trial). Subjects carried a fire shelter and a Pulaski (the most commonly used fireline construction tool in the United States, consisting of a hoe/ax combination with an 80 cm handle) during each trial. Trials were completed on a dirt trail 660.5 m in length with a vertical rise of 137 m (average grade = 20.75%). Expired air samples were analyzed continuously during each trial (Cosmed K4 or Aerosport VO2000). Blood samples were collected before and 2 min after exercise for lactate analysis. Transit time was significantly faster during the No pack trial, representing a 21.5 and 26.3% faster transit time for males and females, respectively. For the males, mean VO2 was higher during the No pack trial. The difference in blood lactate (peak-rest) was significantly higher during the Pack trial for the male subjects. High correlations between peak VO2 (L min-1) and transit rates were noted (r = 0.82 for the Pack trial and 0.87 for the No pack trial), indicating the contribution of aerobic fitness to transit time. These data suggest that escape routes should include a physical strain index related to load carriage, distance and slope and that line gear weight standards should be further evaluated.
CONTEXT: Improper bicycle helmet fit increases the risk of head injury. Information on the rate of proper use of bicycle helmets is lacking. Promotion of helmet use is recommended at well-child and adolescent visits. Actual helmet assessment during such visits has not been reported.
OBJECTIVES: The primary goal of this study is to measure the proportion of children whose helmets are in proper condition and can be made to fit properly by the child and/or parent. The secondary goal is to begin to assess the value and practicality of helmet inspection during well-child and adolescent visits.
METHODS: The study took place at a private pediatric office in Falmouth, Massachusetts, from June 1 through August 31, 2001. Eligible children and adolescents were those aged 4 to 18 years presenting for well examination, along with siblings present at the visit. Eligible families completed a questionnaire, then had a timed attempt to fit a helmet, followed by an assessment of helmet fit and condition against a predetermined standard.
FINDINGS: Eighty-four percent (395/473) of eligible families participated. A total of 479 participants were assessed. Eighty-eight percent of participants (419/478) owned a helmet. Reported helmet use "always" or "almost always" was 73% for bicycling (317/434), 69% for in-line skating (193/279), 58% for scootering (179/310), and 50% for skateboarding (79/158). Compared with younger children, teenagers were less likely to wear helmets for all activities. Complete pass rate for every aspect of condition and fit was 4% (20/478, 95% confidence interval: 3-6). The pass rate when the parent alone fit the helmet was 0% (0/52). Three individual aspects of fit were most problematic: 1) helmet 'resting position' too high on the forehead (pass rate 249/479; 52%), 2) improper strap position (pass rate 157/476; 33%), and 3) excessive movement of the helmet from front to back of the head (pass rate 247/479; 52%). Mean time for questionnaire completion was 4 (standard deviation: +/-1) minutes, and 7 (standard deviation: +/-3) minutes for helmet assessment.
COMMENTS: Ninety-six percent of children and adolescents wore helmets in inadequate condition and/or with inadequate fit. This occurred despite a high acceptance of helmet use by this population. Initial evidence suggests that helmet assessment during well visits may be practical and valuable.
Methodology for quantifying whole-body vibration experienced by bicyclists.
- Torbic D, El-Gindy M, Elefteriadou L. Int J Vehicle Des 2003; 31(4): 452-480.
Correspondence: Darren J. Torbic, Midwest Research Institute, 425 Volker Boulevard, Kansas City,
MO 64110, USA; (email: dtorbic@mriresearch.org).
This paper presents an examination of the fundamental relationships between rumble strip dimensions, bicyclists' perceptions of ride comfort and the controllability of a bicycle. These relationships were developed using data gathered during a study, the Bicycle-Tolerable Shoulder Rumble Strips project conducted at the Pennsylvania Transportation Institute and by gathering supplemental data to evaluate the ride quality of bicycles. These relationships will help highway agencies develop better rumble strips policies that consider the entire range of highway users. The research methodology consisted of 5 primary tasks.
First, a method was developed for quantifying whole-body vibration experienced by bicyclists. Second, the relationships between whole-body vibration, bicyclists' perceptions of comfort and the controllability of a bicycle were assessed. Third, a regression model was developed to explain how whole-body vibration varies with the dimensions of rumble strips, the characteristics of the bicycle and the characteristics of the bicyclist. Fourth, by modeling whole-body vibration and by understanding the relationship between whole-body vibration, comfort and control, the conditions that cause bicyclists to experience the highest levels of discomfort and control problems while traversing rumble strips were identified. Fifth, the ride characteristics of the bicycles were assessed using vehicle ride models. It is concluded that bicyclists' concerns of traversing rumble strips are warranted. Bicyclists can experience extremely high levels of whole-body vibration while traversing rumble strips and the analysis suggests the relationship between whole-body vibration and bicyclists' perceptions of
comfort is linear; as vibration increases comfort decreases. The analysis also indicates there is no clear relationship between whole-body vibration and the controllability of a bicycle. It is also concluded that whole-body vibration increases with unit increases in groove depth and tire pressure, while whole-body vibration decreases with unit increases in groove spacing. In addition, a bicyclist experiences the highest levels of whole-body vibration while traversing rumble strip configurations at a speed of approximately 20 km/h. Finally, bicycles without active suspensions exhibit poor vibrational characteristics because the oscillation centers of the bicycles are not located near the optimum location for a good ride.
Comparison of live skit and video delivery styles using presentations with and without fluorescent tracer dyes at pesticide applicator training for promotion of self-protection from dermal exposure.
Program delivery has a major impact on pesticide applicators' reception to learning. This study evaluated the impact of different training delivery styles, with and without the demonstration of fluorescent tracers, on dermal pesticide exposure. Three delivery styles were each tested at three large-group pesticide license recertification courses: live fluorescent tracer dye skit, video-taped dye presentation, instructional video. The target pesticide applicator group (764 people) comprised active, non-agricultural applicators that were similar in terms of group size, response rate, age, gender, employer type, and applications performed. Results of the ANOVA tests on eight questionnaire outcome variables showed that the live fluorescent tracer dye skit produced significantly greater positive responses (p < 0.05) than the other two delivery styles and that the taped dye presentation produced greater responses than the instructional video.
Pesticide safety education centers: a feasibility study.
Correspondence: Barry M. Brennan, Extension Pesticide Coordinator, Plant and Environmental Protection Science Department, Gilmore Hall 310, 3050 Maile Way, University of Hawaii, Honolulu, HI 96822, USA; (email: barry@hpirs.stjohn.hawaii.edu).
Pesticide education and safety training are critical to reducing personal and environmental exposure to pesticides. It is essential that pesticide safety instructors and state regulatory personnel be able to demonstrate an understanding of pesticide use, classification, regulation, toxicology, and environmental fate. Their credibility with applicators and the general public also requires that they develop effective communication and instructional skills. The feasibility of establishing Pesticide Safety Education Centers to train extension pesticide safety instructors and state and federal regulatory personnel was examined. Possible instructors and trainee groups were identified, mission and goals of a PSEC were defined, existing training models were examined, staff requirements were considered, sources of funding were explored, and a training evaluation system was suggested.
This study examined the relations between risk cognitions and risk behavior. Adolescents' perceptions of the risks associated with driving after drinking (DAD) and their perceptions of the prevalence of this behavior among their peers were assessed, and these perceptions were used to predict their DAD behavior. Results provided evidence of a type of cognitive social influence: the more common adolescents thought the behavior was, the less risk, both personal and general, they attributed to it. As expected, however, this relation was significant only for those who were high in a tendency to engage in social comparison. Perceptions of risk, in turn, were prospectively related to risk behavior for all participants. Specifically, low perceived risk, especially personal risk, was associated with an increase in DAD behavior. Implications of the results for DAD interventions are discussed.
Epidemiology of non-submersion injuries in aquatic sporting and recreational activities.
- Chalmers D, Morrison L. Sports Med 2003; 33(10): 745-770.
Correspondence: David Chalmers, Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, NEW ZEALAND; (email: david.chalmers@ipru.otago.ac.nz).
Although the issues of drowning and near-drowning in aquatic sporting and recreational activities receive considerable attention in the epidemiological literature, there is not a recognised literature on non-submersion injuries occurring in these activities. This review draws together the epidemiological literature on non-submersion injuries and describes the incidence, nature and causes of these injuries, common risk factors, and strategies for prevention.Activities covered by the review include swimming, diving, boating, surf sports, fishing, water polo and water sliding. For most activities there is a dearth of good quality descriptive studies, with most involving cases-series designs and few providing estimates of incidence. Inconsistencies in inclusion criteria and the reporting of incidence rates makes comparisons within and between activities difficult. Incidence rates were identified for most activities and in general the incidence of injury was low, especially for more serious injury. However, some activities were associated with severely disabling injury, such as spinal cord injury (diving) and amputation (from propeller strikes in water skiing and swimming).Only three studies reporting the significance of postulated risk factors were identified. Lack of knowledge about the water being entered and alcohol consumption are significant risk factors in recreational diving; increased blood alcohol concentrations were reported to increase the risk of death in boating; and obesity and tandem riding were reported to increase the risk of injury on public water slides. Few evaluations of preventive measures were identified. Two studies reported reductions in the incidence of water slide injuries following the introduction of design changes and supervision, but neither had a non-intervention comparison group. Improvements in swimming and diving skills were reported in three studies, but these were not designed to measure changes in the risk of injury.This review demonstrates that there is a need for well-designed epidemiological research on non-submersion injury in aquatic sporting and recreational activities. The first priority should be for studies designed to describe accurately the incidence, nature, severity and circumstances of these injuries, followed by research on the significance of postulated risk factors. Once this research has been undertaken, interventions targeted at reducing the incidence of injury in aquatic sporting and recreational activities can be designed and evaluated.
CONTEXT: Skiing is a sport that has exploded in popularity over the past 20 years. There are estimated to be 200 million skiers worldwide.
OBJECTIVE: This article outlines the type and prevalence of ski injuries, and measures that have been made to reduce the incidence of injuries to skiers.
FINDINGS: The incidence of injury has decreased with the development of improved equipment, resort management and skier preparation. This decrease has been reflected in a lower rate of foot, ankle and tibial injuries. The overall incidence of knee injuries has increased and in particular an increase in more serious knee injuries. Snowboard injuries now account for approximately half the presentations to ski resort medical centres.
Correspondence: Paul D. Kiely, Department of Orthopaedic Surgery, The Adelaide and Meath Hospital (AMNCH), Tallaght, 24, Dublin, IRELAND; (email: paul.kiely@amnch.ie).
Hurling is a contact sport, associated with significant morbidity. We have identified specific hand injuries sustained by participants and quantified the functional and financial implications of these injuries. Over a 3-month period, all hand injuries seen in the fracture clinic of our regional trauma unit were studied prospectively. Of the 123 consecutive injuries, 41 (33%) were sustained during hurling matches. Metacarpal (47%) and proximal phalangeal (37%) fractures were the most frequent. Eight hurlers (20%) required surgical intervention. Only four (10%) of the injured players were wearing hand protection. The mean cost of injury to the player was pound 615. We suggest the introduction of the mandatory use of hand protection for hurling.
- Jaslow D, Ufberg J, Marsh R. J Emerg Med 2003; 25(2): 167-170.
Correspondence: David Jaslow, Department of Emergency Medicine, Episcopal Division, Temple University, 100 E. Lehigh Avenue, Philadelphia, PA 19125, USA; (email: Djaslow@nimbus.ocis.temple.edu).
Injury prevention is increasingly recognized as an important part of health care delivery. Emergency Medical Services (EMS) personnel may be called upon to deliver primary injury prevention (PIP) by educating both patients and peers about how to avoid future similar injury. The purpose of this study was to determine EMS provider attitudes toward PIP and knowledge and practice of PIP during day-to-day clinical work. A brief survey was administered to a sample of paramedics assessing their attitudes toward primary injury prevention, how often they practice it, and whether or not they have received any PIP education during their training. One hundred sixty-two paramedics completed surveys. Of those surveyed, 70% believe that PIP should be a core mission of EMS systems, and 82% believe PIP should be implemented at the local or regional level. However, only 33% routinely educate their patients how to modify injury risk behaviors, and only 19% routinely provide instruction about proper use of protective devices. Approximately 63% of our paramedics received any PIP education during their training. A majority of paramedics in our survey believe that PIP should be a routine part of EMS. However, many paramedics have not received any PIP education, and few paramedics practice PIP during their clinical practice.
A study of the investigation of death (coroner system) in Sri Lanka.
- Fernando R. Med Sci Law (not on-line). 2003; 43(3): 236-240.
Correspondence: R. Fernando, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, SRI LANKA; (email: unavailable).
Sri Lanka (Ceylon) inherited the 'coroner system' of investigating death in the early nineteenth century. Unlike in England and Wales, the coroner system in Sri Lanka did not change much in the last century. This study, the first of its kind, was performed for a period of three months in 1995 to analyse the causes and circumstances of deaths reported for inquest, and the number of autopsies performed. Of the 868 cases reported to the Inquirer, the circumstances were not determined in 94 cases at the initial inquest proceedings. Of the other 774 cases, 454 (58.7%) were natural deaths. Autopsies were performed on 44.5% of natural deaths, 58.2% of accidental deaths, 96% of road traffic accidents, 44.9% of suicides and 81.6% of homicides. Coronary heart disease was the leading cause of natural death (33.9%). Head injuries were responsible for 31.8% of accidental deaths while burns accounted for 24.5% of accidental deaths and 46.3% of suicides. There were 38 cases (4.9%) of homicide of which autopsies were performed in 31. There is an urgent need to reform the century-old laws relating to inquest procedures in the country.
Evaluation of fire danger rating indexes using logistic regression and percentile analysis.
- Andrews PL, Loftsgaarden DO, Bradshaw LS. Int J Wildland Fire 2003; 12(2): 213-226.
Correspondence: Patricia L. Andrews, US Forest Service, (email: pandrews@fs.fed.us).
Methods are presented for analyzing the relationship between fire danger rating indexes and fire activity as a means of evaluating the performance of fire danger rating systems. Percentile analysis is used to examine the data itself; logistic regression provides a means for statistical analysis. Ranking of selected items indicates indexes that deserve further assessment using subjective considerations. Methods rely on generally available data: the fire danger index for every day in the fire season, fire discovery date, and final fire size. For logistic regression analysis, the independent variable is the index, and dependent variables are fire-day, large-fire-day, and multiple-fire-day. Data analysis methods have been incorporated into the FireFamily Plus computer program for easy application. Potential uses of the analysis include choosing the most appropriate fire danger index and fuel model for an area, evaluating proposed changes to a fire danger rating system, and assessing the performance of a system in a location other than that for which it was designed. As a demonstration, this technique was applied to evaluation of several indexes and fuel models of the U.S. National Fire Danger Rating System on the Tonto National Forest in Arizona, USA, using fire and weather data for 1974-2001.
Correspondence: Danny G. Kaloupek, VA Boston Healthcare System and Department of Psychiatry, National Center for PTSD, Boston University School of Medicine, Boston, Massachusetts 02130, USA; (email: kaloupek@med.va.gov).
Lifetime exposure to traumatic events was assessed by means of a multimethod protocol applied to 76 male military veterans. Consistency of retrospective reporting was determined for physical and sexual assault and abuse, accidents, disasters, combat and warzone experiences, serious illness or injury, and hazardous duty. Findings demonstrate that respondents are generally consistent in reporting traumatic events, although the majority report more events upon reevaluation. Reporting about traumatic events shows some variation as a function of the life epoch in which events occurred, whether they were directly or indirectly experienced, and the type of trauma involved. Discussion addresses memory-related processes triggered by trauma evaluation or tied to characteristics of events themselves as potential sources of inconsistency.
Neighborhood characteristics and emergency department utilization.
- Li G, Grabowski JG, McCarthy ML, Kelen GD. Acad Emerg Med 2003; 10(8): 853-859.
Correspondence: Guohua Li, Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21205, USA; (email: ghli@jhmi.edu).
OBJECTIVES: Neighborhood environments have been linked to the prevalence and incidence rates of a variety of diseases and injuries. This study assessed the relations between neighborhood demographic and socioeconomic characteristics and emergency department (ED) utilization.
METHODS: Billing data for the calendar year 2000 for adult patients residing within a one-mile radius of the study ED were geo-coded based on home addresses and merged with neighborhood data from the U.S. Census Bureau. Annual ED visit rates per 100 population were computed for each census block within the study area and analyzed in relation to neighborhood characteristics.
FINDINGS: The study area consisted of 714 census blocks and 42,278 adult residents, with a total of 16,427 visits to the study ED. Annual ED visit rates increased from 17 visits per 100 population for neighborhoods where less than 50% of the population were African American to 51 visits per 100 population for neighborhoods where all residents were African American (p < 0.001). Annual ED visit rates decreased from 53% for neighborhoods where <20% of housing units were owner-occupied to 27% for neighborhoods with >45% owner occupied housing units (p < 0.001). Multivariate linear regression modeling revealed that proportions of African American residents and owner-occupied housing units were significantly associated with ED utilization, independent of age and gender compositions and the distance between residence and the study ED.
COMMENTS: Even within a small geographic area, ED utilization may vary greatly by neighborhood characteristics. Neighborhood racial composition and housing tenure are independent predictors of ED visit rates in this urban community.
Gender-related traumatic deaths in Transkei: incidence and causes.
- Meel BL. Med Sci Law (not on-line). 2003; 43(3): 215-220.
Correspondence: B.L. Meel, Department Forensic Medicine, Faculty of Health Sciences, University of Transkei P/bag X1 Unitra, Umtata 5100, SOUTH AFRICA; (email: meel@getafix.utr.ac.za).
This study is unique in that it strives to unfold, perhaps for the first time, the problem of female mortality due to trauma in the Transkei region of the Eastern Cape Province of South Africa. This study was carried out in the Umtata and Ngqeleni magisterial districts which have a combined population of about 400,000. Most of the people have very few resources and have historically relied on money repatriated by migrant workers. The objective was to establish the incidence and the causes of deaths due to gender-related trauma and to formulate recommendations which could probably help prevent or reduce these deaths. The study reviewed cases of female traumatic death during the period January 1993 to December 1999 that were brought to the mortuary in Umtata General Hospital (UGH). There were 1,054 (23%) traumatic deaths recorded in females between 1993 and 1999. Of these 486 (28%) were related to motor vehicle collisions, 219 (18%) due to gunshot injuries, 152 (19%) due to stab wounds and 139 (21%) as a result of blunt trauma. The male to female ratio was 3.3:1 in traumatic deaths. In homicides the male:female ratio was 4.4:1, gunshot 4.5:1, stab 4.2:1 and blunt injuries 3.7:1. In motor vehicle collisions (MVC's) the ratio was 2.5:1. There is an increasing incidence of traumatic deaths in women. Gun shot injuries are the commonest among traumatic deaths in females. This article recommends stricter measures to protect women in the form of legislation. Social uplifting and economic support should be carried out as part of the process of social change. In this case educating the entire community is necessary to safeguard women and their future survival.
Causes and circumstances of injuries in children.
- Borzecki A, Lukawski K, Robak L, Borzecka H, Sieklucka-Dziuba M. Ann Univ Mariae Curie Sklodowska [Med]. 2002; 57(1): 421-425.
Correspondence: A. Borzecki, Department of Hygiene, Department of Pediatric Nephrology, Medical University of Lublin, POLAND; (email: unavailable).
The problem of the incidence of traumas among children is still topical and statistical data confirm an increasing tendency in the last decades. The purpose of the work was to estimate the causes and circumstances of injuries in children at the age of 7 to 15, who were admitted to Surgical Ward of Specialist Paediatric Hospital in Kielce between 30th June 1997 and 30th June 1998. A retrospective analysis of medical documentation concerned 768 patients. Our studies showed that the biggest number of injuries was related to children 10-12 years old (46%). The majority of patients were boys. Most injuries occurred in summer (33%). In the studied population dominant were accidents at home (56%) and then road accidents (18%), injuries at school (13%) and on farms (7%). Accidents and injuries occurred more often in children from the rural areas (53%).
Liver injury in children: causes, patterns and outcomes.
- Wakeman C, Beasley S, Pearson S, Frizelle F, Gooding A, Sharr J, Dobbs B. N Z Med J 2003; 116(1178): U515.
Correspondence: Christopher Wakeman, Department of General Surgery, Christchurch Hospital, Christchurch, NEW ZEALAND; (email: unavailable).
OBJECTIVE: To compare the causes, patterns and outcomes of hepatic trauma in children with those in adults.
METHODS: A retrospective audit was conducted of a five-year period from 1996 of adults and children admitted to Christchurch Hospital with liver injuries. Details of age, mechanism of injury, injury severity score (ISS), radiological grade of liver injury, operations and mortality were recorded and analysed.
FINDINGS: There were 93 liver injuries over the five-year period: 22 in children and 71 in adults. The median age of each group was 7 and 29 years respectively. The most common causes of injury in children were bicycle (7/22) and motor vehicle accidents (MVAs) (7/22). The majority (37/71) of adult injuries were caused by MVAs. The median length of hospital stay was significantly shorter in the paediatric group: 4 days (range 1-12) in children vs 9 days (range 0-52) in adults.
COMMENTS: Liver trauma in children has a different spectrum of causes, and results in more severe liver injury than in adults. However, children are more likely to have an isolated liver injury that results in a shorter length of stay in hospital. A nationwide paediatric-injury surveillance system might allow better identification of preventable causes of injury.
Identity, activity, and the well-being of adolescents and youths: lessons from young people in a Micronesian society.
Correspondence: Edward D. Lowe, Center for Culture and Health, University of California, Los Angeles, 760 Westwood Plaza C9-752 NPI, Los Angeles, CA 90095-1759, USA; (email: elowe@ucla.edu).
Comparative studies of the health, well-being, and social functioning of adolescents and youths have, in the past two decades, been focused on young people in developing countries where rapid social, cultural, and economic changes have been associated with dramatic increases in the rates of social problems indicative of poorer mental health. Young people in many Pacific Island societies suffer from some of the highest rates of social problems like suicide and substance abuse in the world. It is generally agreed that the increases in rates of social problems among youths in this region result from increases in psychosocial stress, anger, and frustration surrounding intergenerational conflict within the family. Much less is known about the aspects of everyday experiences of young people in the Pacific that can lead to psychosocial stress and the angry episodes of interpersonal conflict that often precede suicide attempts and binge drinking. This paper examines 40 cases of interpersonal conflict in young men's and women's experiences in the islands of Chuuk of the Federated States of Micronesia to better understand what can lead to elevated levels of psychosocial stress for youths in the Pacific. This study shows that the emotional crises of young people in Chuuk often emerge from the incongruence in their pursuit of valued personal and social identities within the family, the community, and the peer group. Thus youths who experience more incongruity in their engagements across the multiple activity settings of everyday life are at greater risk for stressful experiences.
Developing a school functioning index for middle schools.
- Birnbaum AS, Lytle LA, Perry CL, Murray D, Story M. J Sch Health 2003; 73(6): 232-238.
Correspondence: A.S. Birnbaum, Dept. of Public Health, Weill Cornell Medical College, 411 East 69th St., Room KB-209, New York, NY 10021, USA; (email: asb2006@med.cornell.edu).
Despite widespread recognition of schools' role in the healthy development of youth, surprisingly little research has examined the relationships between schools' overall functioning and the health-related behavior of students. School functioning could become an important predictor of students' health-related behavior and may be amenable to intervention. This paper describes the development and testing of the School Functioning Index (SFI) as a first step in investigating this question. The index was developed for use with middle schools and conceived as a predictor of students' violent behavior, with the potential for extending research applications to additional health and social behaviors. Using social cognitive theory, social ecological theory, and social disorganization theory as guides, three domains were identified to operationalize school functioning and identify candidate SFI items: 1) resources available to the school and students; 2) stability of the school population; and 3) the schools' performance as a socializing agent for students. Data for candidate SFI items were collected from public archives and directly from 16 middle schools participating in a school-based dietary intervention study. Data collection from schools, particularly concerning student aggressive behavior and disciplinary actions, presented challenges. The final SFI comprised nine items and demonstrated good internal consistency and variability. The SFI was modestly correlated in expected directions with violence and other health behaviors. This work supports the feasibility of combining multiple school-level indicators to create a measure of overall school functioning. Further investigation of validity and more acceptable data collection methods are warranted.
Urban-rural differences in suicide trends in young adults: England and Wales, 1981-1998.
- Middleton N, Gunnell D, Frankel S, Whitley E, Dorling D. Soc Sci Med 2003; 57(7): 1183-1194.
Correspondence: N. Middleton, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, BS8 2PR, Bristol, UK; (email: unavailable).
Suicide rates amongst young people, particularly males, have increased in many industrialised countries since the 1960s. There is evidence from some countries that the steepest rises have occurred in rural areas. We have investigated whether similar geographical differences in trends in suicide exist in England and Wales by examining patterns of suicide between 1981 and 1998 in relation to rurality. We used two complementary population-based indices of rurality: (1) population density and (2) population potential (a measure of geographic remoteness from large concentrations of population). We used the electoral ward (n=9264, median population aged 15-44: 1829) as the unit of analysis. To assess whether social and economic factors underlie rural-urban differences in trends we used negative binomial regression models to investigate changes in suicide rates between the years for which detailed national census data were available (1981 and 1991). Over the years studied, the most unfavourable trends in suicide in 15-44-year olds generally occurred in areas remote from the main centres of population; this effect was most marked in 15-24-year-old females. Observed patterns were not explained by changes in age- and sex-specific unemployment, socio-economic deprivation or social fragmentation. The mental health of young adults or other factors influencing suicide risk may have deteriorated more in rural than urban areas in recent years. Explanations for these trends require further investigation.
Self-inflicted abdominal stab wounds.
- Abdullah F, Nuernberg A, Rabinovici R. Injury 2003; 34(1): 35-39.
Correspondence: Section of Trauma and Surgical Critical Care, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, LH 118, New Haven, CT 06520-8062, USA; (email: reuven.rabinovici@yale.edu).
CONTEXT: Self-inflicted abdominal stab wounds (ASWs) are uncommon. The present study aims to characterize the clinical profile of this unique group of psychiatric-surgical patients.
METHODS: A retrospective review of 23 patients with intentional self-inflicted ASWs at two urban level I trauma centers during a 10-year period.
FINDINGS: Most patients were males (70%), ages ranging from 21 to 82 years (mean 40 years). Seventy-four percent of patients had a previous psychiatric history and prior suicide attempts were common (41%). Half of the patients had a positive admission drug or alcohol screen. Hypotension (systolic blood pressure (SBP) < 90 mmHg) was present in only two patients. Mean injury severity, revised trauma and Glasgow coma scores were 5.8, 7.7 and 14.5, respectively. The most commonly used instrument was a knife (87%). There were 1.5 external wounds per patient located primarily in the right upper quadrant (40%) and right lower quadrant (23%). These were associated with extra-abdominal wounds in 22% of cases. Local wound exploration was positive in 15 patients (65%), who all underwent laparotomy. Injured intra-abdominal or retroperitoneal organs were identified in 10 patients and included the stomach, duodenum, small bowel, colon, mesentery, inferior vena cava (IVC) and psoas muscle with a mean of 1.7 injuries per patient. Wound infection was the only post-operative complication (two patients). All eight patients with a negative local wound exploration were observed without complication. Seventy percent of patients were ultimately transferred to a psychiatric ward with a mean length of stay on the surgical service of 8 days. Only one patient died during admission due to metastatic malignant disease.
COMMENTS: Self-inflicted ASWs in suicidal patients can induce significant although most likely non-lethal abdominal and retroperitoneal injuries. This observation should guide the trauma surgeon when treating such patients.
Are seasonalities in suicide dependent on suicide methods? A reappraisal.
- Ajdacic-Gross V, Wang J, Bopp M, Eich D, Rossler W, Gutzwiller F. Soc Sci Med 2003; 57(7): 1173-1181.
Correspondence: Vladeta Ajdacic-Gross, Institute of Social and Preventive Medicine, University of Zurich, Sumatrastr. 30, CH-8006, Zurich, SWITZERLAND; (email: k320256@ifspm.unizh.ch).
In general, suicide frequencies peak in spring and early summer and depict a low in autumn and winter months. Suicide seasonality is a ubiquitous phenomenon; however, recent studies have indicated that it is related particularly to violent suicide methods. We investigated differences in suicide seasonalities by suicide methods using Swiss mortality data. The suicide data were extracted from the Swiss cause of death statistics and cover the period 1969-1994. In this period 37,518 suicides (ICD-8 codes 950-959) were registered in the mortality statistics. The data were analysed by the Edwards' method, which examines unimodal sinusoidal patterns in aggregated monthly data, and by spectral analysis with disaggregated monthly data. Overall, Swiss suicide data in 1969-1994 depict the expected pattern with a peak in May and June and a low in December. However, analyses by suicide methods show that there is no common pattern. Suicide seasonalities are absent or weak in some violent as well as non-violent methods (firearms, cutting, crashing, poisoning). Even if clearly present (hanging, drowning, jumping from high places, unspecified/other), the seasonalities show distinct patterns and cycles. Apart from sinusoidal patterns, there are also outliers: in overall data as well as in most method-specific data, the December frequencies fall more than 10% below the neighbouring months. The decrease of the frequencies culminates at Christmas/New Year and then returns to average levels. Hence, the seasonality of the overall Swiss suicide frequencies is but a compound seasonality. It largely depends on specific suicide methods and different cyclical dynamics.
Family history of suicide among suicide victims.
- Runeson B, Asberg M. Am J Psychiatry 2003; 160(8): 1525-1526.
Correspondence: Bo Runeson, Institute of Clinical Neuroscience, Karolinska Institute, Department of Psychiatry, St Goran's Hospital, SE-112 81 Stockholm, SWEDEN; (email: unavailable).
OBJECTIVE: The aim was to compare the rates of suicide in family members of suicide victims and comparison subjects who died of other causes.
METHOD: The Swedish cause of death register identified all suicides in subjects born between 1949 and 1969 (N=8,396). The comparison group comprised persons of the same age who died of other causes (N=7,568). First-degree relatives of the suicide victims (N=33,173) and comparison subjects (N=28,945) were identified.
FINDINGS: Among families of the suicide victims there were 287 suicides, representing 9.4% of all deaths in family members. Among comparison families there were 120 suicides, 4.6% of all deaths. The difference was significant. Previous psychiatric care and suicide in a family member predicted suicide in the logistic regression model.
DISCUSSION: The rate of suicide was twice as high in families of suicide victims as in comparison families. A family history of suicide predicted suicide independent of severe mental disorder.
Deliberate self-harm in a nonclinical population: prevalence and psychological correlates.
- Klonsky ED, Oltmanns TF, Turkheimer E. Am J Psychiatry 2003; 160(8): 1501-1508.
Correspondence: E. David Klonsky, University of Virginia, Department of Psychology, 102 Gilmer Hall, P.O. Box 400400, Charlottesville, VA 22904-4400, USA; (email: klonsky@virginia.edu).
OBJECTIVE: Research on deliberate self-harm (intentionally injuring oneself without suicidal intent) has focused on clinical and forensic populations. Studying only these populations, which typically have serious psychopathology, may lead to inflated estimates of the association between self-harm and psychiatric disorder, as well as of the prevalence of deliberate self-harm. The present study investigated the prevalence and correlates of deliberate self-harm in a large group of nonclinical subjects.
METHOD: Participants were 1,986 military recruits, 62% of whom were men, who were participating in a study of peer assessment of personality traits and pathology. Individuals who did and did not report a history of self-harm were compared on measures of personality and psychopathology.
FINDINGS: Approximately 4% of the participants reported a history of deliberate self-harm. Compared with participants without a history of deliberate self-harm, self-harmers scored higher on self- and peer-report measures of borderline, schizotypal, dependent, and avoidant personality disorder symptoms and reported more symptoms of anxiety and depression. Item-level analyses indicated that peers viewed self-harmers as having strange and intense emotions and a heightened sensitivity to interpersonal rejection.
COMMENTS: About one of every 25 members of a large group of relatively high-functioning nonclinical subjects reported a history of self-harm. Self-harmers had more symptoms of several personality disorders than non-self-harmers, and their performance across measures suggested that anxiety plays a prominent role in their psychopathology. Future research should investigate whether psychotherapies or psychiatric medications known to reduce symptoms of anxiety can be effective in treating deliberate self-harm.
Peripubertal suicide attempts in offspring of suicide attempters with siblings concordant for suicidal behavior.
- Brent DA, Oquendo M, Birmaher B, Greenhill L, Kolko D, Stanley B, Zelazny J, Brodsky B, Firinciogullari S, Ellis SP, Mann JJ. Am J Psychiatry 2003; 160(8): 1486-1493.
Correspondence: David A. Brent, Western Psychiatric Institute and Clinic, Pittsburgh, PA 15213, USA; (email: brentda@msx.upmc.edu).
OBJECTIVE: The authors sought to determine 1) whether the risk for familial transmission of suicidal behavior is greater with increased family loading for suicide attempts, and 2) whether the transmission of suicidal behavior is mediated by impulsive aggression.
METHOD: A reanalysis of a high-risk study compared the offspring of three mood disorder proband groups: suicide attempters with a sibling who also attempted suicide (N=19), suicide attempters whose siblings never made a suicide attempt (N=73), and nonsuicidal probands whose siblings also never engaged in suicidal behavior (N=73). Probands and offspring were assessed with respect to psychopathology, suicide attempt history, impulsive aggression, and exposure to familial adversity.
FINDINGS: Offspring of suicide attempters with siblings concordant for suicidal behavior showed a higher risk of suicide attempt than did offspring of nonsuicidal probands and had an earlier age at onset of suicidal behavior than offspring of suicide attempters with siblings discordant for suicidal behavior. Probands from sibling pairs concordant for suicidal behavior and their offspring reported greater lifetime impulsive aggression compared with each of the other two proband/offspring groups. In the offspring, impulsive aggression was the most powerful predictor of early age at first suicide attempt.
COMMENTS: Familial loading for suicide attempts may affect rates of transmission as well as age at onset of suicidal behavior, and its effect may be mediated by the familial transmission of impulsive aggression.
Suicides in northern India: causes, methods used and prevention.
- Sharma BR, Sharma V, Harish D, Vij K. Med Sci Law (not on-line). 2003; 43(3): 221-229.
Correspondence: B.R. Sharma, Department of Forensic Medicine, Govt. Medical College and Hospital, Sector 32, Chandigarh-160030 INDIA; (email: drbrsharma@yahoo.com).
Suicide patterns and rates differ in various populations and cultures. It has been reported that developing countries have lower suicide rates, possibly because of a lower level of environmental stress but the Indians have a very high suicide rate (Elfawal, 1999). The choice of method used to commit suicide depends on availability of means, knowledge about lethal effectiveness, and the victim's motivation and intent. The present work was designed to investigate the different methods of self-destruction, the age and gender susceptibility to suicide, the groups particularly affected and the underlying motivating factor for such an extreme step among the North Indians. Various suggestions relating to decreasing the tensions of the modern mechanical life-style, educating the public in general and the availability, use and storage of agrochemicals have been put forward. Marriage counselling and the concept of family planning are also advocated.
Climatic and diurnal variation in suicide attempts in the ED.
- Doganay Z, Sunter AT, Guz H, Ozkan A, Altintop L, Kati C, Colak E, Aygun D, Guven H. Am J Emerg Med 2003; 21(4): 271-275.
Correspondence: Zahide Doganay, Department of Emergency Medicine, Ondokuz Mayis University, School of Medicine, Samsun, TURKEY; (email: zahidedoganay@yahoo.com).
The aim of this study was to determine whether there is a relationship between climatic factors and suicidal behavior. A total of 1,119 suicide attempts were collected from hospital records between 1996 and 2001. A clear seasonal variation was seen in suicide attempts in the 15-24, 25-34, and over 65 age groups in men and in the 15-24, 25-34, and 35-44 age groups in women with peaks in the spring and summer. Suicide attempts were more frequent between the hours of 6:00-9:00 pm in males and 3:00-6:00 pm in females. People attempting suicide who have depression, anxiety, or a psychotic disorder usually attempt suicide in the summer. Whereas the monthly averages of humidity, ambient temperature, duration and intensity of sunlight were positively correlated with the number of monthly suicide attempts, cloudiness and atmospheric pressure were negatively correlated. In conclusion, we must keep in mind that suicides and suicide attempts are not only the effect of climatic changes and that the most important component is the individual's ability to deal with conflicts.
Female suicides in major Texas cities, 1994 through 1998.
- Doddakashi V, Wilcox RE, Hauser LA. Tex Med 2003; 99(7): 50-58.
Correspondence: V. Doddakashi, Austin Psychiatry Residency Program, Austin State Hospital, Austin, Texas, USA; (email: unavailable).
From 1976 to 1985, Texas ranked first among states in the proportion of injury deaths caused by firearms, with an annual rate of 21.2 per 100,000. From 1995 to 1997, suicide was the eighth leading cause of death in Texas, claiming 2137 lives and accounting for 20% of all injury deaths in Texas. Firearm injuries significantly affect mortality rates in many states. The rates of suicide have continued to rise, particularly in young adults, and the rate of suicide by firearms has also increased significantly throughout the United States. We have focused on the most common method of suicide by age and race among women in Texas from 1994 through 1998. This work extended that of Li et al on suicide in Austin, Travis County, Texas, from 1994 through 1998. Those investigators found that the most common method of suicide in females was by firearms. In this current study, we asked whether the Austin data for females were unique or were representative of other major cities in Texas, including Dallas, El Paso, Houston, and San Antonio. Our major finding was that the use of firearms was the most common method of suicide among women in all of these cities. Women aged from 35 to 44 years had the highest incidence of deaths, followed by those aged from 45 to 54 years. Hispanic women had the lowest rate of suicide compared with African American and white women. Overall, rates of suicide among white males and females are at or higher than the US average in all Texas cities examined, except Dallas. Suicide rates among African-American males are at or below the US average, whereas the suicide rate for African-American females exceeds the national average. Nationwide rates for Hispanics were not available.
This paper uses a set of "natural experiments," created by the passage of a U.S. Department of Transportation drug-testing mandate and 13 state testing laws, to examine the effects of testing truckers for illicit substances on highway safety. Since truckers do not bear the full costs of their driving and employers cannot contract on all aspects of their behavior, drug testing may be one means for companies to either screen or monitor employees and lower expected accident costs. Indeed, I find that testing led to a 910 percent reduction in truck accident fatalities. The social benefits of mandated testing appear to outweigh the costs of the program. However, the similarity between the effect of mandating testing and simply clarifying state law suggests that extending the right to perform drug tests may have been as effective at lower cost.
Post-licence driver education for the prevention of road traffic crashes (Cochran Review).
- Ker K, Roberts I, Collier T, Renton F, Bunn F. Cochrane Library 2003, Issue 3: (Available online: Download Document).
CONTEXT: Worldwide, each year over a million people are killed and some ten million people are permanently disabled in road traffic crashes. Post-licence driver education is used by many as a strategy to reduce traffic crashes. However, the effectiveness of post-licence driver education has yet to be ascertained.
OBJECTIVES: To quantify the effectiveness of post-licence driver education in reducing
road traffic crashes.
METHODS: We searched the following electronic databases: the Cochrane Injuries Group's Specialized Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, TRANSPORT (NTIS, TRIS, TRANSDOC, IRRD), Road Rest (ARRB), ATRI, National Research Register, PsycInfo, ERIC, SPECTR, Zetoc, SIGLE, Science (and Social Science) Citation Index. We searched the
Internet, checked reference lists of relevant papers and contacted appropriate organizations. The search was not restricted by language or publication status. Randomized controlled trials comparing post-licence driver education versus
no education, or one form of post-licence driver education versus another. Two reviewers independently screened search results, extracted data and assessed methodological trial quality.
FINDINGS: We found 24 trials of driver education, 23 conducted in the USA and one in Sweden. Twenty trials studied remedial driver education. The methodological quality of the trials was poor and three reported data unsuitable for meta-analysis. Nineteen trials reported traffic offenses: pooled relative risk (RR) = 0.96, 95% confidence interval (95% CI) = 0.94, 0.98); trial heterogeneity was significant (p = < 0.00001). Fifteen trials reported traffic crashes: pooled RR = 0.98 (95% CI
0.96, 1.01), trial heterogeneity was not significant (p=0.75). Four trials reported injury crashes: pooled RR = 1.12 (95% CI 0.88, 1.41), trial heterogeneity was significant (p = < 0.00001).
No one form of education (correspondence, group or individual) was found to be substantially more effective than another, nor was a significant difference found between advanced driver education and remedial driver education. Funnel plots indicated the presence of publication bias affecting the traffic offense and crash outcomes. Reviewers' conclusions
COMMENTS: This systematic review provides no evidence that post-licence driver education is effective in preventing road traffic injuries or crashes. Although the results are compatible with a small reduction in the occurrence of traffic offenses, this may be due to selection biases or bias in the included trials. Because of the large number of participants included in the
meta-analysis (close to 300,000 for some outcomes) we can exclude, with reasonable precision, the possibility of even modest benefits.
Mobile telephone use among Melbourne drivers: a preventable exposure to injury risk.
- Taylor DM, Bennett DM, Carter M, Garewal D. Med J Aust 2003; 179(3): 140-142.
Correspondence: David McD. Taylor, Emergency Department, Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050, AUSTRALIA; (email: david.taylor@mh.org.au).
OBJECTIVES: To determine the rate of handheld mobile telephone use among motor vehicle drivers.
DESIGN & SETTING: Observational study of motor vehicle drivers at three times (10:00-11:00; 14:00-15:00; 17:00-18:00) on three consecutive Fridays in October 2002 at 12 highway sites in metropolitan Melbourne.
MAIN OUTCOME MEASURES: Rates of mobile phone use overall and by sex and age group, highway site (major metropolitan road, central business district, freeway exit ramp) and time of day (morning, afternoon, evening).
FINDINGS: 315 of 17 023 drivers were observed using mobile phones (18.5 users/1000 drivers; 95% CI, 16.5-20.6). Men had a slightly higher rate of use (19.0; 95% CI, 16.5-21.6) than women (17.5; 95% CI, 14.1-20.9), but the difference was not significant. Older drivers (50 years or more) had a significantly lower rate (4.8; 95% CI, 2.5-7.0) than middle-aged (21.9; 95% CI, 18.8-25.1) or young drivers (23.2; 95% CI, 18.9-27.5). Central business district drivers had a slightly, but not significantly, higher rate (20.5; 95% CI, 16.8-24.3) compared with those on major metropolitan roads (16.7; 95% CI, 13.3-20.2) or freeway exit ramps (18.2; 95% CI, 14.8-21.6). The rate of mobile phone use was significantly higher in the evening (23.5; 95% CI, 19.8-27.3) compared with the morning (16.0; 95% CI, 12.6-19.4) and afternoon (15.2; 95% CI, 11.9-18.4).
COMMENTS: Mobile phone use is common among Melbourne metropolitan drivers despite restrictive legislation. This issue needs to be further addressed by Victoria Police and public health and education agencies. Similar research is indicated to determine the extent of mobile phone use in other states.
The role of driver distraction in traffic crashes: distractions in everyday driving.
- Stutts J, Feaganes J, Rogman E, Hamlett C, Meadows T, Reinfurt D, Gish K, Mercadante M, Staplin L. AAA Foundation for Traffic Safety, (2003). Washington, DC: AAA Foundation for Traffic Safety, 1-104.
CONTEXT: The National Highway Traffic Safety Administration (NHTSA) has estimated that driver inattention or distraction is responsible for 25% to 30% of police-reported traffic crashes, or an estimated 1.2 million crashes per year (Sundeen, 2002; Shelton, 2001). This study performed for the AAA Foundation for Traffic Safety is one of only a few studies identified in the literature to examine the full range of distractions contributing to crashes.
OBJECTIVES: To determine the occurrence in the U.S. driving population of the various driver distractions and to examine the potential consequences of these distractions on driving performance.
METHODS: The methodology developed for the field data collection activities entailed a camera unit containing three miniature video cameras, a recording unit containing a VCR and battery packaged in a closed container, cables for connecting the two units, and a trigger device that automatically powered the units whenever the vehicle was turned on.
The recording equipment was installed in the vehicles of 70 volunteer subjects, equally distributed among males and females in five age groups: 18-29, 30-39, 40-49, 50-59 and 60+. Half the subjects were recruited from a base in Chapel Hill, North Carolina, and half from Kulpsville, Pennsylvania, just outside of Philadelphia. Subjects were informed only that the study was being conducted to learn "how traffic and roadway conditions affect driving behavior." They were instructed to "drive normally" and scheduled to return one week later for removal of the equipment.
FINDINGS: Results revealed that distractions are a common component of everyday driving. During their three hours of coded driving time, nearly all subjects were observed manipulating vehicle controls (such as air conditioning or window controls) and reaching for objects inside their moving vehicle. Nearly as many were observed manipulating music/audio controls, or had their attention drawn to something outside the vehicle. Approximately three-fourths ate or drank something while driving or conversed with a passenger. Reading/writing and grooming activities were also relatively common, but declined to less than half of the participants when observations were restricted to moving vehicles only. About a third of the subjects used a cell phone while driving, and nearly as many were distracted by passengers riding in their vehicle. Taking into account the shorter amount of time that children and especially babies were carried in vehicles, children were about four times and infants almost eight times more likely than adults to be a source of distraction to the driver, based on number of distracting events per hour of driving.
COMMENTS: Although recent research has primarily been focused on the safety implications of wireless communications and other in-vehicle technologies, the results have demonstrated that many driver distractions are neither new nor technological in nature. Rather, they are aspects of everyday driving that people are likely to seldom think about. A challenge for the highway safety community is to develop effective strategies for modifying people's driving behavior, so that they do not engage in these potentially dangerous activities at inappropriate times while driving. The human element is, and always has been, the most difficult to influence in the quest for increased safety on our roadways.
The extent to which schedules are sufficiently tight to encourage violations of Hours-of-Service Regulations, speed limits, or both was investigated through a survey of over 1,600 tractor-trailer drivers. The focus was on drivers with refrigerated trailers. The results indicate high incidence levels of tight schedules. For example, assuming average speed limits of 65 mph, 24% had violation-inducing schedules with regard to the movement they were making at the time of the interviews. Incorporating information about previous driving, the incidence of violation-inducing schedules rose to 40%. Comparison with an earlier study suggests that, despite increases in speed limits which would tend to loosen schedules, schedules have become tighter over the past decade. The implications of these findings for reforms of Hours-of-Service Regulations are briefly discussed.
Safety impacts of vehicular information technology.
Although road traffic fatalities in the high-income countries have fallen markedly in recent decades, non-fatality crashes have not. Further reduction in crash severity and frequency will be hampered by probable changes to the car-driving population, car weight, and share of non-motorized travel. Distraction from the driving task could also increase in parallel with in-vehicle telematics use. Use of the new information technology is increasingly seen as a solution to the road safety problem.
It is argued here that although the new technology has a key role to play in improving road transport generally, and could be very useful in crash protection, it will be of less help in reducing collision frequency.
Anti-dive front suspension mechanism design for scooter motorcycles.
Correspondence: Fu-Chen Chen, Department of Mechanical Engineering, Kun Shan University of Technology, P.O. Box 40-070, Tainan 701, TAIWAN ROC; (email: fcchen@mail.ksut.edu.tw).
The purpose of this paper is to synthesize all possible designs of anti-dive front suspension mechanisms with simple and multiple joints for scooter motorcycles. At first, the creative design methodology is presented. Then, the topological characteristics of the anti-dive front suspension mechanisms are analyzed, and the design requirements and constraints are
concluded and summarized. By way of the creative mechanism design methodology, all possible suspension mechanisms for motorcycles are synthesized. The results show that there are 11 design concepts for anti-dive front suspension mechanisms with six links.
Background noise cancellation for hands-free communication system of car cabin using adaptive feedforward algorithms.
This paper describes the background noise attenuation for hands-free communication systems of car cabins using adaptive feedforward noise control algorithm. For hands-free telephone system, the quality of communication usually is effect by background noise such as engine noise and aerodynamic noise. In the present study, an active noise control (ANC) design for reducing car cabin periodic background noise from engine and broadband random noise using adaptive feedforward control
are investigated. The control algorithm is based on Filtered-x least mean square (FXLMS) with multi-sine synthesized reference signal and frequency counting technology is implemented on a digital signal processor (DSP) platform. Experimental results indicated that the proposed design was effective suppressing 15 dB in periodic engine noise and 2-3 dB in broadband random background noise.
Sliding mode control for rollover prevention of heavy vehicles based on lateral acceleration.
Correspondence: A. Scott Lewis, Pennsylvania State Applied Research Laboratory, The Pennsylvania
State University, State College, PA 16804, USA; (email: asl103@psu.edu).
This paper presents a new active control strategy to prevent heavy vehicle rollover and focuses mainly on cases of maneuver-induced rollover such as rollover in cornering and lane-change maneuvers. The lateral acceleration at the center of gravity of the trailer has been used in the development of the control law. A nonlinear 75,000 pound 5-axle tractor/semitrailer computer simulation model has been used to demonstrate the effectiveness of the proposed active control system. Tyre cornering stiffness
characteristic variations, as possible uncertainty, were included in the controller design to prove the robustness of the system. A new nonlinear sliding mode controller has been designed and found to be effective in improving the dynamic performance and roll stability, regardless of parameter uncertainties, such as tyre cornering stiffness. The controller torque requirement is limited by the differential dynamic braking forces that the tractor drive axles are able to produce as a function of the applied dynamic loads and road surface condition. The results show that with this new controller, the vehicle lateral acceleration can be controlled to prevent rollover without significant change of the vehicle trajectory when active yaw torque is applied to the tractor drive axles. Also, simulation results indicate that the vehicle rollover might be prevented, by reducing the lateral load transfer ratio, using the lateral acceleration at the trailer center of gravity as a control strategy.
CONTEXT: No randomized controlled studies have been conducted to date on the effectiveness of psychological interventions for children with symptoms of posttraumatic stress disorder (PTSD) that has resulted from personally witnessing or being personally exposed to violence.
OBJECTIVE: To evaluate the effectiveness of a collaboratively designed school-based intervention for reducing children's symptoms of PTSD and depression that has resulted from exposure to violence.
DESIGN: A randomized controlled trial conducted during the 2001-2002 academic year.
SETTING AND PARTICIPANTS: Sixth-grade students at 2 large middle schools in Los Angeles who reported exposure to violence and had clinical levels of symptoms of PTSD.
INTERVENTION: Students were randomly assigned to a 10-session standardized cognitive-behavioral therapy (the Cognitive-Behavioral Intervention for Trauma in Schools) early intervention group (n = 61) or to a wait-list delayed intervention comparison group (n = 65) conducted by trained school mental health clinicians.
MAIN OUTCOME MEASURES: Students were assessed before the intervention and 3 months after the intervention on measures assessing child-reported symptoms of PTSD (Child PTSD Symptom Scale; range, 0-51 points) and depression (Child Depression Inventory; range, 0-52 points), parent-reported psychosocial dysfunction (Pediatric Symptom Checklist; range, 0-70 points), and teacher-reported classroom problems using the Teacher-Child Rating Scale (acting out, shyness/anxiousness, and learning problems; range of subscales, 6-30 points).
FINDINGS: Compared with the wait-list delayed intervention group (no intervention), after 3 months of intervention students who were randomly assigned to the early intervention group had significantly lower scores on symptoms of PTSD (8.9 vs 15.5, adjusted mean difference, - 7.0; 95% confidence interval [CI], - 10.8 to - 3.2), depression (9.4 vs 12.7, adjusted mean difference, - 3.4; 95% CI, - 6.5 to - 0.4), and psychosocial dysfunction (12.5 vs 16.5, adjusted mean difference, - 6.4; 95% CI, -10.4 to -2.3). Adjusted mean differences between the 2 groups at 3 months did not show significant differences for teacher-reported classroom problems in acting out (-1.0; 95% CI, -2.5 to 0.5), shyness/anxiousness (0.1; 95% CI, -1.5 to 1.7), and learning (-1.1, 95% CI, -2.9 to 0.8). At 6 months, after both groups had received the intervention, the differences between the 2 groups were not significantly different for symptoms of PTSD and depression; showed similar ratings for psychosocial function; and teachers did not report significant differences in classroom behaviors.
COMMENTS: A standardized 10-session cognitive-behavioral group intervention can significantly decrease symptoms of PTSD and depression in students who are exposed to violence and can be effectively delivered on school campuses by trained school-based mental health clinicians.
Injury patterns related to use of less-lethal weapons during a period of civil unrest.
- Suyama J, Panagos PD, Sztajnkrycer MD, FitzGerald DJ, Barnes D. J Emerg Med 2003; 25(2): 219-227.
Correspondence: Joe Suyama, Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA; (email: unavailable).
This case series documents injury patterns related to beanbag and other less-lethal (LL) weapons during a period of civil unrest in a major U.S. city. A retrospective review of injuries related to LL weapons usage presenting to an urban Emergency Department (ED) from April 10, 2001 to April 18, 2001 was performed. Patients under 18 years of age and those without signed consent to treat were excluded. Twenty-seven patients were identified. Two were excluded due to lack of signed consent for treatment. Mean age was 28.4 +/- 11.7 years; 76% of patients were male. Significant morbidity was found in 7 (28%) cases with no fatalities. Three (12%) individuals, with the diagnoses of pulmonary contusion, liver laceration, and Achilles tendon rupture, required admission. Two (8%) individuals had delayed complications of pneumonia and post-concussive syndrome. Reports of injury patterns associated with beanbag munitions in the medical literature are limited. Physicians should be aware of the injuries and delayed sequelae associated with their use.
A population-based study of inflicted traumatic brain injury in young children.
Correspondence: Heather T. Keenan, Department of Social Medicine, University of North Carolina at Chapel Hill, NC 27599-7240, USA; (email: hkeenan@med.unc.edu).
CONTEXT: Physical abuse is a leading cause of serious head injury and death in children aged 2 years or younger. The incidence of inflicted traumatic brain injury (TBI) in US children is unknown.
OBJECTIVE: To determine the incidence of serious or fatal inflicted TBI in a defined US population of approximately 230 000 children aged 2 years or younger.
DESIGN, SETTING, AND SUBJECTS: All North Carolina children aged 2 years or younger who were admitted to a pediatric intensive care unit or who died with a TBI in 2000 and 2001 were identified prospectively. Injuries were considered inflicted if accompanied by a confession or a medical and social service agency determination of abuse.
MAIN OUTCOME MEASURE: Incidence of inflicted TBI. Multivariate logistic regression models were used to compare children with inflicted injuries with those with noninflicted injuries and with the general state population aged 2 years or younger.
FINDINGS: A total of 152 cases of serious or fatal TBI were identified, with 80 (53%) incurring inflicted TBI. The incidence of inflicted traumatic brain injury in the first 2 years of life was 17.0 (95% confidence interval [CI], 13.3-20.7) per 100 000 person-years. Infants had a higher incidence than children in the second year of life (29.7 [95% CI, 22.9-36.7] vs 3.8 [95% CI, 1.3-6.4] per 100 000 person-years). Boys had a higher incidence than girls (21.0 [95% CI, 15.1-26.6] vs 13.0 [95% CI, 8.4-17.7] per 100 000 person-years). Relative to the general population, children who incurred an increased risk of inflicted injury were born to young mothers (< or =21 years), non-European American, or products of multiple births.
COMMENTS: In this population of North Carolina children, the incidence of inflicted TBI varied by characteristics of the injured children and their mothers. These data may be helpful for informing preventive interventions.
Death and injury from landmines and unexploded ordnance in Afghanistan.
Correspondence: Oleg O. Bilukha, Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Ga 30341, USA; (email: OBiloukha@cdc.gov).
CONTEXT: Afghanistan is one of the countries most affected by injuries due to landmines and unexploded ordnance.
OBJECTIVE: To understand the epidemiological patterns and risk factors for injury due to landmines and unexploded ordnance.
DESIGN AND SETTING: Analysis of surveillance data on landmine and unexploded ordnance injuries in Afghanistan collected by the International Committee of the Red Cross in 390 health facilities in Afghanistan. Surveillance data were used to describe injury trends, injury types, demographics, and risk behaviors of those injured and explosive types related to landmine and unexploded ordnance incidents.
PARTICIPANTS: A total of 1636 individuals injured by landmines and unexploded ordnance, March 2001 through June 2002.
FINDINGS: Eighty-one percent of those injured were civilians, 91.6% were men and boys, and 45.9% were younger than 16 years. Children were more likely to be injured by unexploded ordnance (which includes grenades, bombs, mortar shells, and cluster munitions), whereas adults were injured mostly by landmines. The most common risk behaviors for children were playing and tending animals; for adults, these risk behaviors were military activity and activities of economic necessity (eg, farming, traveling). The case-fatality rate of 9.4% is probably underestimated because surveillance predominantly detects those who survive long enough to receive medical care.
COMMENTS: Landmine risk education should focus on hazards due to unexploded ordnance for children and on landmine hazards for adults and should address age-specific risk behaviors. Expanding community-based and clinic-based reporting will improve the sensitivity and representativeness of surveillance.
Patterns of injury in hospitalized terrorist victims.
- Peleg K, Aharonson-Daniel L, Michael M, Shapira Sc S. Am J Emerg Med 2003; 21(4): 258-262.
Correspondence: Kobi Peleg, Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Tel-Hashomer, ISRAEL; (email: pongpel@zahav.net.il).
Acts of terror increase the demand for acute care. This article describes the pattern of injury of terror victims hospitalized at 9 acute-care hospitals in Israel during a 15-month period of terrorism. To characterize patients hospitalized as a result of terror injuries, we compared terror casualties with other injuries regarding severity, outcome, and service utilization. Using data from the National Trauma Registry, characteristics of casualties are portrayed. During the study period, 23,048 patients were recorded, 561 of them (2.4%) were injured through terrorist acts. Seventy percent were younger than 29 years. Seventy-five percent were males. Thirteen percent of terror victims compared with 3% with other traumatic injuries, arrived by helicopter. Injury mechanism consisted mainly of explosions (n = 269, 48%) and gunshot injuries (n = 266, 47%). One third of the population experienced severe trauma (Injury Severity Score >/= 16). One hundred-forty-two patients (26%) needed to be admitted to the intensive-care unit. Inpatient mortality was 6% (n = 35). Fifty-five percent of the injuries (n = 306) included open wounds and 31% (n = 172) involved internal injuries; 39% (n = 221) sustained fractures. Half of the patients had a procedure in the operating room (n = 298). Duration of hospitalization was longer than 2 weeks for nearly 20% of the population. Injuries from terrorist acts are severe and impose a burden on the healthcare system. Further studies of the special injury pattern associated with terror are necessary to enhance secondary management and tertiary prevention when occurring.
Early risk factors for violence in Colombian adolescents.
- Brook DW, Brook JS, Rosen Z, De La Rosa M, Montoya ID, Whiteman M. Am J Psychiatry 2003; 160(8): 1470-1478.
Correspondence: David W. Brook, Mount Sinai School of Medicine, New York, NY 10029, USA; (email: david.brook@mssm.edu).
OBJECTIVE: Violence and homicide are more prevalent in Colombia, South America, than in the United States, but the role of psychosocial factors in the violent behavior of Colombian adolescents remains unclear. The objective of the study was to identify personality, familial, peer, and ecological variables associated with violence in Colombian adolescents.
METHOD: A survey of adolescents was conducted in 1995-1996. A standard self-report measure was adapted to ensure linguistic and cultural relevance. A total of 2,837 adolescents ages 12-17 years from various self-reported ethnic groups were randomly selected from the community in three Colombian cities: Bogota, Medellin, and Barranquilla. Eighty percent of eligible adolescents agreed to participate. Data were collected concerning the adolescent's personality attributes, family characteristics, peer characteristics, and ecological/cultural factors, including the availability of illicit drugs and the prevalence of violence in the community. The dependent variable was the adolescent's self-reported frequency of violent behavior.
FINDINGS: Violence directed at the adolescent and the adolescent's own drug use were both more highly correlated with the adolescent's violent behavior than were other risk factors. Significant risk factors of less importance included tolerance of deviance, peer drug use, peer deviance, and exposure to violence on television.
COMMENTS: The results supported a model in which violent behavior was correlated independently with a number of risk factors from several domains. The findings point to the use of specific intervention procedures for adolescents to prevent their own subsequent acts of violent behavior.
Childhood homicide: a 1990-2000 retrospective study at the Institute of Legal Medicine in Lausanne, Switzerland.
- Romain N, Michaud K, Horisberger B, Brandt-Casadevall C, Krompecher T, Mangin P. Med Sci Law (not on-line). 2003; 43(3): 203-206.
Correspondence: Nathalie Romain, Institut Universitaire de Medecine Legale de Lausanne, rue du Bugnon 21, 1005 Lausanne, SWITZERLAND; (email: Nathalie.Romain@hospvd.ch).
The authors retrospectively reviewed all homicides of children under 15 years of age referred to the Institute of Legal Medicine in Lausanne from January 1990 to December 2000. We report on 41 cases during this eleven-year period. Among those, 17 newborns and 24 older children, a higher proportion of males was found. Regarding newborn homicides, when the identity of the mother was known she was always identified as the perpetrator. With non-newborn homicides, the majority of the victims were killed at home and knew the offender. Two common profiles of these homicides could be determined. In the first scenario, one of the parents shot all the children and committed suicide afterwards. The second profile is defined as 'fatal child abuse' and concerned younger victims whose cause of death was the result of a cranio-cerebral trauma from battering or shaken baby syndrome.
Depression, homicide and diminished responsibility: new Scottish directions.
- Collins P, White T. Med Sci Law (not on-line). 2003; 43(3): 195-202.
Correspondence: P. Collins, Michael Rutter Centre, Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK; (email: unavailable).
In a recent Scottish Appeal Court opinion (Kim Louise Scarsbrook or Galbraith v. Her Majesty's Advocate, 2001) it was successfully argued by the appellant that her conviction of murder was unsound inter-alia on the basis of overly restrictive pre-existing definitions of diminished responsibility in Scottish law resulting in unduly narrow directions being given by the trial judge to the jury in her case. We felt it timely to present a revised overview of the defence of diminished responsibility in Scotland and to consider the issues surrounding its applicability in cases of clinical depression. The psychiatric literature regarding depression and homicide is reviewed.
Male-perpetrated violence among Vietnam veteran couples: relationships with veteran's early life characteristics, trauma history, and PTSD symptomatology.
- Orcutt HK, King LA, King DW. J Trauma Stress 2003; 16(4): 381-390.
Correspondence: Holly K. Orcutt, Department of Psychology, Northern Illinois University, DeKalb, Illinois 60115-2892, USA; (email: horcutt@niu.edu).
Using structural equation modeling, we examined the impact of early-life stressors, war-zone stressors, and PTSD symptom severity on partner's reports of recent male-perpetrated intimate partner violence (IPV) among 376 Vietnam veteran couples. Results indicated that several variables demonstrated direct relationships with IPV, including relationship quality with mother, war-zone stressor variables, and PTSD symptom severity. Importantly, retrospective reports of a stressful early family life, childhood antisocial behavior, and war-zone stressors were indirectly associated with IPV via PTSD. One of our 2 war-zone stressor variables, perceived threat, had both direct and indirect (through PTSD) relationships with IPV. Experiencing PTSD symptoms as a result of previous trauma appears to increase an individual's risk for perpetrating IPV. Implications for research and treatment are discussed.
The relationship between intimate partner violence and PTSD: an application of Cox regression with time-varying covariates.
- Yoshihama M, Horrocks J. J Trauma Stress 2003; 16(4): 371-380.
Correspondence: Mieko Yoshihama, School of Social Work, University of Michigan, Ann Arbor, Michigan 48109-1106, USA; (email: miekoy@umich.edu).
This study uses Cox regression with time-varying covariates to examine the relationship between intimate partner violence and posttraumatic stress disorder (PTSD) in a random sample of Japanese American women and immigrant women from Japan (N = 211). Because applications of survival analysis in trauma research are scarce, this paper presents the utility of this analytical approach by contrasting it with other common methods of analysis (chi-square tests and Cox regression with covariates that do not change over time).
