The objective of this study was to get an insight into the prevalence of medicinal and illegal drugs among car drivers in a Danish rural area. The police randomly stopped about 1000 car drivers and asked them to deliver a saliva sample and gave them a questionnaire to fill in at home. Laboratory analyses by specific methods of samples, which a screening found positive, confirmed that 2% were positive for benzodiazepines or illegal drugs (amphetamine, cannabis, cocaine or opiates): 1.3% were positive for illegal drugs and 0.7% for benzodiazepines. Questionnaire statements from some of the drivers confirm that occasionally some of these drive despite a suspicion to be under the influence of an illegal drug (2.8%), an illegal drug including alcohol (4%), a hazardous medicinal drug including alcohol (8.5%), or alcohol alone above the legal limit (24.5%). These results are considered reliable for the survey area and may not reflect national conditions. The overall results indicate that in this study driving under the influence of illegal drugs or alcohol seems to be associated to especially men, aged 22-44 years. Driving under the influence of hazardous medicinal drugs seems to be associated to middle-aged/elderly drivers, both men and women.
Why are sobriety checkpoints not widely adopted as an enforcement strategy in the United States?
- Fell JC, Ferguson SA, Williams AF, Fields M. Accid Anal Prev 2003; 35(6): 897-902.
Correspondence: James C. Fell, Pacific Institute for Research and Evaluation, 11710 Beltsville Drive, Suite 300, Calverton, MD 20705-3102, USA; (email: fell@pire.org).
Sobriety checkpoints have been used by police in the United States for at least the past two decades to enforce impaired driving laws. Research has indicated that sobriety checkpoints are effective in reducing drinking and driving and alcohol-related fatal crashes. Despite this evidence, many police agencies have been unenthusiastic about using checkpoints. Information was collected from all 50 states plus the District of Columbia on the use of sobriety checkpoints. A total of 37 states and the District of Columbia reported conducting sobriety checkpoints at least once or twice during the year. Only 11 states reported that checkpoints were conducted on a weekly basis. Thirteen states do not conduct checkpoints either because of legal or policy issues. More detailed information was collected from five states that conduct checkpoints frequently and matched with information from five similar states that conduct checkpoints infrequently. States with frequent checkpoint programs had several common features such as program themes, support from task forces and citizen activist groups, use of a moderate number of police at the checkpoints, and use of all available funding mechanisms (federal, state, local) to support them. States with infrequent checkpoints claimed a lack of funding and police resources for not conducting more checkpoints, preferred saturation patrols over checkpoints because they were more "productive," and used large numbers of police officers at checkpoints. Ways to overcome perceived barriers to checkpoint use are discussed.
Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants.
- Ashe M, Jernigan D, Kline R, Galaz R. Am J Public Health 2003; 93(9): 1404-1408.
Correspondence: Marice Ashe, Technical Assistance Legal Center, Public Health Institute, 505 14th Street, Suite 810, Oakland, CA 94612, USA; (email: mashe@phi.org).
We desired to understand how legal tools protect public health by regulating the location and density of alcohol, tobacco, firearms, and fast food retail outlets. We reviewed the literature to determine how land use regulations can function as control tools for public health advocates. We found that land use regulations are a public health advocacy tool that has been successfully used to lessen the negative effects of alcohol retail outlets in neighborhoods. More research is needed to determine whether such regulations are successful in reducing the negative effects of other retail outlets on community health.
Deleterious effects of alcohol intoxication: diminished cognitive control and its behavioral consequences.
- Casbon TS, Curtin JJ, Lang AR, Patrick CJ. J Abnorm Psychol 2003; 112(3): 476-487.
Correspondence: Todd S. Casbon, Department of Psychology, Florida State University, Tallahassee 32306-1051, USA; (email: tsc8830@garnet.acns.fsu.edu).
The authors tested the hypothesis that impaired behavioral performance during intoxication results partly from alcohol's deleterious effects on cognitive control. The impact of alcohol on perseverative behavior was examined with an n-back working memory task that included manipulations of task complexity and prepotency of inclinations to respond or withhold responding. Thirty-two social drinkers (16 men) participated in either an alcohol (.075g/100ml) or a no-alcohol condition. Alcohol increased perseveration of prepotent, task-inappropriate response patterns only under cognitively demanding (heavy memory load) conditions. This effect was evident for both commission errors (response persistence despite contingencies altered to require restraint) and omission errors (failure to respond when contingencies were revised to encourage action). Findings suggested that alcohol-induced perseveration arises from impairments in cognitive control.
Correspondence: Lynda Doll, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, K-02, Atlanta, GA 30341 (email: lsd1@cdc.gov).
Violent and unintentional injuries place a severe physical, emotional, and financial burden on US communities. Injuries affect people of all ages, from infants through older adults, and are the leading cause of death in the first four decades of life. In 1995, the economic cost of injuries was estimated to be over $260 billion, including the costs of health care and lost productivity.
Despite the large burden on US communities, injury prevention is still a relatively new area of public health. In 1992, Congress mandated the establishment of the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control to coordinate research and programmatic responses to the problem of injuries in this country. In partnership with other federal, state, and local organizations and universities, the Center has encouraged the use of a population-based or public health approach to injury research and programs. This approach complements engineering, mental health, and criminal justice approaches to injury prevention and control.
Evaluation of interventions is an important aspect of injury prevention. Results of evaluations have the power to change injury prevention practice. For example, bicycle helmet use increased following demonstration of the impact of helmets on brain injury. The number of programs promoting installation of smoke detectors and provision of fire injury prevention education grew once these programs were shown to be highly effective and to save money. The number of states with laws prohibiting blood alcohol concentrations of 0.08 percent or higher increased after such laws were shown to decrease fatal motor vehicle injuries.
In this paper, our goal is to discuss the evaluation of injury prevention interventions in two contexts -- intervention research (efficacy or effectiveness trials) and program evaluation. Our goal is not to present an exhaustive methodological review of evaluation strategies. The reader is referred to several excellent articles and texts that provide overviews of evaluation methods used in research and program evaluation. Rather, our intent is to review selected broad issues and challenges faced by injury researchers and practitioners as they undertake an evaluation activity. Attention to these issues is important to ensure that evaluation findings are both credible and useful.
The prevalence of lifetime exposure to violence, natural disaster, or major accidents involving injuries or fatalities was examined in the largest population-based epidemiologic survey of U.S. military personnel to date. The psychosocial and health effects of types of exposure experience (witness only, victim/survivor, relief worker), gender differences, and social support were also evaluated. Over 15,000 active duty U.S. military personnel from stratified random samples of active duty U.S. personnel from all services responded to either mail questionnaires and/or worksite surveys. The lifetime exposure to one or more traumatic events was 65%; the most prevalent trauma for men was witnessing a major accident, and for women, witnessing a natural disaster. Victims of any traumatic event were at twice the risk of having two or more physical and mental health problems than nonexposed controls. Health outcomes of trauma exposure vary by type of traumatic event: type of exposure experience, rank, and gender.
First Reports Evaluating the Effectiveness of Strategies for Preventing Violence: Early Childhood Home Visitation: Findings from the Task Force on Community Preventive Services.
- Centers for Disease Control and Prevention. Task Force on Community Preventive Services. MMWR Recommendations and Reports 2003; 52(RR-14): 1-9.
Early childhood home visitation programs are those in which parents and children are visited in their home during the child's first 2 years of life by trained personnel who provide some combination of the following: information, support, or training regarding child health, development, and care. Home visitation has been used for a wide range of objectives, including improvement of the home environment, family development, and prevention of child behavior problems. The Task Force on Community Preventive Services (the Task Force) conducted a systematic review of scientific evidence concerning the effectiveness of early childhood home visitation for preventing several forms of violence: violence by the visited child against self or others; violence against the child (i.e.,
maltreatment [abuse or neglect]); other violence by the visited parent; and intimate partner violence. On the basis of strong evidence of effectiveness, the Task Force recommends early childhood home visitation for the prevention of child abuse and neglect. The Task Force found insufficient evidence to determine the effectiveness of early childhood home visitation in preventing violence by visited children, violence by visited parents (other than child abuse and neglect), or intimate partner violence in visited families. (Note that insufficient evidence to determine effectiveness should not be interpreted as evidence of ineffectiveness.) No studies of home visitation
evaluated suicide as an outcome. This report provides additional information regarding the findings, briefly describes how the reviews were conducted, and provides information that can help in applying the recommended intervention locally.
CONTEXT: The aim of this study was to compile nationally representative statistics describing inpatient hospital care for patients with work-related injuries and illnesses covered under workers' compensation (WC) insurance in the United States.
METHODS: Three years of data (1997-1999) from the Nationwide Inpatient Sample (NIS) were used to describe WC inpatient stays with respect to patient and hospital characteristics, principal diagnoses, number and type of procedures provided, total charges, length of stay, and time from admission to administering of the principal procedure.
FINDINGS: Approximately 209,139 WC hospitalizations occurred annually, representing 0.62% of all inpatient admissions. The average total charge per WC hospitalization was $14,966. After adjusting for the type of diagnosis and other factors, WC hospital care was found to involve 13-24% more procedures, have a slightly longer (4%) length of stay, and take 23-54% less time from admission to the principal procedure than inpatient care for comparable diagnoses paid by other sources. Inpatient care for disc and spinal disorders paid by WC had 16% higher charges than similar non-WC cases. Three-year trends showed a steady decline in the number of WC hospitalizations between 1997 and 1999 but a sharp 16% rise in total charges per WC stay.
COMMENTS: This research provides an initial foundation for understanding the extent and nature of hospitalized care for injured workers in the US and identifying significant trends in the delivery of care.
Parent-child concordance on reported barriers to helmet use by children.
- Forjuoh SN, Schuchmann JA, Fiesinger T, Mason S. Med Sci Monit 2003; 9(10): CR436-441.
Correspondence: Samuel Forjuoh, Department of Family & Community Medicine, Scott & White Memorial Hospital and Scott, Sherwood and Brindley Foundation, Texas A&M University System Health Science Center, College of Medicine, Temple, TX, USA; (email: sforjuoh@swmail.sw.org).
CONTEXT: We determined the agreement between parents and their school-age children on reported barriers to bicycle helmet use.
METHODS: We conducted a cross-sectional survey in a 2-county Central Texas region with no helmet use legislation. Parent-child pairs, selected through a randomized, multi-stage sampling procedure and pre-matched by unique identifiers, were surveyed independently with self-administered questionnaires. Parent-child concordance was assessed using Kappa statistic.
FINDINS: Of 1,987 surveys distributed, children returned 1,203 (61%) while parents returned 636 (53% of child respondents). Parents included 31% college graduates and 33% reported annual income of >$55,000. Children included 60% whites, 16% blacks, and 16% Hispanics. The most popular reasons cited by children as barriers to helmet use were not having one (34%), being a safe rider (31%), and helmets messing up hair (18%). Good concordance was found on reported child bicycle riding (parent=88.0% vs. child=88.0%; K=0.64) and child helmet use the last time child rode a bicycle (parent=25.1% vs. child=28.0%; K=0.54). While good concordance was also found for reported helmet ownership (parent=31.9% vs. child=29.9%; K= 0.50), poor concordance was found for other barriers to helmet use including helmets looking ugly (parent=6.5% vs. child=13.4%; K=0.38) and messing up hair (parent=5.6% vs. child=15.2%; K=0.36).
COMMENTS: Although parents may be generally aware of their children's bicycle riding and helmet use habits, they may not be fully aware of the reasons why their children may not use a helmet. Public education and interventions on helmet promotion need to focus on parents.
Pedestrian head impact conditions depending on the vehicle front shape and its construction--full model simulation.
- Okamoto Y, Sugimoto T, Enomoto K, Kikuchi J. Traffic inj prev 2003; 4(1): 74-82.
For the evaluation of pedestrian protection, the European Enhanced Vehicle-Safety Committee Working Group 17 report is now commonly used. In the evaluation of head injuries, the report takes into account only the hood area of the vehicle. But recent pedestrian accident data has shown the injury source for head injury changing to the windshield and A-pillar from the hood. The head contact points are considered to fall on a parallel to the front shape of the vehicle along the lateral direction, but the rigidity of the outer side construction is different from the center area. The purpose of this study is to consider the reason for the change in injury source for recent vehicle models. The head contact points and contact conditions, speed and angle, are thought to be influenced not only by the vehicle's geometry, but also its construction (rigidity). In this study, vehicle-pedestrian impact simulations were calculated with a finite element model for several hitting positions, including the outer side areas. Full dummy sled tests were conducted to confirm the simulation results. These results show that, for impacts at the outer sides of the vehicle, the head contact points are more rearward than at the vehicle center. In addition, the speed and angle of the head contact were found to be influenced by the pedestrian height.
In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.
Walking and Talking as Predictors of Falls in the General Population: The Leiden 85-Plus Study.
- Bootsma-Van Der Wiel A, Gussekloo J, De Craen AJ, Van Exel E, Bloem BR, Westendorp RG. J Am Geriatr Soc 2003; 51(10): 1466-1471.
Correspondence: Jacobijn Gussekloo, Section of Gerontology and Geriatrics, Department of General Internal Medicine, Leiden University Medical Center, C-2-R, PO Box 9600, 2300 RC Leiden, THE NETHERLANDS; (email: jgussekloo@lumc.nl).
OBJECTIVES: To compare the value of dual tasking in predicting falling in the general population of oldest old with that of easy-to-administer single tasks.
SETTING: Municipality of Leiden, the Netherlands. PARTICIPANTS: : Representative cohort of 380 individuals, all aged 85 at baseline.
MEASUREMENTS: During enrollment, walking time over a 12-meter distance was measured, as well as the verbal fluency to recite names of animals or professions during a 30-second period. In the dual task, performance was assessed when participants combined walking with reciting names. Incidence of falls and fractures was assessed by interviewing participants and checking their medical histories.
FINDINGS: After 1 year of follow-up, 42% of the participants reported one or more falls, and 4% suffered a fracture. Total walking time, number of steps, and verbal fluency were all strongly related to incident falls (P for trend for all <.01), but dual-task performance was not a better predictor for incident falls than single-task performance.
COMMENTS: The dual-task test in this study had no predictive value above that of a single-task test to predict falling. Dual tasks with more-sensitive measures of impaired dual-task execution might have better test characteristics. In this study, history of falls and performance on an easy-to-administer single walking task identified old persons at higher risk for falling who could benefit from fall preventive strategies.
CONTEXT: Deaths from injury and poisoning (suicide, accidents, undetermined deaths, and homicide) are the major cause of death among young men aged 15-39 years in England and Wales and have been increasing in recent years.
OBJECTIVE: To describe common characteristics among young men who die from injury and poisoning.
DESIGN: We employed a retrospective survey methodology to investigate factors associated with deaths by injury and poisoning among young men aged 15-39 years (n = 268) in Merseyside and Cheshire during 1995. Data were collected from Coroner's inquest notes and General Practitioner records.
FINDINGS: The most common cause of death was poisoning by alcohol and drugs (29.1%, n = 78). A high proportion of cases were unemployed (39.4%, n = 106). Cases were also more likely to be single compared to the general population (74.2% vs 55.5%). Self-destructive behaviour was evident in 77% of deaths (n = 206).
COMMENTS: Alcohol and drug use are important contributory factors to injury and poisoning deaths. More research is needed into the effects of unemployment and being single on the health of young men, and to investigate the motivations behind risk taking and self-destructive behaviour.
Parent-child discrepancy in reporting children's post-traumatic stress reactions after a traffic accident.
- Dyb G, Holen A, Braenne K, Indredavik MS, Aarseth J. Nord J Psychiatry 2003; 57(5): 339-344.
Correspondence: Grete Dyb, Department of Psychiatry and Behavioural Medicine Norwegian University of Science and Technology NO-7489 Trondheim, NORWAY; (email: unavailable).
This study examines possible parent-child discrepancies in the reporting of post-traumatic stress reactions in children after a traffic accident. Sixteen children exposed to the same traffic accident were interviewed about post-traumatic stress reactions at 5 weeks and at 6 months after the event, utilizing the Child Posttraumatic Stress Reaction Index (CPTS-RI). Independently, the parents' reported their child's degree of post-traumatic stress reactions on the CPTS-RI: Parent questionnaire, at the same two times. Clinicians also assessed the children's level of general functioning on the Children's Global Assessment Scale. The children reported significantly more post-traumatic stress reactions than observed by their parents 4 weeks after the accident. The parent-child discrepancy was more pronounced among younger children. The level of children's self-reported post-traumatic stress reactions decreased significantly from the first to the second assessment. At the second assessment, 6 months after the accident, there was no significant parent-child discrepancy observed. The children showed a normal level of functioning despite their post-traumatic stress reactions. The reported parent-child discrepancy indicates that information about children's post-traumatic stress reactions after an accident is best obtained directly from the children.
Traumatic injuries of children and adolescents--are they associated with psychiatric contacts?
- Ebeling H, Vuokko A, Moilanen I. Nord J Psychiatry 2003; 57(5): 345-350.
Correspondence: Hanna Ebeling, Department of Child Psychiatry University and University Hospital of Oulu, NORWAY; (email: hanna.ebeling@oulu.fi).
Our aim was to investigate whether a large number of hospital visits by children and adolescents because of injuries are associated with psychiatric treatments and subsequent suicides. We examined the case records of 250 randomly chosen patients, 156 (62%) boys and 94 (38%) girls, out of 2306 outpatients who were 0-16 years old and had been treated because of traumatic injuries in Oulu University Hospital in 1984 and were alive in 1997. Boys with seven or more accidents had had psychiatric treatments more commonly than did boys with fewer accidents (39% vs. 8%). In addition, the case records of the patients who had died before the end of 1997 out of the 2306 patients were examined. Twenty-one (0.9%) patients (20 males and one female) had died, and seven (0.3%) of them had committed suicide. The traumatically injured male patients had a twofold suicide rate compared to the national average. The researchers also re-coded the causes of death from the death certificates. There seems to be a tendency to interpret adolescent suicides as accidental, as one of the seven registered suicides (14%), but six of the seven re-coded suicides (86%) had occurred before the age of 20.
OBJECTIVE: Concussion in professional football was studied with respect to impact types and injury biomechanics. A combination of video surveillance and laboratory reconstruction of game impacts was used to evaluate concussion biomechanics.
METHODS: Between 1996 and 2001, videotapes of concussions and significant head impacts were collected from National Football League games. There were clear views of the direction and location of the helmet impact for 182 cases. In 31 cases, the speed of impact could be determined with analysis of multiple videos. Those cases were reconstructed in laboratory tests using helmeted Hybrid III dummies and the same impact velocity, direction, and head kinematics as in the game. Translational and rotational accelerations were measured, to define concussion biomechanics. Several studies were performed to ensure the accuracy and reproducibility of the video analysis and laboratory methods used.
FINDINGS: Concussed players experienced head impacts of 9.3 +/- 1.9 m/s (20.8 +/- 4.2 miles/h). There was a rapid change in head velocity of 7.2 +/- 1.8 m/s (16.1 +/- 4.0 miles/h), which was significantly greater than that for uninjured struck players (5.0 +/- 1.1 m/s, 11.2 +/- 2.5 miles/h; t = 2.9, P < 0.005) or striking players (4.0 +/- 1.2 m/s, 8.9 +/- 2.7 miles/h; t = 7.6, P < 0.001). The peak head acceleration in concussion was 98 +/- 28 g with a 15-millisecond half-sine duration, which was statistically greater than the 60 +/- 24 g for uninjured struck players (t = 3.1, P < 0.005). Concussion was primarily related to translational acceleration resulting from impacts on the facemask or side, or falls on the back of the helmet. Concussion could be assessed with the severity index or head injury criterion (the conventional measures of head injury risk). Nominal tolerance levels for concussion were a severity index of 300 and a head injury criterion of 250.
COMMENTS: Concussion occurs with considerable head impact velocity and velocity changes in professional football. Current National Operating Committee on Standards for Athletic Equipment standards primarily address impacts to the periphery and crown of the helmet, whereas players are experiencing injuries in impacts to the facemask, side, and back of the helmet. New tests are needed to assess the performance of helmets in reducing concussion risks involving high-velocity and long-duration injury biomechanics.
Wilderness injury, illness, and evacuation: National Outdoor Leadership School's incident profiles, 1999-2002.
OBJECTIVE: This paper describes field injury, illness, near miss, and evacuation profiles of the National Outdoor Leadership School (NOLS).
METHODS: The NOLS incident database is used to record injuries, illnesses, near-miss incidents (close calls), evacuations, and nonmedical incidents. The database has been used continually since 1984.
FINDINGS: During the period September 1, 1998, through August 31, 2002, there were 630,937 program days on which 1940 incidents were reported involving 1679 students and 233 staff. Athletic injuries account for 50% of all injuries, and soft-tissue injuries account for 30%. Athletic injuries are most often sprains and strains of knees (35%), ankles (30%), and backs (13%). Falls and slips around camp or while hiking are the leading contributing factors. The most common illnesses are gastrointestinal symptoms such as nausea, vomiting, and diarrhea (26.4%) and all flu-like illness, including flu symptoms and respiratory symptoms (16.6%). Rock fall was the leading near-miss incident. Two hundred fifty-seven (53%) medical evacuees received treatment and were able to rejoin and finish their course. There was one fatality from 1999 to 2002. The fatality rate for this period is 0.002 per 1000 program days.
COMMENTS: The number of injuries and, specifically, the number of athletic injuries have declined. The number and rate of near-miss incidents increased as a result of better reporting; the rate of nonmedical incidents held steady. Motivation continues to be our leading category of nonmedical incident. Efforts at collecting incident data provide a useful measurement from which we can gauge our risk-management performance.
All-terrain vehicle rules and regulations: Impact on pediatric mortality.
CONTEXT: All-terrain vehicles (ATV) use by children leads to severe injury and death. Since the US Consumer Product Safety Commission consent decree expired in 1998, there has been little movement in regulating ATV use for children (<16 yr). The authors hypothesized that states with laws and regulations restricting pediatric ATV use may abrogate excess death compared with states without such restrictions.
METHODS: Pediatric mortality data reported to the consumer product safety commission from 1982 to 1998 were analyzed as well as state all-terrain vehicle requirements compiled by the Specialty Vehicle Institute of America in August 2001. The authors calculated ATV mortality rate by dividing ATV mortality frequency by 1980-2000 pediatric census results. They compared the top 26 states with the highest ATV mortality rates (TOP) with those of all other states (OTH) in terms of age, ATV type, ATV occupancy, and ATV laws. Chi-square analysis was performed.
FINDINGS: There were 1,342 ATV pediatric deaths during the 16-year period. The TOP states averaged approximately a 2-fold increase in adjusted ATV mortality rate compared with the national ATV pediatric mortality rate. Ninety-two percent of TOP states have no licensing laws compared with 73% of the OTH states (P <.07). There is no difference between groups with regard to minimum age requirements and safety certification.
COMMENTS: Current legal and regulatory standards have low probability of decreasing ATV-related pediatric mortality. States should adopt laws that restrict the use of ATV's for children less than 16 years of age and potentially prevent excess ATV-related pediatric mortality.
CONTEXT: Although much is known about injury-related deaths from the use of external cause of injury codes (ecodes) on death certificates, the contribution of nonfatal injury is unknown, with most information based on estimates from national surveys. Some states mandate ecoding of charts for hospitalized patients, but few require ecode assignment for emergency department (ED) records. Missouri and Nebraska mandated ecoding of ED records in 1993 and 1994, respectively, allowing for a more complete description of injuries in those states. We describe fatal and nonfatal injury frequencies in Missouri and Nebraska by using ecodes, with graphic representation in the form of injury pyramids.
METHODS: Ecode frequencies for 1996 to 1998 for all injury causes in Missouri and Nebraska were reported directly from their respective health departments. The ecode frequencies were grouped according to the Centers for Disease Control and Prevention's ecode matrix for presenting injury and mortality data.
FINDINGS: During the study period, 13,052 deaths, 131,210 hospitalizations, and 1,914,140 ED visits occurred as the result of injury. The most frequent lethal injuries were unintentional motor vehicle crashes (32.3% of total deaths), self-inflicted gunshot wound (13.2%), unintentional falls (11.3%), gunshot wound from an assault (7.7%), and unintentional poisoning (4.3%). The leading causes of injury-related hospitalization were unintentional falls (47.8% of total hospitalizations), unintentional motor vehicle crashes (15.5%), self-inflicted poisoning (6.5%), and overexertion or strenuous movements (2.4%). Of 1.9 million ED injury visits, unintentional falls accounted for 24.3%, unintentionally being struck by an object or person for 14.6%, unintentional motor vehicle crashes for 11.4%, unintentionally being cut or pierced for 10.7%, and overexertion or strenuous movements for 8.5%.
COMMENTS: Ecoding in Missouri and Nebraska provides a comprehensive data retrieval system that allows for a graphic depiction of the burden of injury derived from real patient encounters within specific geographic regions.
Mechanism of injury affects 6-month functional outcome in children hospitalized because of severe injuries.
- Macpherson AK, Rothman L, McKeag AM, Howard A. J Trauma 2003; 55(3): 454-458.
Correspondence: Andrew Howard, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, CANADA; (email: andrew.howard@sickkids.ca).
CONTEXT: The burden of childhood injury is often described using vital statistics for mortality and hospital admissions as a measure of morbidity. Hospital admissions, however, reflect the process of care and do not directly measure children's functional disability. The purpose of this study was to determine the influence of mechanism of injury on the functional outcome 6 months after injury in children in an inpatient trauma unit of a pediatric referral hospital.
METHODS: A retrospective cohort of 357 children aged 2 to 15 with an Injury Severity Score (ISS) > 12 was studied to determine the relationship between mechanism of injury (based on International Classification of Diseases, Ninth Revision e-code) and functional outcome 6 months after hospital discharge. Wee Functional Independence Measure (WeeFIM) was used to assess functional outcome. Any child with a WeeFIM score less than the maximum (of 126) attainable was classed as requiring assistance, and the relative risk of requiring assistance at 6 months was calculated for each injury mechanism. Poisson regression analysis was used to assess the importance of mechanism of injury, after adjusting for age, gender, ISS, and a primary diagnosis of central nervous system (CNS) injury.
FINDINGS: Mechanism of injury had a significant effect on the functional outcome at 6 months: 72% of pedestrians, 64% of cyclists struck by cars, and 59% of injured motor vehicle occupants required assistance during daily activities. By contrast, only 27% of those injured playing sports and 22% of cyclists injured without motor vehicle involvement required assistance. The relative risk of children requiring assistance was similar with or without adjustment for age, gender, ISS, and CNS injury.
COMMENTS: Mechanism of injury is significantly associated with requiring assistance 6 months postdischarge, even after controlling for age, injury severity, and the presence of a CNS injury. These data are important both when discussing the prognosis for an individual patient and also when considering the population impact of childhood injuries.
Equalisation of socioeconomic differences in injury risks at school age? A study of three age cohorts of Swedish children and adolescents.
- Engstrom K, Laflamme L, Diderichsen F. Soc Sci Med 2003; 57(10): 1891-1899.
Correspondence: Karin Engstrom, Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Norrbacka, S-171 76, Stockholm, SWEDEN; (email: karin.engstrom@phs.ki.se).
The objective of the study was to investigate whether there is equalisation of socioeconomic differences in injury risks among Swedish children and adolescents. Equalisation was defined as a reduction in relative differences in risks between socioeconomic groups. All Swedish children and adolescents aged 5-19 in 1990 were grouped into three age cohorts and allocated to four household socioeconomic statuses, considering boys and girls separately. Each cohort was then followed up over a 5-year period (1990-1994) with regard to three injury diagnosis groups (as registered in the national Hospital Discharge and Causes of Death registers) with documented socioeconomic differences: injuries due to traffic, interpersonal violence, and self-infliction. The Relative Index of Inequality was used to measure the magnitude of relative socioeconomic differences, for each year of observation. Where applicable, relative risks were computed in order to see whether equalisation benefited all socioeconomic groups. Tendencies of equalisation were found among girls for two of the diagnosis groups: in traffic injuries for the youngest cohort (aged 5-9 in 1990) and in the case of self-inflicted injuries within the two older cohorts (10-14 and 15-19, in 1990). In conclusion, this study provides limited evidence of equalisation in injury risks between socioeconomic groups among Swedish adolescents. Equalisation appears to be a gender-specific phenomenon, that is, among girls, and manifests itself around the age of 5-13 in traffic-related injuries, when girls are in first and second levels of compulsory school, and later on in self-inflicted injuries. Given the economic recession in Sweden at the time of the study period, whether the equalisation processes are attributable to school, peer group and youth culture effects-as hypothesised by West-is debatable, particularly in the case of self-inflicted injuries.
Epidemiology of Terror-Related Versus Non-Terror-Related Traumatic Injury in Children.
- Aharonson-Daniel L, Waisman Y, Dannon YL, Peleg K. Pediatrics 2003; 112(4): E280.
Correspondence: Limor Aharonson-Daniel, Israel National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Services Research, ISRAEL; (email: limorad@gertner.health.gov.il).
OBJECTIVE: In the past 2 years hundreds of children in Israel have been injured in terrorist attacks. There is a paucity of data on the epidemiology of terror-related trauma in the pediatric population and its effect on the health care system. The objective of this study was to review the accumulated Israeli experience with medical care to young victims of terrorism and to use the knowledge obtained to contribute to the preparedness of medical personnel for future events.
METHODS: Data on all patients who were younger than 18 years and were hospitalized from October 1, 2000, to December 31, 2001, for injuries sustained in a terrorist attack were obtained from the Israel National Trauma Registry. The parameters evaluated were patient age and sex, diagnosis, type, mechanism and severity of injury, interhospital transfer, stay in intensive care unit, duration of hospitalization, and need for rehabilitation. Findings were compared with the general pediatric population hospitalized for non-terror-related trauma within the same time period.
FINDINGS: During the study period, 138 children were hospitalized for a terror-related injury and 8363 for a non-terror-related injury. The study group was significantly older (mean age: 12.3 years [standard deviation: 5.1] v 6.9 years [standard deviation: 5.3]) and sustained proportionately more penetrating injuries (54% [n = 74] vs 9% [n = 725]). Differences were also noted in the proportion of internal injuries to the torso (11% in the patients with terror-related trauma vs 4% in those with non-terror-related injuries), open wounds to the head (13% vs 6%), and critical injuries (Injury Severity Score of 25+; 25% vs 3%). The study group showed greater use of intensive care unit facilities (33% vs 8% in the comparison group), longer median hospitalization time (5 days vs 2 days), and greater need for rehabilitative care (17% vs 1%).
COMMENTS: Terror-related injuries are more severe than non-terror-related injuries and increase the demand for acute care in children.
The cost of trauma.
- Lanzarotti S, Cook CS, Porter JM, Judkins DG, Williams MD. Am Surg 2003; 69(9): 766-770.
Correspondence: John M. Porter, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona 85724-5063, USA; (email: jporter@email.arizona.edu).
Trauma is a financial burden. For the 2634 trauma patients seen in 1999, the percentage of their hospital bill reimbursed and cost coverage (CC), whether that reimbursement covered their hospital costs, were analyzed. Student t tests to compare the mean percentage reimbursements (mPR) and logistic regression with CC (yes/no) as dependent variable with results as odds ratio (OR) were done. The overall mPR was 36 per cent. Among the 947 patients admitted (36%), there was no association between injury severity and mPR. For penetrating trauma, the mPR (25%) was lower than for blunt trauma (37%, P = 0.05). The assault mPR (21%) was lower than for motor vehicle crash (39%, P < 0.001). The mPR for patients transferred in (26%) was lower than for all others (37%, P < 0.001). Male sex (OR = 0.76), Hispanic ethnicity (OR = 0.46), admission (OR = 0.69), severe brain injury (OR = 0.58), abdominal injury (OR = 0.65), and extremity injury (OR = 0.69) were significant predictors for no CC. Reimbursement is better for blunt trauma. That transfers had a significantly lower mPR may represent "dumping" of patients. There is an association between anatomic regions injured and CC. No reimbursement was obtained for 26 per cent of the patients, and in 56 per cent the reimbursement did not cover costs. A change in financing for trauma is needed.
Burns in southern Turkey: electrical burns remain a major problem.
- Nursal TZ, Yildirim S, Tarim A, Caliskan K, Ezer A, Noyan T. J Burn Care Rehabil 2003; 24(4): 309-314.
In Turkey, burns represent a relatively small number of injuries overall, but they continue to be a major public health problem. Our aim in this study was to identify risk factors that affect outcome in burn patients hospitalized in the southern part of our country, with special emphasis on electrical burns. The database for 109 burn patients who were admitted to our burn center from April, 2000, through August, 2001, was retrospectively analyzed. Electrical injury was the cause of burn in 23 (21%) of the 109 cases. The burn causes differed among age groups and between the sexes, with males constituting 95% of the electrical burn patients. The mortality rate for the electrical burn group was lower than the rate for the rest of the burn patients (1/23 vs 17/86, respectively; P <.001); however, the opposite was true for complication rate (10/23 vs 5/86, respectively; P <.001), cost of treatment ($US 8351 vs $US 5122, respectively; P =.009), and length of hospital stay (39.9 vs 26.2 days, respectively; P < 0.001). The rate of electrical burn injury in Turkey has changed very little in the past two decades. This underlines the need for stronger efforts aimed at prevention, such as better public education and strict regulations regarding the distribution and use of electricity.
Zones of prevention: the geography of fall injuries in the elderly.
- Yiannakoulias N, Rowe BH, Svenson LW, Schopflocher DP, Kelly K, Voaklander DC. Soc Sci Med 2003; 57(11): 2065-2073.
Correspondence: Nikolaos Yiannakoulias, Health Surveillance Branch, Alberta Health and Wellness, 24th Floor, PO Box 1360, Alta., T5J 2N3, Edmonton, CANADA; (email: nwy@ualberta.ca).
Our investigation of the geography of fall injuries considers the relationship between injury prevention and contextual approaches to health research. We use a geographic information system (GIS) to describe the pattern of emergency department reported falls of the elderly in the Capital Health Region, an administrative health area in Alberta, Canada. We used empirical Bayes estimates to obtain a geographic measure of fall incidence over the study area and a cluster detection statistic to measure the presence of a significant spatial cluster in the region. Inner-city Edmonton had the highest incidence of risk, suburban Edmonton the lowest, and surrounding rural regions and smaller communities had more moderate fall incidence. We argue that descriptive geography can enhance the effectiveness of injury prevention programs by identifying zones of high risk, even when the individual-level and contextual factors that explain the underlying patterns are unknown.
A prominent school health issue in the United States is the use of backpacks, however, there is a paucity of literature on the effectiveness of backpack safety programs. The purpose of this paper is to describe a school-based backpack health promotion program: Backpack Intelligence, report on its effectiveness, and suggest avenues for future research. Three-hundred-seventy-two 6th and 7th grade students participated in the program which was integrated into their physical education curriculum. Of those students, 242 completed post-education surveys to assess its effectiveness. Pre-education, 44% reported that their backpack was uncomfortable to carry, and 61% reported two or more warning signs that their backpack was too heavy. Only 57% wore their backpack properly and less than half organized the contents in their backpack correctly. Post-education, 63% reported the program worthwhile. Forty-two percent changed the way they used their backpack, and 93% felt knowledgeable about backpack safety, a 24% increase. Both grade and gender differences were found. Areas identified in the literature as fruitful for future research were suggested. Until we have definitive research on the link between backpack use and injury, interventions may be imperfect, but as a society we are compelled to safeguard the health of our children.
A case-control study on the risk factors of injuries in middle school students in southern part of Anhui province
Correspondence: Y.S. Yao, Department of Preventive Medicine, Wannan Medical College, Wuhu 241001, CHINA; (email: unavailable).
OBJECTIVE: To investigate the risk factors of injuries in middle school students and to provide basis for the prevention and reduction of such incidence.
METHODS: 1:1 case-control study was conducted on 254 cases and 254 controls on a basis of sex, age and grade. The relationship between risk factors and injuries were analyzed by conditional univariate and multivariate logistic regression.
FINDINGS: Seven risk factors responsible for the incidence of injury were identified as follows: high risk behaviors (OR = 18.060 0), negligence of defence (OR = 12.645 5), scramble (OR = 9.655 2), father being illiterate (OR = 7.719 1), risky environment around their houses (OR = 5.740 2), extrovert temperament (OR = 5.470 7) and mother being illiterate (OR = 3.058 1). We also distinguished 5 protective factors as follows: education on safety (OR = 0.235 6), harmonic relation between parents (OR = 0.494 1), one-child per families (OR = 0.523 3), students were more knowledgeable and having positive attitude towards road traffic (OR = 0.534 0) and high economy level (OR = 0.560 9).
COMMENTS: The injuries in middle school students were caused by multiple factors, hence should carry out intervention measures to modify the influencing factors of injuries. Injury prevention and control program should focus on certain strategies such as education and supervision of environment hazards.
- Ystgaard M, Reinholdt NP, Husby J, Mehlum L. Tidsskr Nor Laegeforen 2003; 123(16): 2241-2245.
Correspondence: Mette Ystgaard, Seksjon for selvmordsforskning og -forebygging, Det medisinske fakultet, Universitetet i Oslo, 0320 OSLO; (email: mette.ystgaard@psykiatri.uio.no).
CONTEXT: The multisenterstudy Child and Adolescent Self Harm in Europe aims at gaining more valid knowledge about the prevalence of deliberate self harm in adolescents and the factors associated with it. A new method was developed by which the adolescents' self-reported acts of deliberate self harm are included and categorised according to strict predefined criteria.
METHODS: 4,060 11th grade students (response rate 91.2 %) aged 15 and 16 in 36 Norwegian high schools filled in an anonymous self-report questionnaire.
RESULTS: 266 (6.6 %) reported one or more acts of deliberate self harm that met the study criteria over the course of the previous twelve-month period. Cutting (74.1 %) and self-poisoning (16.9 %) were most prevalent. 14.7 % had been in contact with a hospital; 46.7 % of self-poisoning episodes but only 6.1 % of cutting episodes were treated in hospital. Deliberate self harm was more common in females than in males (10.2 % vs 3.1 %, odds ratio 3.5, 95 % CI 2.66 - 4.72). Multiple logistic regression showed significant associations for both sexes between deliberate self harm and low self-esteem, deliberate self harm by friends, serious conflicts with parents, or drug misuse. For girls, alcohol misuse, parents being divorced, being sexually abused, anxiety and impulsivity were also significant; so was deliberate self harm in the family for boys.
COMMENTS: Deliberate self harm among adolescents requires varied and intensified efforts.
A population-based study of help-seeking for self-harm in young adults.
Correspondence: Shyamala Nada-Raja, Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, PO Box 913, University of Otago, Dunedin, NEW ZEALAND; (email: shyamala.nada-raja@ipru.otago.ac.nz).
CONTEXT: To examine help-seeking for self-harm in a population-based sample of young adults.
METHOD: Nine hundred and sixty-five participants aged 26 years were interviewed about help-seeking and barriers to help-seeking for a range of self-harmful behaviours. Self-harm included the traditional methods of suicide (ICD-9 self-harm) and other self-harmful behaviours such as self-battery and self-biting.
FINDINGS: Just over half of the 25 in the ICD-self-harm group (based on ICD-9 self-harm criteria) and one-fifth of the 119 in the other self-harmful behaviour group had sought professional help. Counsellors, psychologists, and general practitioners were the commonest sources of help. Most participants rated help received from health services favourably, however, emergency services were rated less favourably than other health services. Among 77 self-harm participants who did not seek help, just over one-third reported attitudinal barriers.
COMMENTS: To encourage help-seeking by young adults who self-harm, especially young men who are at high risk for self-harm and suicide, it may be necessary to identify ways to reduce attitudinal barriers.
Predisposing factors for self-inflicted burns.
- Pham TN, King JR, Palmieri TL, Greenhalgh DG. J Burn Care Rehabil 2003; 24(4): 223-227.
Correspondence: David G. Greenhalgh, Burn Surgery, Shriners Hospital for Children Northern California, 2425 Stockton Boulevard, Sacramento, California 95817, USA; (email: unavailable).
Self-inflicted burn injuries, although uncommon, are a significant source of morbidity and mortality. The purpose of this study was to delineate the characteristics of these burns and to examine their impact on society. Records of 32 adult patients admitted for self-inflicted burns at our regional burn center between January 1996 and August 2001 were retrospectively reviewed. The mean burn size was 34 +/- 29% TBSA, with the majority of burns being the result of self-immolation using a flammable liquid. There was a slight male predominance (59%) and a significant mortality rate (25%). Ninety-one percent of patients had an active psychiatric diagnosis, with 47% having had a previous suicide attempt. Two thirds had a chronic stressor, such as a chronic medical illness and/or long-term disability. Only four patients had private insurance, whereas the remainder relied on underfunded state- and county-sponsored programs or were uninsured. In addition to well-described psychiatric factors, common characteristics predisposing to self-inflicted burns include chronic medical illnesses, long-term disability, and a lack of access to adequate mental health care. Better treatment of mental illness in the underfunded population might ultimately save the high costs of these burn injuries.
Workshop on applied suicide intervention skills training: is it well suited for medical students?
- Guttormsen T, Hoifodt TS, Silvola K, Burkeland O. Tidsskr Nor Laegeforen 2003; 123(16): 2284-2286.
Correspondence: Torbjorg, Guttormsen, Hogskolen i Tromso, MH-Bygget, Breivika, 9293 Tromso, THE NETHERLANDS; (email: torbjorg.guttormsen@hitos.no).
CONTEXT: The department of psychiatry of the University Hospital of North Norway in Tromso sought to improve suicide prevention skills among medical students through a workshop on applied suicide intervention skills training (ASIST).
METHODS: Over the course of the academic year 1998/99, 76 medical students attended workshops. Results were assessed through focus group interviews.
FINDINGS: By the end of the workshop, students reported more professional confidence and better skills in suicide intervention. They found it very useful to get this opportunity to role-play situations and receive feedback on their own behaviour. Working with suicidal patients is a great and challenging responsibility and students were well aware of the importance of paying attention to the boundaries between one's professional and one's private life. They reported that they saw the benefits of working with caregivers from other professions.
COMMENTS: The workshop appears to enhance suicide intervention skills and will continue to be a part of the clerkship in psychiatry at the University of Tromso.
Suicidal adolescents: what should clinicians look for?
CONTEXT: Over the past decades, suicidal behaviour has increased among adolescents. We wanted to explore what characterises adolescents who come in to see a general practitioner prior to a suicide attempt.
METHOD: 87 % of a group of adolescents below the age of 20 (N = 92) who were admitted to hospital after attempted suicide were interviewed and compared to a non-suicidal control group.
FINDINGS: 41 out of the 92 saw a doctor within six weeks prior to the attempt; 27 presented with purely physical problems, 6 with psychological problems and eight with a combination of both. Only 2 brought up suicidal thoughts with their doctors. Those who saw a doctor prior to the suicide attempt were older and more frequently had eating disorders than those who did not. No other significant differences were found. Compared to the control group, suicidal adolescents who came in to see a general practitioner more often reported divorced parents, fewer siblings, little support from family and peers, having sex at an early age, frequent use of tobacco and illegal drugs, low self-esteem, loneliness and depressive symptoms (p < 0.01).
COMMENTS: Adolescents who saw a doctor prior to a suicide attempt differed significantly from the non-suicidal controls. General practitioners need to have extensive knowledge about risk factors in order to recognise suicidal adolescents. Active inquiry about psychosocial problems, psychopathology and suicidal ideation is necessary.
See item 2 under Psychological and Attentional Issues
Correspondence: R. Peiro, Centro de Salud Publica de Alzira. Direccion General de Salud Publica. Generalitat Valenciana. Valencia. SPAIN; (email: unavailable).
We describe priority issues and some of the results obtained from the implementation of the Prevention and Reduction of Traffic Accident Injuries program in a health area. Since 1999 the public health center has made a priority of identifying and recruiting partners from other sectors (the local police association and the local education authority), increasing its capacity for working together, and setting up an intersectorial working group. Teaching activities and meetings were held. A network of people was created from 17 of a total of 39 town halls that participate in activities supported by the intersectorial group. Ten are involved in educational activities and a further seven focus on ensuring compliance with the law. The intersectorial group promoted their visibility through the local media. These activities are not aimed at reducing injuries from road traffic accidents, but rather at creating an action framework through which all the sectors involved can be mobilized. The aim is to strengthen commitment among political, technical and civil sectors by focussing on social values of respect for a healthier life.
Motor vehicle accidents resulting in injuries: underreporting, characteristics, and case fatality rate.
- Barros AJ, Amaral RL, Oliveira MS, Lima SC, Gon alves EV. Cad Saude Publica 2003; 19(4): 979-986.
Correspondence: A. J. Barros, Departamento de Medicina Social, Universidade Federal de Pelotas, Pelotas, RS, 96001-970, BRAZIL; (email: abarros@epidemio-ufpel.org.br).
In order to describe traffic accidents in a medium-sized Brazilian city and compare the risks of injury and death among different types of vehicles and pedestrians, all traffic accidents identified through police and hospital emergency records were registered for two years Deaths by such accidents were identified and confirmed through the coroner's office. The number of registered vehicles in the municipality was obtained through the State traffic authority. Morbidity and mortality rates were calculated and tests of association between selected variables performed. There was a relevant underreporting of accidents by the police (up to 53%), which varied according to the type of accident and time of occurrence. The highest case fatality rate was observed among bicyclists and pedestrians (around 5%), followed by motorcyclists (3%). Pedestrians formed the highest contingent of deaths. Motorcyclists had an eightfold risk of dying, a fourfold risk of injury, and a twofold risk of running over pedestrians as compared to automobile drivers. We conclude that pedestrians and motorcyclists are priority groups for interventions aimed at reducing injury and death from traffic accidents.
Medical treatment and traffic fatality reductions in industrialized countries.
Correspondence: Robert B. Noland, Department of Civil and Environmental Engineering, Centre for Transport Studies, Imperial College of Science, Technology and Medicine, SW7 2BU, London, UK; (email: r.noland@ic.ac.uk).
Reductions in traffic-related fatalities in developed industrialized countries have been substantial in the last 30 years. Most analyses have attributed this reduction to changes in vehicle design, better road design, increased seat-belt use, and reductions in driving under the influence of alcohol. This paper analyses the impact of improvements in medical treatment and technology. Data from the International Road and Traffic Accident Database (IRTAD), which includes all developed countries, was used in combination with Organization for Economic Cooperation and Development (OECD) Health Care data. Using proxy measures to account for improvements in medical treatment and technology it is found that these proxy variables are significant and capture much of the residual time trend in the data when they are omitted. Changes in age cohorts, such as fewer young people, also have contributed to a reduction in fatalities. These results suggest that medical technology improvements are associated with reductions in traffic-related fatalities over time.
Correspondence: Stephanie Blows, Institute For International Health, University of Sydney, P.O. Box 576, 144 Burren Street, 2042, NSW, Newton, AUSTRALIA; (email: sblows@iih.usyd.edu.au).
Despite speculation about the role of vehicle insurance in road traffic accidents, there is little research estimating the direction or extent of the risk relationship. Data from the Auckland Car Crash Injury Study (1998-1999) were used to examine the association between driving an uninsured motor vehicle and car crash injury. Cases were all cars involved in crashes in which at least one occupant was hospitalized or killed anywhere in the Auckland region. Controls were 588 drivers of randomly selected cars on Auckland roads. Participants completed a structured interview. Uninsured drivers had significantly greater odds of car crash injury compared to insured drivers after adjustment for age, sex, level of education, and driving exposure (odds ratio 4.77, 95% confidence interval 2.94-7.75). The causal mechanism for insurance and car crash injury is not easily determined. Although we examined the effects of multiple potential confounders in our analysis including socioeconomic status and risk-taking behaviours, both of which have been previously observed to be associated with both insurance status and car crash injury, residual confounding may partly explain this association. The estimated proportion of drivers who are uninsured is between 5 and 15% in developed countries, representing a significant public health problem worthy of further investigation.
Relative risk of injury and death in ambulances and other emergency vehicles.
- Becker LR, Zaloshnja E, Levick N, Li G, Miller TR. Accid Anal Prev 2003; 35(6): 941-948.
Correspondence: L.R. Becker, Public Services Research Institute, Pacific Institute for Research and Evaluation, 11,710 Beltsville Drive, Suite 300, 20705-3102, Calverton, MD, USA; (email: becker@pire.org).
This study addresses the impacts of emergency vehicle (ambulances, police cars and fire trucks) occupant seating position, restraint use and vehicle response status on injuries and fatalities. Multi-way frequency and ordinal logistic regression analyses were performed on two large national databases, the National Highway Traffic Safety Administration's Fatality Analysis Reporting System (FARS) and the General Estimates System (GES). One model estimated the relative risk ratios for different levels of injury severity to occupants traveling in ambulances. Restrained ambulance occupants involved in a crash were significantly less likely to be killed or seriously injured than unrestrained occupants. Ambulance rear occupants were significantly more likely to be killed than front-seat occupants. Ambulance occupants traveling non-emergency were more likely than occupants traveling emergency to be killed or severely injured. Unrestrained ambulance occupants, occupants riding in the patient compartment and especially unrestrained occupants riding in the patient compartment were at substantially increased risk of injury and death when involved in a crash. A second model incorporated police cars and fire trucks. In the combined ambulance-fire truck-police car model, the likelihood of an occupant fatality for those involved in a crash was higher for routine responses. Relative to police cars and fire trucks, ambulances experienced the highest percentage of fatal crashes where occupants are killed and the highest percentage of crashes where occupants are injured. Lack of restraint use and/or responding with 'lights and siren' characterized the vast majority of fatalities among fire truck occupants. A third model incorporated non-special use van and passenger car occupants, which otherwise replicated the second model. Our findings suggest that ambulance crewmembers riding in the back and firefighters in any seating position, should be restrained whenever feasible. Family members accompanying ambulance patients should ride in the front-seat of the ambulance.
Factors associated with young drivers' car crash injury: comparisons among learner, provisional, and full licensees.
This exploratory study aimed to investigate factors associated with car crash injury among young drivers aged <25 years with different license status. Of special interest were the differences in risk patterns among different license holders of different age groups. Data utilised in this study were obtained from the New South Wales (NSW) police. The results indicated that female young drivers were more at risk of being killed or injured in a crash than males. Some risk factors, in particular environment-related factors, were identified as license-status-and-age specific. On the contrary, disregarding their driving experiences and ages, young drivers were more influenced by their own behaviours and driving conditions. Young drivers of 16-17 years with learner and provisional licenses tended to have increased risk of crash injury due to special road features. Night-time driving seemed to be a problem for older and more experienced drivers only. Fully licensed drivers of 18-19 and 20-24 years were more susceptible to the influence of alcohol. Risk-taking, speeding, fatigue, and carrying many passengers increased the risk of crash injury to car occupants for nearly all young drivers disregarding their ages and driving experiences. The results obtained provided indicative information on areas where the graduated licensing systems in NSW might be effective, and on other areas that might be lacking. A population-based case-control study was proposed to overcome the limitations of this study.
Passenger carriage and car crash injury: a comparison between younger and older drivers.
- Lam LT, Norton R, Woodward M, Connor J, Ameratunga S. Accid Anal Prev 2003; 35(6): 861-867.
Correspondence: Lawrence T. Lam, The Royal Alexandra Hospital for Children, Locked Bag 4001, Westmead NSW 2145, Sydney, AUSTRALIA; (email: lawrencl@chw.edu.au).
This study was conducted to investigate the effects of passenger carriage, including the number of passengers and the ages of passengers, on the risk of car crash injury. The study utilised data obtained from a case-control study conducted in the Auckland region of New Zealand between 1998 and 1999. Cases were car drivers who involved in crashes in which at least one occupant was hospitalised or killed. Controls were selected from a cluster random sample of car drivers on the roads in the same region. Self-report information on the numbers of passengers carried and their ages at the time of crash or at the time of the roadside survey, as well as potential confounding factors, was obtained from the drivers, or a proxy, using an interviewer-administered questionnaire. A total of 571 cases (93% response rate), including 195 younger drivers (aged <25 years), and 588 controls (79% response rate), including 94 younger drivers participated in the study. After adjusting for other risk factors, the odds of car crash injury among younger drivers was 15.55 times (95% CI 5.76-42.02) for those who carried two or more same age passengers, and 10.19 times (95% CI 2.84-36.65) for those who carried two or more other age passengers, compared with unaccompanied drivers. In comparison, no increase in risk was observed for older drivers who carried two or more passengers regardless of age. The carriage of two or more passengers, irrespective of the ages of passengers, significantly increases the risk of car crash injury among younger drivers. Passenger restriction as part of the graduate licensing system was discussed in the light of these results.
First Reports Evaluating the Effectiveness of Strategies for Preventing Violence: Firearms Laws:
Findings from the Task Force on Community Preventive Services.
- Centers for Disease Control and Prevention. Task Force on Community Preventive Services. MMWR Recommendations and Reports 2003; 52(RR-14): 11-20.
During 2000-2002, the Task Force on Community Preventive Services (the Task Force), an independent nonfederal task force, conducted a systematic review of scientific evidence regarding the effectiveness of firearms laws in preventing violence, including violent crimes, suicide, and unintentional injury. The following laws were evaluated: bans on specified firearms or ammunition, restrictions on firearm acquisition, waiting periods for firearm acquisition, firearm registration and licensing of firearm owners, "shall issue" concealed weapon carry laws, child access prevention laws, zero tolerance laws for firearms in schools, and combinations of firearms
laws. The Task Force found insufficient evidence to determine the effectiveness of any of the firearms laws or combinations of laws reviewed on violent outcomes. (Note that insufficient evidence to determine effectiveness should not be interpreted as evidence of ineffectiveness.) This report briefly describes how the reviews were conducted, summarizes the Task Force findings, and provides information regarding needs for future research.
Sex differences in the perpetrator-victim relationship among emergency department patients presenting with nonfatal firearm-related injuries.
- Wiebe DJ. Ann Emerg Med. 2003; 42(3): 405-412.
Correspondence: Douglas J. Wiebe, Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, 933 Blockley Hall, Philadelphia, PA 19104-6021, USA; (email: dwiebe@cceb.med.upenn.edu).
OBJECTIVES: I examine whether female and male emergency department (ED) patients are equally likely to have been nonfatally shot or struck with a gun by someone they know versus by a stranger.
METHODS: This case-control study examined patient records from US hospital EDs from 1993 to 1999. The records of patients aged 15 years or older who presented with nonfatal firearm-related injuries were accessed from the National Electronic Injury Surveillance System. Patients were classified according to 2 firearm-related injury types (penetrating or nonpenetrating [eg, struck with gun] trauma) and 5 perpetrator types (injury inflicted by spouse or ex-spouse, other relative, friend or acquaintance, self, or stranger).
FINDINGS: Compared with male patients, female patients were 3.6 times (95% confidence interval [CI] 2.5 to 5.3) more likely to have been shot and 3.9 times (95% CI 1.6 to 9.4) more likely to have been struck with a gun wielded by a spouse or ex-spouse than by a stranger. Conversely, women were considerably less likely than men to have been struck with a gun or shot by another relative, to have been struck with a gun by a friend or acquaintance, or to have a gunshot injury that was self-inflicted.
COMMENTS: The cause of firearm-related injuries varies by sex. Before releasing firearm-injury victims from the ED, health care providers should consider 2 important factors: (1) the patient's relationship to the perpetrator, and (2) the availability and previous use of firearms in the victim's home. This information may be helpful in formulating posttreatment plans to enhance the victim's safety.
Could we have known? A qualitative analysis of data from women who survived an attempted homicide by an intimate partner.
- Nicolaidis C, Curry MA, Ulrich Y, Sharps P, McFarlane J, Campbell D, Gary F, Laughon K, Glass N, Campbell J. J Gen Intern Med 2003; 18(10): 788-794.
Correspondence: Christina Nicolaidis, Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, L475, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; (email: nicolaid@ohsu.edu).
OBJECTIVE: To examine in-depth the lives of women whose partners attempted to kill them, and to identify patterns that may aid in the clinician's ability to predict, prevent, or counsel about femicide or attempted femicide.
DESIGN: Qualitative analysis of 30 in-depth interviews.
SETTING: Six U.S. cities.
PARTICIPANTS: Thirty women, aged 17-54 years, who survived an attempted homicide by an intimate partner.
FINDINGS: All but 2 of the participants had previously experienced physical violence, controlling behavior, or both from the partner who attempted to kill them. The intensity of the violence, control, and threats varied greatly, as did the number of risk factors measured by the Danger Assessment, defining a wide spectrum of prior abuse. Approximately half (14/30) of the participants did not recognize that their lives were in danger. Women often focused more on relationship problems involving money, alcohol, drugs, possessiveness, or infidelity, than on the risk to themselves from the violence. The majority of the attempts (22/30) happened around the time of a relationship change, but the relationship was often ending because of problems other than violence.
COMMENTS: Clinicians should not be falsely reassured by a woman's sense of safety, by the lack of a history of severe violence, or by the presence of few classic risk factors for homicide. Efforts to reduce femicide risk that are targeted only at those women seeking help for violence-related problems may miss potential victims.
Physical violence, intimate partner violence, and emotional abuse among adult American Indian men and women in Montana.
- Harwell TS, Moore KR, Spence MR. Prev Med 2003; 37(4): 297-303.
Correspondence: Todd S. Harwell, Montana Department of Public Health and Human Services, Cogswell Building, C-317, PO Box 202951, 59620-2951, Helena, MT, USA; (email: tharwell@state.mt.us).
Little is known about the experience of American Indian communities relative to physical violence (PV), intimate partner violence (IPV), and emotional abuse.A random sample of adult American Indians living on or near the seven Montana reservations were interviewed through an adapted Behavioral Risk Factor Surveillance System telephone survey in 2001 (N = 1,006). Victimization from physical violence was defined as PV or sexual assault committed by any person. Respondents who reported experiencing PV and who reported that the perpetrator was a current or former spouse, boyfriend, girlfriend, or date were categorized as experiencing IPV. Emotional abuse was defined as fear for one's safety or being controlled by another individual.Nine, one, and twelve percent of men reported experiencing PV, IPV, and emotional abuse in the past year, respectively. Five percent of women reported PV in the past year, 3% reported IPV, and 18% reported emotional abuse. Men who reported PV in the past year were more likely to be younger and report more days of physical and mental health problems in the past month. Women reporting PV in the past year were more likely to be younger and have more days with mental health problems in the past month. Few men (7%) or women (12%) reported ever being assessed for PV or safety.Recent PV, IPV, and emotional abuse are prevalent for both American Indian men and women. Strategies to increase screening for PV and effective interventions for violence are needed.
Coping with youth violence: assessments by minority parents in public housing.
- Howard DE, Kaljee L, Rachuba LT, Cross SI. Am J Health Behav 2003; 27(5): 483-492.
Correspondence: Donna E. Howard, University of Maryland, Department of Public and Community Health, College Park, MD 20742, USA; (email: dh192@umail.umd.edu).
OBJECTIVE: To present the views of predominantly African American public housing residents as they discuss violence prevention.
METHODS: Qualitative research was conducted with 38 parents of adolescents. Data were analyzed inductively and in relation to an appraisal-coping theoretical framework.
FINDINGS: Parents enumerated cues that signaled neighborhood danger and signs and symptoms that suggested youth distress. Narratives reflect both ad hoc and systematic coping responses to incidences of violence that involve their children.
COMMENTS: Parents used a variety of coping strategies and diverse resources such as personal skills, family strengths, and community agencies in an attempt to decrease youth exposure and involvement in violence.
