Alcohol-related injury in the ER: a cross-national meta-analysis from the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP).
- Cherpitel CJ, Bond J, Ye Y, Borges G, MacDonald S, Stockwell T, Giesbrecht N, Cremonte M. J Stud Alcohol 2003; 64(5): 641-649.
Corrrespondence: Cheryl J. Cherpitel, Public Health Institute, Alcohol Research Group, 2000 Hearst Avenue, Berkeley, California 94709, USA; (email: ccherpitel@argo.org).
OBJECTIVE: To examine the impact of usual drinking patterns and related problems on the acute use of alcohol in injury.
METHOD: The impact of quantity and frequency of drinking, alcohol problems and dependence symptoms on admission to the emergency room (ER) for an alcohol-related injury (based, separately, on a positive blood alcohol concentration [BAC] and self-reported drinking within 6 hours prior to injury), compared with a nonalcohol related injury, was examined using meta-analysis, across 15 ER studies covering seven countries.
FINDINGS: Pooled effect size for consuming five or more drinks on an occasion at least monthly was significant but not homogeneous, with odds ratios (ORs) of 4.16 for BAC and 3.92 for self-report. Frequency of drinking among nonheavy drinkers was found to have the largest effect size (5.93 for BAC and 4.93 for self-report). Heavy drinking, controlling for frequency, was also significant (ORs of 2.08 for BAC and 1.86 for self-report), but effect size was homogeneous only for self-report. Effect sizes for consequences of drinking and dependence symptoms were also significant and homogeneous, with ORs of 4.29 and 3.55, respectively, for BAC, and 3.84 and 3.94, respectively, for self-report. In meta-regression analysis, among contextual variables the level to which alcohol use is stigmatized in the culture was most consistently predictive of heavy-drinking effect size on an alcohol-related injury, with larger effect sizes found in those studies reporting a lower level of stigmatization.
COMMENTS: Whereas quantity and frequency of drinking were both found to be highly predictive of an alcohol-related injury, sociocultural variables may affect observed associations of heavy drinking with an alcohol-related injury.
The alcohol-related accident risk in Germany: procedure, methods and results.
Correspondence: Mark Vollrath, Center for Traffic Sciences (IZVW), Psychological Institute, Wuerzburg University, Wuerzburg, GERMANY; (email: mark.vollrath@dlr.de).
This paper presents the first reliable estimation of the alcohol-related accident risk in Germany by comparing a representative sample of accidents to a representative sample of trips not leading to a crash. The information about the trips was taken from the German Roadside Survey 1992-1994 (n=9087) conducted in Unterfranken, part of Bavaria. These data were weighted according to a representative study of driving in Germany (KONTIV 89). The accident study comprises a representative sample of accidents in Unterfranken in 1993 (n=1968). Relating accident risk to BAC, the global risk function indicates an exponential increase of accident risk for BACs above 0.05%. Controlling for correlating factors leads to an overall lower estimation with, however, the same structure, indicating that alcohol is consumed by drivers in circumstances which further increase the risk introduced by alcohol. Analyzing the attributable risk (AR) shows that about 12% of all accidents are attributable to alcohol. Over 96% of these happen with BACs of 0.05% and above. Thus, measures aimed at reducing the alcohol-related accident risk must focus on larger BACs, especially of 0.08% and above.
CONTEXT: Social integration may lead to social support and influence that may in turn protect older community-dwelling adults from falls.
METHODS: We examined incident falls over 3 years across quartiles of social integration scores in 6692 Caucasian women enrolled in the Study of Osteoporotic Fractures (mean age = 77 +/- 5 years). Social integration was assessed using family networks, friendship networks, and interdependence scores. Higher scores correspond to greater integration. Data were analyzed using Poisson regression with generalized estimating equations. Multivariate analyses were used to adjust for other risk factors and potential confounders.
FINDINGS: Women reported 11,863 falls, averaging 0.60 falls per person annually, 95% confidence interval (CI) (0.57, 0.63), or 600 falls per 1000 women. In age-adjusted analysis, the average incidence rate of falls correlated inversely with family networks, interdependence, and composite integration scores (p <.05). In multivariate analysis, increasing family networks were inversely associated with fall risk, p(trend) =.02. Compared to the lowest quartile, the relative risk of falls (95% CI) associated with family network scores in the second, third, and fourth quartiles were 0.90 (0.79-1.03), 0.86 (0.74-1.00), and 0.84 (0.71-0.99), respectively.
COMMENTS: Strong family networks may protect against the risk of falls in older community-dwelling adults.
OBJECTIVES: To create, develop, test and evaluate an interactive system for education and training in disaster medicine, adjustable to any organization and giving an objective assessment of training and testing.
METHODS: A system that is simple to use and does not require sophisticated equipment was developed, based on magnetic symbols representing patients, staff and resources, movable markers indicating priority and treatment, and a large patient-bank with a protocol giving results of treatment based on trauma score. The methodology was tested in two models: classroom mode and advanced interactive mode, at all levels, regionally, nationally and internationally.
FINDINGS: During 1987-2001, a total of 8777 students were trained with the system with the classroom mode in 94 regional, 37 national and 8 international courses. The advanced interactive mode was used for 2518 students in 14 regional, 22 national and 18 international courses. The students' evaluation of the quality of the methodology based on a scoring system of 1-5 was 4.32+/- 0.19 for regional courses, 4.70=/-0.12 for national courses and 4.58+/-0.16 for international courses. The students' subjective appreciation of accuracy of the methodology was 4.58 +/-0.16 for national courses and 4.65+/-0.13 for international courses. Corresponding figures for the advanced interactive mode were 4.78+/-0.12 for national and 4.81+/-0.11 for international courses for the methodology and 4.70+/-0.13 for national and 4.65=/-0.17 for international courses for evaluation of accuracy.
COMMENTS: The methodology was well received and the subjective evaluation of the participants on all levels showed very high scores. On the international level many participants had extensive experience. An objective evaluation of accuracy (validity) of the methodology should be carried out as a next step parallel to further utilization of the considerable potential of this methodology.
Hospital Preparedness for Incidents with Chemical Agents.
Correspondence: Michel Debacker, Department of CRitical Care, Free University Brussels, AZ-VUB, Laarbeeklaan, 101, BE-1090, Brussels, BELGIUM; (email: mickel.debacker@hnbe.com).
Although a chemical terrorist attack is a low-probability event for any single community, recent events have demonstrated that exposure to chemical agents has the potential to pose serious problems for hospitals. The community expects that hospitals are adequately prepared for timely and appropriate medical care of casualties of incidents involving weapons of mass destruction. At present, the medical community has limited experience with these agents and the majority of hospitals are inadequately prepared to deal with such an event. This article presents an overview of hospital preparedness in general and some real issues for hospitals affected by an event involving chemical agents, and discusses specific aspects including identification of the incident, staff and hospital protection, decontamination, triage, logistics, training, and psychological effects. Much research needs to be done to improve the preparedness and response capabilities of hospitals.
Posttraumatic Stress Disorder, Alcohol Use, and Perceived Safety After the Terrorist Attack on the Pentagon
Correspondence: Thomas A. Grieger, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (email: thomas.grieger@na.amedd.army.mil).
OBJECTIVE: The authors examined posttraumatic stress disorder (PTSD), alcohol use, and perceptions of safety in a sample of survivors of the September 11, 2001, terrorist attack on the Pentagon.
METHODS: Analyses were conducted to examine the effect of past traumatic experience, trauma exposure, initial emotional response, and peritraumatic dissociation on probable PTSD, substance use, and perceived safety among 77 survivors seven months after the attack.
FINDINGS: Eleven respondents (14 percent) had PTSD. Those with PTSD reported higher levels of initial emotional response and peritraumatic dissociation. Ten respondents (13 percent) reported increased use of alcohol. Women were more than five times as likely as men to have PTSD and almost seven times as likely to report increased use of alcohol. Persons with higher peritraumatic dissociation were more likely to develop PTSD and report increased alcohol use. Those with lower perceived safety at seven months had higher initial emotional response and greater peritraumatic dissociation and were more likely to have PTSD, to have increased alcohol use, and to be female.
COMMENTS: The association of perceived safety with gender, the presence of PTSD, and increased alcohol use among survivors of the terrorist attack on the Pentagon warrants further study.
CONTEXT: The logging industry has a high rate of both fatal and non-fatal injuries in comparison to other industries, and plays a vital role in WV's economy.
METHODS: Workers' compensation (WC) injury claims and employment data were summarized to examine patterns and rates of non-fatal logging injuries in WV from 1995 through 2001.
FINDINGS: The average annual rate of injury claims was 16.0 per 100 workers per year with rates remaining relatively steady over the 7-year study period. The highest rates of injury were a result of being struck by an object, typically trees, snags, or logs.
COMMENTS: WV loggers most often file injury claims as a result of being struck by trees and tree parts, snags, and logs. Assessment of risk is a critical component in helping regulators, researchers, and the logging industry develop viable prevention strategies to reduce the incidence and severity of logging-related injuries.
Occupational musculoskeletal injuries: a study of 503 claims made to the Norwegian National Insurance Administration
CONTEXT: In Norway over the last decade, we have seen an increase in disability claims based on occupational injury. Though much is known about the injury events, so far there have been few Norwegian studies of the relationship between work-related injuries and their somatic and functional consequences.
METHODS: Over the period 1994 - 2002, 503 individuals who had filed claims for work-related musculoskeletal injuries were examined with special emphasis on the clinical consequences of the injury. The median interval between accident and examination was three years. Injury severity was scored using the Abbreviated Injury Scale (AIS).
FINDINGS: Falls were the most frequent type of accident; contusions, sprains and strains the most frequent injuries sustained. Many accidents were poorly documented. 16 % of the injuries were found to exceed an AIS score of 1. 30 % were working full time, while around two thirds were receiving incapacity benefits. There was no association between disability and AIS score.
COMMENTS: In spite of the low overall level of injury severity, there was a high rate of disability subsequent to the accidents. Our results seem to indicate that injury severity is only one of several factors related to outcome after work-related injuries.
Incidence and prevention of occupational electrical accidents
- Goffeng LO, Veiersted KB, Moian R, Remo E, Solli A, Erikssen J. Tidsskr Nor Laegeforen 2003; 123(17): 2457-2458.
CONTEXT: The Norwegian Directorate for Fire and Electrical Safety receives an annual total of 50 reports of injuries caused by electricity, while the Labour Inspection Authority receives 150 reports. The underreporting is, however, considerable. In this article we estimate the Incidence of occupational electrical accidents and describe the legislation regulating the reporting of injuries from electrical accidents.
METHODS: 326 of 343 electricians (95 %) returned a questionnaire on electrical accidents.
FINDINGS: We received reports that indicated an incidence of 7.6 serious accidents per 100 person-years, which equal more than 3000 electrical accidents annually in Norway. Underreporting complicates accident prevention. Doctors should more often report occupational accidents than what is common today.
Correspondence: Patricia C. Dischinger, University of Maryland, The Charles McC. Mathias, Jr. National Study Center For Trauma and EMS, 701 West Pratt Street, 5th Floor, 21201, Baltimore, MD, USA;(email: pdischin@som.umaryland.edu).
Pedestrian deaths constitute the second largest category of motor vehicle deaths in the US. The present study examined how pedestrian injury is associated with vehicle type, while controlling for vehicle weight and speed. Police, trauma registry, and autopsy data were linked for injured pedestrians. Logistic regression analyses were performed to control for vehicle weight and speed. Outcomes included pedestrian mortality, injury severity score, and injuries to specific body regions.Compared to conventional cars, pedestrians hit by sport utility vehicles and pick-up trucks were more likely to have higher injury severity scores (odds ratio=1.48; 95% confidence interval: 1.18-1.87) and to die (odds ratio=1.72; 95% confidence interval: 1.31-2.28). These relationships diminished when vehicle weight and speed were controlled for. At lower speeds, pedestrians struck by sport utility vehicles, pick-up trucks, and vans were approximately two times as likely to have traumatic brain, thoracic, and abdominal injuries; at higher speeds, there was no such association.The overall increased danger sport utility vehicles and pick-up trucks present to pedestrians may be explained by larger vehicle masses and faster speeds. At slower speeds being hit by sport utility vehicles, and pick-up trucks, and vans resulted in specific injuries, indicating that vehicle design may contribute to different injury patterns.
A case of acute gasoline intoxication at the scene of washing a petrol tank.
- Takamiya M, Niitsu H, Saigusa K, Kanetake J, Aoki Y. Leg Med (Tokyo) 2003; 5(3): 165-169.
Correspondence: M. Takamiya, Department of Legal Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka 020-8505, JAPAN; (email: unavailable).
We encountered a case of acute gasoline intoxication at the scene of washing the inner wall of a petrol tank. The decedent was a 50-year-old male, who was the supervisor. Two young workers wearing mask respirators began to wash the inner wall of the gasoline tank under poor ventilation. About 1 h later, because one of the workers lost consciousness, the supervisor entered the tank, without a mask respirator, to rescue the worker. However, the supervisor immediately fainted, and died 26 h after the accident. In the autopsy, blisters were observed on the skin of the face, neck, anterior chest, upper extremities, and back. The heart contained hemolyzed blood. Histologically, hemorrhagic pulmonary edema, pneumonia, and proximal tubular necrosis were found. In the toxicological analyzes, toluene, xylene, and trimethylbenzene were detected in the blood, brain, and gastric contents. Toluene concentrations in the blood and brain were 0.3 mug/ml and 3.7 mug/g, respectively. Since pathological findings were consistent with the reported findings concerning gasoline intoxication, and constituents of gasoline were in the body, death was attributed to acute gasoline intoxication. It was considered that sufficient ventilation and proper use of a mask respirator were essential for this kind of work.
Correspondence: Rod McClure, Injury Prevention Unit, School of Population Health, Mayne Medical School, University of Queensland, Herston Road, Herston, 4006, Qld, Brisbane, AUSTRALIA; (email: r.mcclure@sph.uq.edu.au).
There is a substantial body of work in the scientific literature discussing the role of risk-taking behavior in the causation of injury. Despite the quantity of diverse writings on the subject most is in the form of theoretical commentaries. This review was conducted to critically assess the empirical evidence supporting the association between injury and risk-taking behavior. The review found six case-control studies and one retrospective cohort study, which met all the inclusion criteria. Meta-analysis was not possible due to the diversity of the independent and outcome variables in each of the studies reviewed. Overall the review found that risk-taking behavior, however it is measured, is associated with an increased chance of sustaining an injury except in the case of high skilled, risk-taking sports where the effect may be in the other direction. Drawing specific conclusions from the research presented in this review is difficult without an agreed conceptual framework for examining risk-taking behavior and injury. Considerable work needs to be done to provide a convincing evidence base on which to build public health interventions around risk behavior. However, sufficient evidence exists to suggest that effort in this area may be beneficial for the health of the community.
Impact of exposure to community violence and psychological symptoms on college performance among students of color.
- Rosenthal BS, Wilson WC. Adolescence 2003; 38(150): 239-249.
Correspondence: B.S. Rosenthal, Department of Social Sciences, York College and the Graduate Center, The City University of New York, Jamaica, New York 11451, USA; (email: Rosenthal@york.cuny.edu).
This study examined longitudinal relationships among exposure to chronic community violence during high school, psychological distress during the first semester of college, and academic performance during the first three semesters of college. The sample comprised 385 students of color in a large city. Exposure to community violence and psychological distress were measured with additive scales; academic performance (school persistence, grade point average) was obtained from transcripts. It was found that exposure to community violence and academic performance were not related; exposure to community violence and psychological distress were related; psychological distress and college persistence were related; and psychological distress and grade point average were not related. The findings are consistent with the causal chain model; specifically, that the effects of exposure to community violence in high school on academic performance in college are mediated by psychological distress.
The Hyperbaric Treatment Center (HTC) at the University of Hawaii, has evaluated and treated over 1100 divers for dysbaric disease from 1983 to 2001. We describe some epidemiological parameters and compare trends between local residents and tourist divers in this article. Data obtained from this review were analyzed for age, gender, type of injury and resident status. While trends in Hawaii have mirrored national figures, we did determine that there were some significant differences between resident and tourist divers' patterns of injury over this period of time.
Knowledge and attitudes of coaches of secondary school athletes in Ibadan, Nigeria regarding oro-facial injuries and mouthguard use by the athletes.
Correspondence: C. O. Onyeaso, Department of Preventive Dentistry, College of Medicine, University of Ibadan, Ibadan, NIGERIA; (email: coonyeaso@yahoo.com).
-The objective of this study was to assess the perceptions of secondary school sports' coaches about oro-facial injuries and mouth protector usage in sports by the adolescent athletes. A 10-item, self-completion questionnaire was distributed to 42 coaches from 23 secondary schools randomly selected from different parts of Ibadan city in Nigeria between May and June, 2002. The questionnaire sought information on why a mouth protector (mouthguard) is used, when it is required; the types of mouth protector used, the major reasons for choosing a specific mouth protector, and personal feeling as to whether mouthguards prevent oral injury. Descriptive statistics were used for the data while the chi-square statistic was employed to test the significance of association between variables. All the coaches, 25 (59.5%) males and 17 (40.5%) females with age range of 19-51 years and mean age of 38.07 +/- 8.97 years (mean +/- SD), completed and returned the forms (100% completion rate). 95.2% of the coaches believed that mouthguards prevent oral injuries and 95.2% of them also would like more information on different types of mouthguard, while 4.8% each felt otherwise. The main factor determining the choice of the type of mouthguard for athletes by the coaches was the quality of oral protection (57.1%), and the next was the cost (23.8%). Acceptance of mouthguard was scored as positive by 88.1% of the athletes. 81.0% of the coaches felt that mouthguard should be worn at all times (during practices and competitions) while 19.0% would prefer the use during competitions only. The majority of the coaches (71.4%) believed that boxing needs mouthguards, 2.4% each indicated football (soccer) and Judo while 11.9% of the coaches did not indicate any sport. The majority of these Nigerian coaches agreed on the protective effectiveness of mouthguard against sport-related oro-facial injuries, but they are yet to be adequately informed about mouthguards generally so as to correctly advise and influence these adolescent athletes in this regard.
Use of mouthguards by basketball players in Victoria, Australia.
Copies of the questionnaires and intervention information are available from the corresponding author.
Louise Brearley Messer, School of Dental Science, The University of Melbourne, 711 Elizabeth Street, Melbourne, Victoria 3000, AUSTRALIA; (email: ljbm@unimelb.edu.au).
Basketball is a popular sport in Australia. Although orofacial injuries are common, mouthguard (MG) wear in basketball appears to be low. The purposes of this study were: to measure mouthguard wear by basketball players before and after a promotional intervention; to assess players' knowledge of the value of mouthguards for prevention of injury; and to describe their experience of orofacial injury. Two questionnaires (baseline and follow-up) were administered to a convenience sample of 496 basketball players in Victoria, Australia. Players recruited were youths (12-15-year olds, n = 208) and adults (18 years and over, n = 288), from all basketball levels (social to elite). Completion of the baseline questionnaire was followed immediately by an intervention comprising written and verbal information, a mouthguard blank and instructions on mouthguard construction. The follow-up questionnaire was mailed to all respondents 10-12 weeks later; 135 youths (65%) and 157 adults (54%) completed this. Mouthguard wear at baseline was low but was more frequent at games (62%) than at training (25%). Despite 90% of players acknowledging the protective value of a mouthguard, wear by youths did not increase following the intervention, and wear by adults increased by only 14% for training and 10% at games. Previous orofacial injury was recorded at baseline by 23% of players, but few had requested compensation from Basketball Australia (youths, 17%; adults, 30%). Two predictor variables were statistically identified as related to mouthguard wear: previous orofacial injury and age group. Mouthguard wear was significantly more frequent amongst players with previous injury; such players were 2.76 times more likely to be wearers than those without previous injury. Youths were 2.31 times more likely to wear mouthguards than adults. Only 34 players (12% of respondents at follow-up) had a mouthguard constructed from the blank provided. Although youth and adult groups differed, the overall extent of mouthguard use was disappointingly low. Despite wide recognition of mouthguard value, the intervention had little effect on promoting their use.
Orofacial trauma and rugby in France: epidemiological survey.
- Muller-Bolla M, Lupi-Pegurier L, Pedeutour P, Bolla M. Dent Traumatol 2003; 19(4): 183-192.
Correspondence: Laurence Lupi-Pegurier, Faculty of Odontology, Department of Public Health, 24 Avenue des Diables Bleus, 06357 Nice Cedex 4, FRANCE; (email: llm.pegurier@wanadoo.fr).
A stratified epidemiological survey was carried out among the best French rugby players to assess the prevalence of trauma to the lower or middle part of the face (TLMPF) and the frequency at which the mouthguards (MGs) were worn. The 1140 randomized players (elite 1, elite 2 and national 1 clubs) filled in the same form anonymously. The variables were first subjected to univariate analysis (Chi-square, anova). Secondly, they were included in a multivariate model (logistic regression). Some 29.57% of players had already been affected by a TLMPF. The risk increased for the oldest forward players. It also increased with the number of yearly competitions and number of hours of weekly training. Some 64.3% of players used a MG. The frequency at which it was worn increased with the number of yearly competitions, for those who had experinced a previous trauma and for the pack players who had been playing for a long time.
To enhance patient safety, data about actual clinical events must be collected and scrutinized. This paper has two purposes. First, it provides an overview of some of the methods available to collect and analyze retrospective data about medical errors, near misses, and other relevant patient safety events. Second, it introduces a methodological approach that focuses on non-routine events (NRE), defined as all events that deviate from optimal clinical care. In intermittent in-person surveys of anesthesia providers, 75 of 277 (27%) recently completed anesthetic cases contained a non-routine event (98 total NRE). Forty-six of the cases (17%) had patient impact while only 20 (7%) led to patient injury. In contrast, in the same hospitals over a two-year period, we collected event data on 135 cases identified with traditional quality improvement processes (event incidence of 0.7-2.7%). In these quality improvement cases, 120 (89%) had patient impact and 74 (55%) led to patient injury. Preliminary analyses not only illustrate some of the analytical methods applicable to safety data but also provide insight into the potential value of the non-routine event approach for the early detection of risks to patient safety before serious patient harm occurs.
Trusting the record.
- Clarke K, Hartswood M, Procter R, Rouncefield M, Slack R. Methods Inf Med 2003; 42(4): 345-352.
Correspondence: M. Rouncefield, Department of Computing Lancaster University Lancaster LA1 4YR UK; (email: m.rouncefield@lancaster.ac.uk).
OBJECTIVES: This paper aims to contribute to a longstanding interest in documents and paperwork in healthcare work through an examination of everyday work with patient records in a clinic.
METHODS: An ethnographic study of record keeping practices in a deliberate self harm clinic was conducted to consider the role that document work plays in the development of trust in the routine social interactions of a working division of labor.
FINDINGS: Issues of trust are seen to play central roles within the complexities of organizational working and some consequent implications for the deployment and use of electronic medical record systems are considered.
Because injuries generally are considered a problem of the young, injuries among older adults (i.e., persons aged > or =65 years) have received little attention. However, injuries are the eighth leading cause of death among older adults in the United States. In 2001, approximately 2.7 million older adults were treated for nonfatal injuries in hospital emergency departments (EDs); the majority of these injuries were the result of falls. To characterize nonfatal injuries among older adults, CDC analyzed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP). This report summarizes the results of that analysis, which indicate differences in type and mechanism of injury by sex, suggesting that prevention programs should be designed and tailored differently for men and women.
Deaths: Final Data for 2001.
- Arias E, Anderson RN, Kung HC, Murphy SL, Kochanek KD. Natl Vital Stat Rep 2003; 52(3): 1-115.
Correspondence: Elizabeth Arias, Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics, Hyattsville, Maryland 20782, USA; (email: unavailable).
OBJECTIVES: This report presents final 2001 data on U.S. deaths and death rates according to demographic and medical characteristics such as age, sex, Hispanic origin, race, marital status, educational attainment, injury at work, State of residence, and cause of death. Trends and patterns in general mortality, life expectancy, and infant and maternal mortality are also described. A previous report presented preliminary mortality data for 2001.
METHODS: In 2001 a total of 2,416,425 deaths were reported in the United States. This report presents descriptive tabulations of information reported on the death certificates. Funeral directors, attending physicians, medical examiners, and coroners complete death certificates. Original records are filed in the State registration offices. Statistical information is compiled into a national database through the Vital Statistics Cooperative Program of the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention. Causes of death are processed in accordance with the International Classification of Diseases Tenth Revision (ICD-10).
FINDINGS: The age-adjusted death rate for the United States in 2001 was 854.5 deaths per 100,000 standard population, representing a decrease of 1.7 percent from the 2000 rate and a record low historical figure. Life expectancy at birth rose by 0.2 years to a record high of 77.2 years. Considering all deaths, age-specific death rates rose only for those 25-44 years, and declined for a number of age groups including those under 1 year, 5-14 years, 55-64 years, 65-74 years, 75-84 years, and 85 years and over. The 15 leading causes of death in 2001 remained the same as in 2000. Heart disease and cancer continued to be the leading and second leading causes of death, together accounting for over half of all deaths. Homicide became the 13th leading cause in 2001, rising from the 14th leading cause in 2000 as a result of the September 11, 2001, terrorist attacks. The infant mortality rate remained at a record low level, declining slightly but insignificantly from 6.9 in 2000 to 6.8 in 2001.
COMMENTS: Generally, mortality patterns in 2001 were consistent with long-term trends. Life expectancy in 2001 increased again to a new record level. The age-adjusted death rate declined to a record low historical figure. Although statistically unchanged from 2000, the trend in infant mortality has shown a steady, although slowing, decline. The declining trend in the homicide death rate was reversed primarily as a result of the September 11, 2001, terrorist attacks.
There is great value in exploring the prevalence of school bullying from a cross-national perspective. Smith, Morita, Junger-Tas, Olweus, Catalano, and Slee in 1999 presented a cross-national perspective on the nature, prevalence, and correlates of school bullying that encompassed a wide range of countries. However, Northern Ireland was not included, despite potentially being an important country to include, given its volatile social, ethnic, and religious history--leading to the concern that the population has become somewhat habituated to low level aggression. Thus, the present paper provides a review of the current literature on school bullying in the Northern Ireland school system. Evidence presented suggests that the incidence of school bullying in Northern Ireland may be higher than that in the rest of Ireland and the United Kingdom.
- Levi F, La Vecchia C, Lucchini F, Negri E, Saxena S, Maulik PK, Saraceno B. Acta Psychiatr Scand 2003; 108(5): 341-349.
Correspondence: Fabio Levi, Cancer Epidemiology Unit, University Institute of Social and Preventive Medicine, Bugnon 17, 1005 Lausanne, SWITZERLAND; (email: fabio.levi@inst.hospvd.ch).
OBJECTIVE: To analyse trends in mortality from suicide over the period 1965-99.
METHOD: Data were derived from the WHO database, including data for 47 countries.
FINDINGS: In the European Union (EU), all age suicide mortality peaked at 16.1/100 000 in men in 1980-84, and declined thereafter to 14.4/100 000 in 1995-98. In females, the fall was 29% to reach 4.6/100 000. A similar pattern of trends was observed in several eastern European countries. In contrast, mortality from suicide rose substantially in the Russian Federation, from 37.7/100 000 in males in 1985-89 to 58.3/100 000 in 1995-98 (+55%), and to 9.5/100 000 (+12%) in females. In the USA and most other American countries providing data, no consistent pattern was evident for males, but falls were observed in females. Steady declines were registered for Japan, starting from the highest suicide rates worldwide in the late 1950s. Suicide rates were upwards in Ireland, Italy, Spain, the UK, Cuba, Australia and New Zealand. Substantial rises were observed in a few countries (Ireland, Cuba, Mexico, Australia and New Zealand) for young males.
COMMENTS: In spite of mixed trends, suicide remains a significant public health problem worldwide.
Relationship between antidepressant medication treatment and suicide in adolescents.
- Olfson M, Shaffer D, Marcus SC, Greenberg T. Arch Gen Psychiatry 2003; 60(10): 978-982.
Correspondence: Mark Olfson, Department of Psychiatry, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York, USA; (email: olfsonm@child.cpmc.columbia.edu).
CONTEXT: A decade of increasing antidepressant medication treatment for adolescents and corresponding declines in suicide rates raise the possibility that antidepressants have helped prevent youth suicide.
OBJECTIVE: To evaluate the relationship between regional changes in antidepressant medication treatment and suicide in adolescents from 1990 to 2000.
DESIGN: Analysis of prescription data from the nation's largest pharmacy benefit management organization, national suicide mortality files, regional sociodemographic data from the 1990 and 2000 US Census, and regional data on physicians per capita.
PARTICIPANTS: Youth aged 10 to 19 years who filled a prescription for antidepressant medication and same-aged completed suicides from 588 three-digit ZIP code regions in the United States.
MAIN OUTCOME MEASURES: The relationship between regional change in antidepressant medication treatment and suicide rate stratified by sex, age group, regional median income, and regional racial composition.
FINDINGS: There was a significant adjusted negative relationship between regional change in antidepressant medication treatment and suicide during the study period. A 1% increase in adolescent use of antidepressants was associated with a decrease of 0.23 suicide per 100 000 adolescents per year (beta = -.023, t = -5.14, P<.001). In stratified adjusted analyses, significant inverse relationships were present among males (beta = -.032, t = -3.81, P<.001), youth aged 15 to 19 years (beta = -.029, t = -3.43, P<.001), and regions with lower family median incomes (beta = -.023, t = -3.73, P<.001).
COMMENTS: An inverse relationship between regional change in use of antidepressants and suicide raises the possibility of a role for using antidepressant treatment in youth suicide prevention efforts, especially for males, older adolescents, and adolescents who reside in lower-income regions.
Correspondence: R.A. Quinton, Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9073, USA; (email: unavailable).
In a three month period of 2000, three suicide hanging deaths involving the use of telephone cords occurred in Texas jails and were autopsied at the Southwestern Institute of Forensic Sciences in Dallas. In each case, the telephone was located within the cell, allowing the prisoners unhindered access at any time. Because of these incidents, two of the jails shortened their receiver cords to a total length of 6-8 in. The telephones were otherwise unaltered, and are still in the same locations. The third jail replaced their entire phone with a cordless telephone. Despite the attention that these cases received, standards have not been set regarding the type or placement of telephones used within jail cells, and a fourth incident in 2002 underscores this ongoing problem. These three incidents highlight the need to provide telephones that, if placed within holding cells or other jail cells, do not provide a possible means of suicide.
Suicide by fire in a car trunk: a case with potential pitfalls.
- Adair TW, DeLong L, Dobersen MJ, Sanamo S, Young R, Oliver B, Rotter T. J Forensic Sci 2003; 48(5): 1113-1116.
Correspondence: T.W. Adair, Arapahoe County Sheriff's Office, 13101 E. Broncos Parkway, Centennial, CO 80112, USA; (email: unavailable).
We present an unusual case in which an adult female committed suicide by fire while enclosed in the trunk of her vehicle. A finding of suicide was reached only because several key investigative facts were uncovered. Without these discoveries the case may still remain open as a suspicious death. Fire is rarely used as a mechanism of suicide in Western culture, and, as such, similar cases should be reported to advance our recognition of this phenomenon.
Attempted suicide among young people: risk factors in a prospective register based study of Danish children born in 1966.
Correspondence: Mogens Nygaard Christoffersen, The Danish National Institute of Social Research, Herluf Trolles Gade 11, DK-1052 Copenhagen K, DENMARK; (email: mc@sfi.dk).
OBJECTIVE: In order to prevent suicidal behaviour among adolescents and young adults it would be valuable to know if altering the conditions of their upbringing could reduce their suicidal behaviour. The study surveys possible risk factors.
METHODS: Population-based registers covering children born in Denmark in 1966 at the age span of 14-27 years and their parents for: health, education, family dissolution, suicidal behaviour, substance abuse, criminality and unemployment. A discrete-time proportional hazard modelling was used to analyse the longitudinal observations.
FINDINGS: First-time suicide attempts were associated with parental psychiatric disorder, suicidal behaviour, violence, child abuse and neglect. Increased risks were also found among adolescents and young adults who suffered from psychiatric disorder or physical handicap, had been legally imprisoned, were addicted to drugs, or without graduation, vocational training or employment.
COMMENTS: Stigmatization, social exclusion, and mental disorders in the adolescents or young adults and parents increased risks for attempted suicide.
Suicidal ideations and attempts in juvenile delinquents.
- Ruchkin VV, Schwab-Stone M, Koposov RA, Vermeiren R, King RA. J Child Psychol Psychiatry 2003; 44(7): 1058-1066.
Correspondence: Vladislav Ruchkin, Yale Child Study Center, Yale University School of Medicine, New Haven, CT 06520-7900, USA; (email: vladislav.ruchkin@yale.edu).
CONTEXT: Suicidality among adolescents is a common focus of clinical attention. In spite of links to disruptive behaviors and other types of psychopathology, it is not clear whether other factors commonly associated with suicide, such as personality and parenting, predict suicidality over and above psychopathology. The purpose of the present study was to assess suicidal ideations and attempts and their relationship to psychopathology, violence exposure, personality traits and parental rearing in Russian male juvenile delinquents with conduct disorder (CD).
METHODS: Suicidality and psychopathology were assessed using a semi-structured psychiatric interview in 271 incarcerated male juvenile delinquents diagnosed with CD. Violence exposure, personality characteristics and perceived parental rearing were assessed via self-reports.
FINDINGS: Thirty-four percent of those diagnosed with CD (92 subjects) reported a lifetime history of either suicidal thoughts or attempts. Suicidal ideators and attempters did not differ significantly on any variable of interest, but both reported significantly higher rates of psychopathology and violence exposure than the non-suicidal group, as well as higher levels of harm avoidance, lower self-directedness, and higher rates of perceived negative parental rearing. Finally, even when controlling for the relationship with psychopathology, personality and perceived parental rearing factors showed significant associations with suicidality.
COMMENTS: Juvenile delinquents with CD have high rates of suicidal ideations and attempts, related to a wide spectrum of psychopathology and specific personality traits. These findings suggest that a combination of intrinsic and extrinsic factors create vulnerability to stressors, which under the influence of situational factors (e.g., repeated traumatization) may lead to suicidal thoughts and acts. Factors potentially contributing to vulnerability for suicidality should be identified when planning prevention and rehabilitation efforts for troubled youth.
- Charbotel B, Martin JL, Gadegbeku B, Chiron M. Am J Epidemiol 2003; 158(8): 753-759.
Correspondence: Barbara Charbotel, UMRETTE (Transport, Work and Environment Epidemiology Research Unit), Joint Research Unit of INRETS (French National Institute for Transport and Safety Research) and University Claude Bernard, Lyon, FRANCE; (email: unavailable).
A study was carried out in 1995-1999 to assess severity factors for truck drivers' crashes. The authors used data from the trauma registry of road crash victims of the Rhone region, France. Several descriptive characteristics of the victims (age, place of residence) and their crashes (place, time, antagonist, seatbelt wearing) were analyzed. The injuries of 300 male truck drivers were described by body region, and their severity was measured by using the injury severity score comparing these drivers with 9,488 male car drivers (age: 18-67 years). Truck drivers were more seriously injured than car drivers; the odds ratio was 1.87 (95% confidence interval: 1.33, 2.63) for having an injury severity score of 9 or more. Limb and abdominal lesions were more frequent and more serious among truck drivers. The lack of seatbelt wearing by truck drivers was one of the factors that explained the particular severity of their injuries; the odds ratio, adjusted for seatbelt wearing, for truck drivers to be seriously injured was 1.04 (95% confidence interval: 0.73, 1.47) compared with car drivers. When all of the severity factors were taken into account, the risk was even lower, but not significantly so.
Effects on road safety of new urban arterial roads.
This paper presents an evaluation of the effects on road safety of new urban arterial roads in Oslo, Norway, and a synthesis of evidence from similar studies that have evaluated the safety effects of new urban arterial roads in other cities. A before-and-after study was made of four urban arterial road projects in Oslo. The study controlled for general accident trends in Oslo and for regression-to-the-mean. A statistically non-significant reduction of 9% in the number of injury accidents was found for all four projects combined. The effects on safety of new urban arterial roads were found to vary, depending on whether a new arterial road was built, or an existing arterial road upgraded by means of lane additions and reconstruction of junctions to interchanges. New arterial roads tend to induce more traffic, which tends to offset the benefits of a lower accident rate on the new roads. The results for other cities are very consistent with those for Oslo. For a total of seven cases in which new arterial roads were built, a statistically non-significant reduction of 1% in the number of injury accidents was found. Two cases that involved lane additions and converting at-grade junctions to interchanges resulted in a mean accident reduction of 51%, which was highly significant. On the average, the nine arterial road projects from which evidence was summarised resulted in a net induced traffic of 16%, and a net reduction in accident rate (accidents per million vehicle kilometres) of 18%. These effects almost cancel each other, leading to a very small net change in the expected number of accidents.
The stability of driver acceleration behavior, and a replication of its relation to bus accidents.
Correspondence: Anders E. af Wahlberg, Department of Psychology, Uppsala University, P.O. Box 1225, 75142, Uppsala, SWEDEN; (email: anders.af_wahlberg@psyk.uu.se).
The reliability over time of a method for measuring driver acceleration behavior was tested on bus drivers in regular traffic. Also, a replication of an earlier finding of a correlation between driver acceleration behavior and accident frequency for the individual drivers was made. It was found that the split-half correlation is probably around 0.50 for the mean (of accelerations) of a 30-min drive, and similar for the test-retest of 2.5h measured about a month apart. With such reliability, the sample was probably too small to reliably determine any association with accidents, but some significant correlations were found. Some ways of holding constant the differences in exposure and driving environment were tried with mixed success. Alternate ways of analyzing the data and several methodological problems were briefly discussed. It was concluded that the measurements of acceleration behavior, for bus drivers, are fairly reliable over at least a few months. However, some strange discrepancies between samples make all interpretations concerning the link to accidents tentative.
Characteristics of low speed accidents with buses in public transport: part II.
A number of accident characteristics of bus crashes are analyzed in relation to each other using data from 2237 accident involvements in the city of Uppsala (Sweden) during the years 1986-2000. The breakdown of accidents into sub-categories show, for example, that injury was common in intersection accidents, that bus stops present large risk for shunts and side contacts, while single vehicle accidents were seldom preceded by the loss of control or a skid. The treatment of accident data is discussed in terms of methodology, statistics and data reduction strategies.
Simple car seat insert to prevent upper airway narrowing in preterm infants: a pilot study.
- Tonkin SL, McIntosh CG, Hadden W, Dakin C, Rowley S, Gunn AJ. Pediatrics 2003; 112(4): 907-913.
orrespondence: Alistair J Gunn, Liggins Institute, University of Auckland, Private Bag 92019, Auckland, NEW ZEALAND: (email: aj.gunn@aukland.ac.nz).
OBJECTIVES: To test prospectively the hypothesis that an infant car seat modification to allow the infant's head to rest in a neutral position on the trunk would prevent narrowing of the upper airway and thus reduce oxygen desaturation in preterm infants who are restrained in car seats.
METHODS: Seventeen preterm infants who were approved for discharge were evaluated in a car seat for newborns, with and without a foam insert that provided a slot for the back of the infants' head. Respiration timed inspiratory radiographs for assessment of upper airway dimensions were taken during quiet sleep in each position. Infants were monitored in each position for 30 minutes with continuous polygraphic recording of respiratory, cardiac, and nasal airflow activity and pulse oximetry.
FINDINGS: Placement of the insert in the car seat was associated with a larger upper airway space (mean +/- standard deviation, 5.2 +/- 1.3 vs 3.6 +/- 1.4 mm). This radiologic improvement was associated with a significant reduction in the frequency of episodes of oxygen desaturation to < 85% (1.5 +/- 2.1 vs 3.5 +/- 3.5 episodes/infant), of bradycardia < 90 bpm (0.1 +/- 0.3 vs 1 +/- 1.7), and of arousal (median [25th, 75th], 2.5 [1.3, 4.0] vs 5.0 [4.0, 7.0]).
COMMENTS: The cause of oxygen desaturation in preterm infants who are restrained in car seats is multifactorial. The present data strongly support the hypothesis that flexion of the head on the body is a significant contributor to these episodes and that the mechanism is posterocephalic displacement of the mandible, leading to narrowing of the upper airway. Critically, this pilot study demonstrates that the frequency of episodes of desaturation in a standard newborn car seat can be substantially reduced by placement of a simple foam insert that allows the infant to maintain the head in a neutral position on the trunk during sleep.
Case-control study of risk factors for fatal and non-fatal injury in crashes of civil aircraft.
CONTEXT: There have been few studies of the risk factors for fatal injury in air crashes, and none of risk factors for all serious injury (fatal and non-fatal).
OBJECTIVE: To identify the potentially modifiable risk factors for fatal and non-fatal injury in civil aircraft crashes in New Zealand.
METHODS: We analyzed records from all reported civil aircraft crashes in New Zealand (1988-1994). Air crash data from the official databases were merged with nationwide injury records and information obtained from coroners' files. Pilots-in-command who were fatally injured were compared with pilots-in-command who were not fatally injured using 50 variables covering pilot, aircraft, environmental, and operational characteristics. A second analysis compared pilots-in-command who were seriously injured (either fatally or non-fatally) with those who were involved in a crash but not hospitalized with an injury. Univariate and multivariate logistic regression analyses were then conducted to estimate the odds associated with each of the factors identified by the above comparisons.
FINDINGS: The most significant risk factors for fatal and serious injury were aerobatic flight, post-crash fire, not having a certificate of airworthiness, and off-airport location. Environmental characteristics including terrain type, wind, rain, and elevation of the crash site were identified as risk factors, as was being under instruction. Flying a twin-engine aircraft was a risk factor for fatal injury, while piloting a microlight aircraft was a risk factor for all serious injury.
COMMENTS: Environmental and operational factors, rather than pilot or aircraft characteristics, are the key determinants of the injury outcome of civil aircraft crashes.
CONTEXT: Domestic violence (DV) is common, yet physicians feel unprepared to address it. Educational interventions may improve the care provided to DV victims, yet the effectiveness of interventions is often unproven.
METHODS: Written questions and DV-specific standardized patient (SP) checklist items from an end-of-clerkship and fourth-year comprehensive multispecialty (the Clinical Performance Examination or CPX) examinations of medical students participating in a DV workshop using SPs was compared with nonparticipants. S: DV workshop participants' and nonparticipants' written question mean scores were 93.2% and 85.8%, respectively, p =.02. End-of-clerkship SP examination DV-specific checklist scores for participants and nonparticipants was 76.3% and 60.0%, respectively, p =.002. Workshop participants scored 44.1% on the CPX DV-specific checklist items versus 35.6% for the nonparticipants, p =.01.
COMMENTS: A DV workshop improved knowledge and skills assessed four and an average of 27 weeks later.
Significance of violence in stories of young children.
Stories told by 72 5-yr.-old children were scored for themes of violence and correlated with their mothers' reports of aggressive or fearful behaviors. Values for the entire sample were not significant. However, when data for Hispanic children were removed from the sample the correlation of violent stories to ratings of children's aggression was significant (r = .27) and for a count of violent words r = .30. The correlation of violent words to fearfulness was .28 and for girls only .35. The count of violent words was also correlated with African-American children's ratings of fearfulness (r = .64).
Identification of Physician and Patient Attributes That Influence the Likelihood of Screening for Intimate Partner Violence.
- Jonassen JA, Mazor KM. Acad Med 2003; 78(90100): S20-S23.
Correspondence: Julie A. Jonassen, Department of Physiology, University of Massachusetts Medical School, 55 Lake Ave. North, Worcester MA, 01655, USA; (email: Julie.Jonassen@umassmed.edu).
CONTEXT: Effective assessment of intimate partner violence (IPV) demands that everyone at risk be screened. To identify potential barriers, paper-and-pencil case scenarios identified possible practitioner and patient attributes that influence IPV screening.
METHODS: First-year residents responded to one of four short written scenarios describing a divorced female patient with nonlocalized abdominal pain; variables were patient's age and abdominal bruising. Residents rated their likelihood of screening for IPV and seven other screening tasks and self-assessed their competence in performing each task. Regression analyses assessed the influence of resident and patient characteristics on screening likelihood.
FINDINGS: Patient bruising, younger patient age, and resident self-assessed competence best predicted IPV screening. Men were less likely than women to screen for IPV.
COMMENTS: Although most physicians receive training on IPV in medical school, barriers to IPV screening still exist. Identifying obstacles to IPV risk-assessment is an essential prerequisite for improving educational programs that promote routine IPV screening.
Sense of coherence: a mediator between violence exposure and psychopathology in Russian juvenile delinquents.
- Koposov RA, Ruchkin VV, Eisemann M. J Nerv Ment Dis 2003; 191(10): 638-644.
Correspondence: Vladislav V. Ruchkin, Yale Child Study Center, Yale University School of Medicine, 230 South Frontage Road, New Haven, CT 06520-7900, USA; (email: vladislav.ruchkin@yale.edu).
Previous research has demonstrated that exposure to community violence tends to have a hazardous impact on the health and well being of youth. In this context, sense of coherence is related to indicators of well being and mental health and is considered crucial for human information processing in resolving conflicts and coping with enduring stress. The aim of the present study was to explore the role of sense of coherence as a potential mediator in the relationships between community violence exposure and psychopathology, controlling for involvement in severe problem behavior. The study was conducted with a group of Russian juvenile delinquents (N = 159; a highly traumatized population with a history of frequent exposure to violence), who completed a set of questionnaires assessing their exposure to community violence, psychopathology, involvement in severe problem behaviors, and sense of coherence. The relationships among the variables of interest were explored using a structural equation modeling approach. Sense of coherence partially mediated the link between victimization and psychopathology. The direct relationships between victimization and psychopathology decreased in size, suggesting that higher levels of sense of coherence can potentially reduce the levels of psychopathology. These results have an important theoretical value and are meaningful for clinical work, suggesting that preventive and therapeutic interventions should aim at increasing sense of coherence, which might be especially valuable in populations at risk.
See item under Psychological and Attentional Issues
