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Dose related risk of motor vehicle crashes after cannabis use.
- Ramaekers JG, Berghaus G, van Laar M, Drummer OH. Drug Alcohol Depend 2004; 73(2): 109-119.
Correspondence: J. Ramaekers, Experimental Psychopharmacology Unit, Department of Neurocognition, Faculty of Psychology, Maastricht University, P.O. Box 616, MD 6200 Maastricht, THE NETHERLANDS; (email: j.ramaekers@psychology.unimaas.nl).
The role of Delta(9)-tetrahydrocannabinol (THC) in driver impairment and motor vehicle crashes has traditionally been established in experimental and epidemiological studies. Experimental studies have repeatedly shown that THC impairs cognition, psychomotor function and actual driving performance in a dose related manner. The degree of performance impairment observed in experimental studies after doses up to 300 microg/kg THC were equivalent to the impairing effect of an alcohol dose producing a blood alcohol concentration (BAC) >/=0.05 g/dl, the legal limit for driving under the influence in most European countries. Higher doses of THC, i.e. >300 microg/kg THC have not been systematically studied but can be predicted to produce even larger impairment. Detrimental effects of THC were more prominent in certain driving tasks than others. Highly automated behaviors, such as road tracking control, were more affected by THC as compared to more complex driving tasks requiring conscious control. Epidemiological findings on the role of THC in vehicle crashes have sometimes contrasted findings from experimental research. Case-control studies generally confirmed experimental data, but culpability surveys showed little evidence that crashed drivers who only used cannabis are more likely to cause accidents than drug free drivers. However, most culpability surveys have established cannabis use among crashed drivers by determining the presence of an inactive metabolite of THC in blood or urine that can be detected for days after smoking and can only be taken as evidence for past use of cannabis. Surveys that established recent use of cannabis by directly measuring THC in blood showed that THC positives, particularly at higher doses, are about three to seven times more likely to be responsible for their crash as compared to drivers that had not used drugs or alcohol. Together these epidemiological data suggests that recent use of cannabis may increase crash risk, whereas past use of cannabis does not. Experimental and epidemiological research provided similar findings concerning the combined use of THC and alcohol in traffic. Combined use of THC and alcohol produced severe impairment of cognitive, psychomotor, and actual driving performance in experimental studies and sharply increased the crash risk in epidemiological analyses.
Brief interventions: good in theory but weak in practice.
Correspondence: Ann M Roche, National Centre for Education and Training on Addiction Flinders University, AUSTRALIA; (email: ann.roche@flinders.edu.au).
A substantial body of research evidence has accumulated in support of the efficacy of brief interventions for a number of alcohol and drug-related problem areas, most notably alcohol and tobacco. This evidence has been used to exhort a range of professional groups such as general practitioners (GPs), and more recently emergency department hospital staff to engage in brief interventions. Internationally, however, these secondary prevention efforts have largely failed. Why have these proven interventions not been embraced by frontline workers? This is a little-asked question as efforts to press-gang unwilling professionals to take up the cudgel continue. This paper examines the characteristics of brief interventions and their principal delivery agents and explores reasons for the failure to move from efficacy to effectiveness. Given the prevention potential that rests with brief intervention, these are crucial questions to address. A key feature of brief intervention delivery also examined is the role of GPs versus the less well-explored option of the practice nurse. It will be proposed that perhaps we have the right vehicle but the wrong driver and that until closer scrutiny is made of this issue efforts in this key prevention area will continue to fail to achieve optimum results.
Sustained increased consumption of cigarettes, alcohol, and marijuana among Manhattan residents after september 11, 2001.
- Vlahov D, Galea S, Ahern J, Resnick H, Kilpatrick D. Am J Public Health 2004; 94(2): 253-254.
Correspondence: David Vlahov, Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY 10029, USA; (email: dvlahov@nyam.org).
We compared reports of increased substance use in Manhattan 1 and 6 months after the September 11, 2001, terrorist attacks. Data from 2 random-digit-dial surveys conducted 1 and 6 months after September 11 showed that 30.8% and 27.3% of respondents, respectively, reported increased use of cigarettes, alcohol, or marijuana. These sustained increases in substance use following the September 11 terrorist attacks suggest potential long-term health consequences as a result of disasters.
Archie Cochrane, the British epidemiologist, posed three key questions to ask about a healthcare intervention: "Can it work?" "Does it work in practice?" and "Is it worth it?"1 It would be great if the answers to these were always positive, but life isn't like that. The possible answers might be classed as "yes," "not sure," and "no." The rules for deciding "yes" are relatively clear and well known, but less has been written about deciding that something doesn't work. This theme issue (of the British Medical Journal) looks at examples of interventions that don't appear to work, the dilemmas of trying to decide between an answer of "not sure" and "no," and what to do when we are not sure.
Doust and Del Mar admit (p 474)2 that "Don't just do something, stand there!" sounds ludicrous. But this is sometimes good advice, as their round up of commonly used but apparently ineffective interventions shows. This issue also includes new evidence of varying kinds and strengths on other interventions that didn't seem to have a marked effect. One of these is a systematic review of mentoring for children with behavioural problems (p 512).3
In each case the type of evidence, its quality, and the potential benefits and harms might lead us to be more or less convinced that an intervention does more good than harm. This is very much a judgment, and if people want to believe there is an effect it can be very hard to persuade them that any effect is too small to be important. As a school textbook puts it when discussing the dilemma of industries or official bodies trying to convince the public that something poses no risk: "It is very hard to persuade people that a factor has no effect. This involves 'proving a negative'."8
When it is difficult to judge effectiveness and benefit from new research, we need all the help we can get from existing evidence. Two articles this week develop this point. McPherson and Hemminki argue that if trials done by pharmaceutical companies to obtain drug licences had to include adequate data on harms and ineffectiveness we could learn much more quickly what we need to know about new drugs (p 518).9 Pound et al propose systematic reviews and meta-analyses of the animal studies that supposedly underpin much human clinical research.10 Such reviews could assess the validity and generalisability to humans of animal research and could prevent unnecessary treatment trials.
Even with all the evidence we can muster, we are often left being uncertain about the right treatment choice.11 As US defense secretary Donald Rumsfeld said at a press briefing on Iraq: "Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns -- the ones we don't know we don't know."12 This much ridiculed statement won the Plain English Campaign's Foot in Mouth award for 2003, but it does make sense when read carefully. Perhaps what we don't know we don't know would be a good topic for a BMJ theme issue.
The role of supervision in child injury risk: definition, conceptual and measurement issues.
- Saluja G, Brenner R, Morrongiello BA, Haynie D, Rivera M, Cheng TL. Inj Control Saf Promot 2004; 11(1): 17-22.
Correspondence: Gitanjali Saluja, National Institute for Child Health and Human Development, National Institutes for Health, U.S. Department of Health and Human Services, Bethesda, MD, USA; (email: salujag@mail.nih.gov).
The purpose of this paper was to examine caregiver supervision and its role as an active strategy in childhood injury prevention. Through a review of the literature, the authors addressed conceptual and methodological issues related to supervision, such as the question of how to define 'adequate supervision.' Three critical dimensions (attention, proximity and continuity) of caregiver supervisory behaviors are identified as important areas for measurement. Presented is a framework for understanding the role of passive and active supervisory behaviors within the social context. The framework includes family and community characteristics and policies/regulations that may be important in caregiver decisions to use active or passive injury prevention strategies. Future research directions are discussed.
A framework for assessing risks to children from exposure to environmental agents.
- Daston G, Faustman E, Ginsberg G, Fenner-Crisp P, Olin S, Sonawane B, Bruckner J, Breslin W, McLaughlin TJ. Environ Health Perspect 2004; 112(2): 238-256.
Correspondence: Stephen Olin, Risk Science Institute, International Life Sciences Institute, One Thomas Circle, Ninth Floor, Washington, DC 20005 USA; (email: solin@ilsi.org).
In recent years there has been an increasing focus in environmental risk assessment on children as a potentially susceptible population. There also has been growing recognition of the need for a systematic approach for organizing, evaluating, and incorporating the available data on children's susceptibilities in risk assessments. In this article we present a conceptual framework for assessing risks to children from environmental exposures. The proposed framework builds on the problem formulation ⇒ analysis ⇒ risk characterization paradigm, identifying at each phase the questions and issues of particular importance for characterizing risks to the developing organism (from conception through organ maturation). The framework is presented and discussed from the complementary perspectives of toxicokinetics and toxicodynamics.
To document drivers' exposure to potential distractions and the effects of these distractions on driving performance, inconspicuous video camera units were mounted in the vehicles of 70 volunteer subjects. The camera units automatically recorded a closeup view of the driver's face, a broader view of the interior of the vehicle, and the roadway immediately ahead of the vehicle whenever it was powered on. Three hours of randomly selected data per subject were coded based on a taxonomy of driver distractions (talking on cell phone, eating, tuning radio, etc.), contextual variables (whether vehicle stopped or moving, road type, traffic level, etc.) and observable measures of driver performance (eyes directed inside or outside vehicle, hands on or off steering wheel, and vehicle position in travel lane). Results were analyzed descriptively and using nonparametric bootstrap analysis techniques. The most common distractions in terms of overall event durations were eating and drinking (including preparations to eat or drink), distractions inside the vehicle (reaching or looking for an object, manipulating vehicle controls, etc.), and distractions outside the vehicle (often unidentified). Although many of the distractions were also associated with negative driving performance outcomes, further research is needed to clarify their impact on driving safety.
Monkey bars are for monkeys: a study on playground equipment related extremity fractures in Singapore.
- Mahadev A, Soon MY, Lam KS. Singapore Med J 2004; 45(1): 9-13.
Correspondence: Arjandas Mahadev, Department of Orthopaedic Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, SINGAPORE; (email: arjandas@kkh.com.sg).
Studies in Caucasian populations have shown that a significant percentage of childhood extremity fractures occur at the playground. There are no comparable studies in Asian populations. Thus this study sets out to determine the pattern of playground related extremity fractures in Asian populations and to suggest modifications to prevent or reduce these injuries. This study involved a retrospective review of 390 patients with these fractures who visited our Department from May 1997 to December 1998. This accounted for 19.5% of all fractures seen in the same period. The largest age group affected were the five through 12-year-old patients with a male to female ratio of 2:1. Monkey bars or upper body devices were the most common cause (66%). The most common fracture was supracondylar fractures (43%). Further studies to determine the actual dimensions of playground equipment will be carried to ascertain with greater certainty the safety of these equipment in our playgrounds.
Correspondence: Stephen Roberts, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Old Road, Oxford OX3 7LF, UK; (email: stephen.roberts@uhce.ox.ac.uk).
OBJECTIVE: To establish and analyse the causes and circumstances of all deaths among British seafarers who were working in flags of convenience merchant shipping between 1976 and 1995, to compare mortality with British seafarers employed in British merchant shipping, and to discuss implications for health and safety.
METHODS: A retrospective longitudinal study of occupational mortality, based on official mortality files.
FINDINGS: Out of a total of 200 deaths in flags of convenience shipping, illnesses caused 68 deaths, accidents 91, homicide 3, suicide 7, drug and alcohol intoxication 4, and disappearances at sea and other unknown causes 27. Deaths from non-natural causes and, in particular, maritime disasters accounted for a significantly higher proportion of all deaths in flags of convenience than in British shipping. The maritime disasters largely involved small cargo ships foundering or disappearing in bad weather.
COMMENTS: Although mortality rates could not be calculated, because of the unavailability of population information, British seafarers who work for flags of convenience registries appear to be at increased risk of mortality through maritime disasters, as well as through occupational accidents and suicide. Many of the occupational accidents, such as asphyxiation in cargo holds, were caused by hazardous working practices, and the disappearances of small cargo ships raises questions about their seaworthiness. Future efforts should focus on investigating the mortality and health of seafarers working in flags of convenience ships, and on improving mortality and population information systems for these registries.
Determinants of work injuries in mines - an application of structural equation modelling.
In spite of stringent regulations and much attention towards reducing risks in the physical environment, the mining industry continues to be associated with high levels of accidents, injuries and illnesses. Only engineering solutions to accident prevention are inappropriate unless coupled with focused attention to the attitudes and behaviours of the mineworkers in coping with the inherent physical, technical and situational risks. The present study identified these various risk factors and analysed their influences on work injury in a causal framework. Data were collected from an underground coalmine of India. The pattern and strength of relationships of 16 causal factors with work injuries were assessed through structural equation modelling. The case study results showed that negatively personified individuals are of major concern for safety improvement in the mine studied. They not only fail to avoid work injuries, they are unable to extend safe work behaviours in their work. The variable safety environment is negatively affected by personality, whereas social support has a positive relationship with safety environment. The variable job hazards appeared to have a significant relationship with job involvement, which has a negative relationship with work injury. Elimination of negative behaviours must be focused and committed by the mine safety management. Long term planning through (i) identification of negative individuals, (ii) proper councelling of adverse effects of negative behaviours, and (iii) special training with psychological treatment is highly required. Identification may begin while recruiting new workers through interview. Proper allocation of jobs (right person for right job) may be a judicial solution to this end.
Matched analysis of parent's and children's attitudes and practices towards motor vehicle and bicycle safety: an important information gap.
- Ehrlich PF, Helmkamp JC, Williams JM, Haque A, Furbee PM. Inj Control Saf Promot 2004; 11(1): 23-28.
Correspondence: P. Ehrlich, Department of Surgery and Pediatrics, Children's Hospital of West Virginia,and Center for Rural Emergency Medicine, West Virginia University, Morgantown, WV, USA; (email: unavailable).
The purpose of this study was to compare parents' and children's attitudes and habits towards use of bicycle helmets and car seat belts. We hypothesized that parental perception of their children's safety practices did not reflect actual behavior and further, that parental practices, rather than their beliefs about a particular safety practice, have a greater affect on their child's risk-taking behavior. The study population consisted of children in grades four and five and their parents/guardians. Participation in the cross-sectional study was voluntary and confidential anonymous questionnaires were used. In separate and independent surveys, children and parents were questioned in parallel about their knowledge, habits and attitudes toward bicycle helmet use and car safety practices. In the study, 731 students participated with 329 matched child-parent pairs. Ninety-five percent of the children own bicycles and 88% have helmets. Seventy percent of parents report their child always wears a helmet, while only 51% of children report always wearing one (p < 0.05). One-fifth of the children never wear a helmet, whereas parents think only 4% of their children never use one (p < 0.05). Parents report their children wear seat belts 92% of the time while 30% of children report not wearing one. Thirty-eight percent of children ride bicycles with their parents and wear their helmets more often than those who do not ride with their parents (p < 0.05). Parents who always wear a seat belt are more likely to have children who sit in the back seat and wear a seat belt (p < 0.05). Parents' perceptions of their children's safety practices may not be accurate and their actions do affect their children's. Injury prevention programs that target both parents and children may have a greater impact on reducing risk-taking behaviors than working with each group in isolation.
OBJECTIVE: Extensive observational studies of acute intoxications (AI) allow the detection of trend changes indispensable for the design of preventive actions. VEIA is an evolutional study of AI attended at the Emergency Services of the Hospital "Doce de Octubre" of Madrid over all-round annual periods (1979, 1985, 1990, 1994 and 1997); we present the results of 2000 and compare them with those of previous years.
METHODS AND RESULTS: An identical method was used. The hospital attended 1,128 AI, 88% of them voluntary. There were 451 suicide attempts. Forty four per cent of drugs involved were benzodiazepines. Alcohol represented 75% of non-pharmacological toxic substances and drugs, 19%.
COMMENTS: An increase of AI caused by alcohol and drugs was observed among women, as well as a decrease of suicide attempts, which reflects an approximation of man/woman roles. An aging trend was observed in suicide attempts (Is suicide "outmoded" among young people?), along with two patterns: Suicide attempts with drugs had a mortality rate of 0.1% and suicide attempts without drugs, of 3%. Two out of five men attempting suicide had drug addictions. There had been a reduction of benzodiazepines use and substitution of aspirine for paracetamol and of other analgesics for NSAID. Alcohol was the predominant non-pharmacological toxic substance, but had decreased 11%. Drugs, that had surpassed the traditional poisons (gases, solvents, etc.) represented 40% more than in 1997. When 1994 and 2000 were compared, heroine had not changed significantly, but cocaine had increased from 13 cases to 67 and amphetamines type MDMA had increased geometrically.
Emergency department management and outcome for self-poisoning: a cohort study.
- Kapur N, Cooper J, Hiroeh U, May C, Appleby L, House A. Gen Hosp Psychiatry 2004; 26(1): 36-41.
Correspondence: Navneet Kapur, Centre for Suicide Prevention, Department of Psychiatry and Behavioural Sciences, 7th Floor Williamson Building, University of Manchester, Oxford Road, M13 9PL, Manchester, UK; (email: nav.kapur@man.ac.uk).
Self-poisoning in adults is an important public health problem across the world, but evidence to guide psychological management is lacking. In the current cohort study we wished to investigate whether aspects of routine Emergency Department management such as receiving a psycho-social assessment, or being referred for specialist follow up, affected the rate of repetition of self-poisoning. The study was carried out in four inner city hospitals in Greater Manchester, United Kingdom, over a 5-month period. We used hospital information systems and reviewed the case notes of every patient presenting to the Emergency Department to identify prospectively all adult patients presenting with deliberate self-poisoning. Data regarding the Emergency Department management of each episode were collected. The Manchester and Salford self-harm database was used to determine the number of individuals who went on to repeat self-poisoning within 6 months of their index episode. During the recruitment period 658 individuals presented with self-poisoning. Traditional risk factors for repetition such as substance dependence, psychiatric contact, and previous self-poisoning were associated with a greater likelihood of receiving a psycho-social assessment or being referred for specialist follow-up. Ninety-six patients (14.6%) repeated self-poisoning within 6 months of their index episode. After adjustment for baseline demographic and clinical characteristics and hospital, receiving a psycho-social assessment was not associated with reduced repetition but being referred for specialist follow-up was [adjusted hazard ratio for repetition (95% CI): 0.49 (0.25 to 0.84), P=.01]. We found that being referred for active follow-up after self-poisoning was associated with a reduced risk of repetition. The implications of this finding are discussed. Further studies using both cohort and randomized controlled study designs will help inform management strategies for patients who poison themselves.
BACKGROUND: Cheerleaders suffer nearly half of catastrophic injuries observed in female scholastic athletes in the United States. However, incidence of noncatastrophic injury in this population has not been described.
HYPOTHESIS: Coach, athlete, and injury circumstance variables may predict the injury rate among cheerleaders.
STUDY DESIGN: Prospective cohort.
METHODS: The authors investigated injury incidence in a sample of North Carolina female cheerleaders who competed inter-scholastically from 1996 to 1999. Injury, exposure, and demographic data were collected from squads that participated in the North Carolina High School Athletic Injury Study.
FINDINGS: Cheerleaders suffered 133 injuries during 1701 athlete seasons. More than 21% of the injuries were ankle sprains. The injury rate was 8.7; the 95% confidence interval (CI) was 6.5 to 11.7 per 10,000 athlete exposures. In a multivariate Poisson regression model, cheerleaders supervised by coaches with the most education, qualifications, and training (coach EQT) had a nearly 50% reduction in injury risk (rate ratio [RR], 0.5; 95% CI, 0.3-0.9), and cheerleaders supervised by coaches with medium coach EQT had a nearly 40% reduction in injury risk (RR = 0.6; 95% CI, 0.3-1.2) compared to cheerleaders supervised by coaches with low coach EQT.
Shoulder injuries to quarterbacks in the National (American) Football League.
- Kelly BT, Barnes RP, Powell JW, Warren RF. Am J Sports Med 2004; 32(2): 328-331.
Correspondence: Russell F. Warren, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021, USA; (email: warren@hss.edu).
BACKGROUND: Quarterbacks are at risk for shoulder injury secondary to both the throwing motion as well as from contact injury.
OBJECTIVE: To delineate the incidence and etiology of shoulder injuries to quarterbacks in the National Football League (NFL).
METHODS: Using the NFL Injury Surveillance System (NFLISS), all reported injuries to quarterbacks between 1980 and 2001 were identified.
FINDINGS: A total of 1534 quarterback injuries were identified with a mean of 18.8 and a median of 6.0 days of playing time lost. The majority of these injuries occurred during a game (83.8%). Passing plays were responsible for 77.4% of all quarterback-related injuries. Shoulder injuries were the second most common injury reported (233 or 15.2%), following closely behind head injuries (15.4%). Direct trauma was responsible for 82.3% of the injuries, with acromioclavicular joint sprains being the most common injury overall (40%). Overuse injuries were responsible for 14% of the injuries, the most common being rotator cuff tendinitis (6.1%) followed by biceps tendinitis (3.5%).
COMMENTS: In this review, the vast majority of shoulder injuries in quarterbacks occurred as a result of direct trauma (82.3%), and less than 15% were overuse injuries resulting from the actual throwing motion.
Snow sports related head and spinal injuries: an eight-year survey from the neurotrauma centre for the Snowy Mountains, Australia.
Neurotrauma from snow-sports related injuries is infrequently documented in the literature. In Australia no collective data has ever been published. The aim of this study is to document the injury pattern of snow sports related neurotrauma admissions to The Canberra Hospital, the regional trauma centre for the Snowy Mountains. A computerised hospital record search conducted between January 1994 and July 2002 revealed 25 head and 66 spinal injury admissions. The incidence of severe injuries requiring referral to tertiary trauma hospital was estimated to be 7.4 per 100,000 skier-days and for head and spinal injury 1.8 per 1,000,000 skier-days and 5.6 per 1,000,000 skier-days, respectively. Collision with a stationary object was disproportionately associated with head injury ( [Formula: see text] ) and falling forward with spinal injury ( [Formula: see text] ). Snowboarders tended to sustain cervical fractures more often than skiers ( [Formula: see text] ). The importance of helmet usage in buffering the impact of head-on collision and the proposition of having both feet fastened to a snowboard in leading to cervical injury were highlighted.
Correspondence: John Langley, Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago Medical School, P.O. Box 913, Dunedin, NEW ZEALAND; (email: john.langley@stonebow.otago.ac.nz).
Injury surveillance has, and will continue to have, a critical role to play in reducing injury. If injury surveillance is going to realise its full potential in reducing injury, however, there are a number of challenges we need to address. These include: (1) agreeing on what is an injury, (2) focusing on important injuries, (3) improving surveillance of important injury events, and (4) improving surveillance of risk and protective factors.
Injuries are among the leading causes of death and disability worldwide. The burden caused by injuries is even greater among the poorer nations and is projected to increase. Very often the lack of technical and financial resources, as well as the urgency of the problem, preclude applying sophisticated surveillance and research methods for generating relevant information to develop effective interventions. In these settings, it is necessary to consider more rapid and less costly methods in applying the public health approach to the problem of injury prevention and control. Rapid Assessment Procedures (RAP), developed within the fields of epidemiology, anthropology and health administration, can provide valid information in a manner that is quicker, simpler, and less costly than standard data collection methods. RAP have been applied widely and successfully to infectious and chronic disease issues, but have not been used extensively, if at all, as tools in injury control. This paper describes Rapid Assessment Procedures that (1) are useful for understanding the scope of the problem and for identifying potential risk factors, (2) can assist practitioners in determining intervention priorities, (3) can provide in-depth knowledge about a specific injury-related problem, and (4) can be used in surveillance systems to monitor outcomes. Finally, the paper describes some of the caveats in using RAP.
Burns caused by hot coolant from the reservoir of motorfarming tricycles have not been reported previously. We performed retrospective studies of such cases in 126 patients with complete records in rural areas of China. The majority of victims were unmarried (59.5%), young (<40 years, >20, 55.6%), and male (male to female ratio 9:1). The burn accident occurred mostly during the busy seasons of spring and summer (66.7%). The mechanism of injury was usually the same. The drivers were trapped under the farming tricycle in a traffic accident and then hot coolant leaked from the mouth of the coolant, resulting in long contact with the hot fluid. The burn wounds were located mostly on the areas of the buttocks and lower extremities (especially on the thigh) (64.3%). The generally burned patients had moderate burn areas, about 20-50% total burn surface area (TBSA) of deep partial thickness or full thickness burn wound. For the purpose of decreasing the number of burns presenting, or at least making them less severe, the suggestions include: (1) the design of motorfarming tricycle should be changed; obviously separation of the coolant tank from the seat is the most important factor in reducing such burns. (2) Road conditions should be improved to reduce traffic accidents and loading regulations introduced. (3) Traffic control should be enhanced, especially in rural areas.
Correspondence: Johan Lund, Department of General Practice and Community Medicine, University of, Oslo, NORWAY; (email: johan.lund@samfunnsmed.uio.no).
This paper presents a model of how three groups of accident prevention measures: modification of attitudes, behaviour, and structural conditions, are influencing two broad categories of risk factors: (a) behaviour, and (b) physical and organisational environment; and two process factors: (c) attitudes and beliefs, and (d) social norms and culture. Some of the hypothesised paths in the model seem to be weak: Attitude modification, Attitude, Behaviour, Accidents and injuries (the KAP-model), while others seem strong: Structural modification, Physical and organisational environment, Behaviour, Accidents and injuries. When various preventive measures are used in combination, and to the extent that they influence social norms and cultural factors, they are probably more effective than interventions affecting individuals (modifying factors such as attitudes and beliefs) only. Although attitude change measures seem to have little direct impact on behaviour, they may still have an important role in accident prevention. Important challenges remain to develop interventions that influence social norms and safety-related aspects of culture and to identify optimal combinations of preventive measures.
OBJECTIVE: To examine return to school and classroom performance following traumatic brain injury (TBI).
METHODS: This cross-sectional study set in the community comprised a group of 67 school-age children with TBI (35 mild, 13 moderate, 19 severe) and 14 uninjured matched controls. Parents and children were interviewed and children assessed at a mean of 2 years post injury. Teachers reported on academic performance and educational needs. The main measures used were classroom performance, the Children's Memory Scale (CMS), the Wechsler Intelligence Scale for Children-third edition UK (WISC-III) and the Weschler Objective Reading Dimensions (WORD).
FINDINGS: One third of teachers were unaware of the TBI. On return to school, special arrangements were made for 18 children (27%). Special educational needs were identified for 16 (24%), but only six children (9%) received specialist help. Two thirds of children with TBI had difficulties with school work, half had attention/concentration problems and 26 (39%) had memory problems. Compared to other pupils in the class, one third of children with TBI were performing below average. On the CMS, one third of the severe group were impaired/borderline for immediate and delayed recall of verbal material, and over one quarter were impaired/borderline for general memory. Children in the severe group had a mean full-scale IQ significantly lower than controls. Half the TBI group had a reading age > or =1 year below their chronological age, one third were reading > or =2 years below their chronological age.
COMMENTS: Schools rely on parents to inform them about a TBI, and rarely receive information on possible long-term sequelae. At hospital discharge, health professionals should provide schools with information about TBI and possible long-term impairments, so that children returning to school receive appropriate support.
BACKGROUND: Recent research studies on the psychological processes underlying suicidal behaviour have highlighted deficits in social problem-solving ability, and suggest that suicide attempters may, in addition, be passive problem-solvers. The aim of this study was to examine problem-solving in suicide attempters (including passivity) and to see whether the deficits are mood-dependent.
METHOD: Two groups, a suicide attempter group and a non-suicidal psychiatric control group completed measures of depression, hopelessness, suicidal ideation and social problem-solving ability shortly after admission, and again 6 weeks later. In addition, a non-psychiatric control group provided baseline data at a single time point.
FINDINGS: The suicide attempter group displayed poorer problem-solving ability than matched psychiatric controls and this difference persisted despite change in mood. However, although suicidal patients were more passive in their problem-solving style than non-psychiatric controls, they were not significantly more passive than psychiatric controls. Problem-solving did not change with improving mood.
COMMENTS: Although passivity is not unique to suicidal patients, in combination with the smaller number and less effective alternatives generated, it may increase vulnerability.
Suicide at 50 years of age and older: perceived physical illness, family discord and financial strain.
- Duberstein PR, Conwell Y, Conner KR, Eberly S, Caine ED. Psychol Med 2004; 34(1): 137-146.
Correspondence: Paul Duberstein, Center for the Study and Prevention of Suicide, University of Rochester Medical Center, Rochester, NY 14642, USA; (email: paul_duberstein@urmc.rochester.edu).
BACKGROUND: Mental disorders amplify suicide risk across the lifecourse, but most people with mental disorder do not take their own lives. Few controlled studies have examined the contribution of stressors to suicide risk.
METHOD: A case-control design was used to compare 86 suicides and 86 controls aged 50 years and older, matched on age, gender, race and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls.
FINDINGS: Perceived physical illness, family discord and employment change amplified suicide risk after controlling for sociodemographic covariates and mental disorders that developed > or = 1 year prior to death/interview. Only the effect of physical illness (OR 6.24, 95% CI 1.28-51.284) persisted after controlling for all active mental disorders.
COMMENTS: Interventions to decrease the likelihood of financial stress and to help families manage discord and severe physical illness may effectively reduce suicides among middle-aged and older adults.
Predictors of suicidal behavior in a sample of Turkish suicide attempters.
- Sayar K, Kose S, Acar B, Ak I, Reeves RA. Death Stud 2004; 28(2): 137-150.
Correspondence: Kemal Sayar, Karadeniz Technical University Medical School, Department of Psychiatry, Trabzon, TURKEY; (email: kemalsayar@hotmail.com).
In a Turkish sample, 100 suicide attempters, were compared with 60 healthy controls on measures of hopelessness, depression, and suicidal ideation. Suicide attempters were more depressive, more hopeless, and displayed greater suicidal ideation than healthy controls. Depression severity rather than hopelessness correlated with suicidal intent. Suicide lethality was independent of depression severity, hopelessness, and suicidal ideation and intent, suggesting that lethality is likely due to chance.
OBJECTIVE: To compare rates of motor vehicle crash (MVC) fatalities among different race/ethnic groups in urban and rural Arizona.
METHODS: Using the Fatality Analysis Reporting System and the National Center for Health Statistics Multiple Cause of Death file, MVC fatalities in Arizona from 1990-96 inclusive were classified by gender, race/ethnicity, and urban or rural residence. Age adjusted rates of total, occupant, pedestrian, and alcohol related fatalities were calculated. The total MVC fatality rate for each race/ethnic group was then adjusted for proportion of rural residence.
FINDINGS: Compared with non-Hispanic whites (NHWs), American Indians had raised relative risks for MVC fatality in all gender and residence subgroups. Hispanic females and rural Hispanic males had lower relative risks, as did rural African-American men. Raised relative risks for American Indian men and women included all subgroups: total, occupant, pedestrian, and alcohol related. Hispanic and African-American men both had raised relative risks of pedestrian related fatalities, and Hispanic men had a slightly higher relative risk while Hispanic women had a lower relative risks, for alcohol related fatality. Hispanic men and women and African-American men had lower occupant fatality rates. Close to half (45%) of the excess MVC fatality among American Indians can be attributed to residence in rural areas, where MVC fatality rates are higher. There were 1.85 occupants in crashes involving NHW deaths compared with 2.51 for Hispanics and 2.71 for American Indians (p<0.001). The proportion of occupants not using a seatbelt was higher in Hispanics and American Indians in both urban and rural areas.
COMMENTS: The major disparity in MVC fatality in Arizona is among American Indians. The higher MVC fatality rates among American Indians occur in all age groups, in both urban and rural areas, and among occupants and pedestrians. Rural residence, lower rates of seatbelt use, higher rates of alcohol related crashes, a greater number of occupants, and higher rates of pedestrian deaths all contribute to the American Indian MVC fatality disparity. High rates of pedestrian fatality occur in men in all three race/ethnic minorities in Arizona and among American Indian women. In contrast to other studies, African-Americans and Hispanics did not have raised total MVC fatality rates and compared to NHWs actually had lower rates in the rural areas of the state.
NCAP test improvements with pretensioners and load limiters.
New Car Assessment Program (NCAP) test scores, measured by the United States Department of Transportation's (USDOT) National Highway Traffic Safety Administration (NHTSA), were analyzed in order to assess the benefits of equipping safety belt systems with pretensioners and load limiters. Safety belt pretensioners retract the safety belt almost instantly in a crash to remove excess slack. They tie the occupant to the vehicle's deceleration early during the crash, reducing the peak load experienced by the occupant. Load limiters and other energy management systems allow safety belts to yield in a crash, preventing the shoulder belt from directing too much energy on the chest of the occupant. In NCAP tests, vehicles are crashed into a fixed barrier at 35 mph. During the test, instruments measure the accelerations of the head and chest, as well as the force on the legs of anthropomorphic dummies secured in the vehicle by safety belts. NCAP data from model year 1998 through 2001 cars and light trucks were examined. The combination of pretensioners and load limiters is estimated to reduce Head Injury Criterion (HIC) by 232, chest acceleration by an average of 6.6 g's, and chest deflection (displacement) by 10.6 mm, for drivers and right front passengers. The unit used to measure chest acceleration (g) is defined as a unit of force equal to the force exerted by gravity. All of these reductions are statistically significant. When looked at individually, pretensioners are more effective in reducing HIC scores for both drivers and right front passengers, as well as chest acceleration and chest deflection scores for drivers. Load limiters show greater reductions in chest acceleration and chest deflection scores for right front passengers. By contrast, in make-models for which neither load limiters nor pretensioners have been added, there is little change during 1998 to 2001 in HIC, chest acceleration, or chest deflection values in NCAP tests.
Risky behavior for traffic accidents: a survey among medical students in Southern Brazil.
- Andrade SM, Soares DA, Braga GP, Moreira JH, Botelho FM. Rev Assoc Med Bras 2003; 49(4): 439-444.
Correspondence: Selma Maffei de Andrade, Centro de Ciencias da Saude, Departamento de Saude Coletiva, Universidade Estadual de Londrina, PR, BRAZIL; (email: semaffei@sercomtel.com.br).
BACKGROUND: Traffic accidents are one of the most frequent cause of mortality among Brazilian youths. Therefore, this study aimed at detecting the prevalence of risk factors for such accidents in a young population.
METHODS: Questionnaires containing questions about risky behavior for traffic accidents were answered by students from the first to the fourth year of the Medical course of the Sate University of Londrina, Paran State, Brazil, during October and November, 2000. The chi-square test was used to detect differences between the sexes, with a 5% significance level.
FINDINGS: Compared to women, male students reported a statistically significant higher frequency of transportation as a car driver, owing a driver license, to have learnt to drive a car under the age of 16 and to have drunk alcoholic beverages before driving a vehicle during the last 30 days. Among regular drivers, a lower proportion of desirable behavior was also noted among male students. Lack of attention (59.3%), disregarding traffic signals (33.5%) and speeding (22.5%) were the main factors cited as determinants for the occurrence of the last accident, with no gender difference.
COMMENTS: These results point out for the need to implement measures in order to reduce factors that favors the occurrence of traffic accidents among these youths, especially among males.
Severe traffic injuries to children, Trent, 1992-1997: time trend analysis.
OBJECTIVE: To examine trends in hospital admission rates and socio-economic gradients for traffic injuries in children, 1992-97.
DESIGN AND LOCATION: Analysis of hospital admission data, Trent, UK.
PARTICIPANTS: Children aged 0-14 years admitted to hospital for pedal, pedestrian or other transport-related injury.
FINDINGS: Admission rates for severe injuries among cyclists and pedestrians significantly increased during the study period. In 1992-93, admission rates (per 100 000) for severe injuries among child cyclists were 22.5. By 1996-97, these had increased to 28.3. The rates for pedestrians were 9.2 and 11.3, respectively. Other transport-related injuries decreased during the study period. Socio-economic gradients in admission rates did not change significantly.
COMMENTS: Hospital admission rates for severe injuries to child cyclists and pedestrians increased in 1992-97, but not the rates for other transport-related injuries.
See item 1 under Alcohol and Other Drugs
See item under Risk Factor Prevalence, Injury Occurrence, and Costs
Studies of violence in stalking have treated interpersonal violence as a homogeneous phenomenon. This study was conducted to ascertain whether the associations of serious violence in stalking are the same as those of general violence in stalking. Of 85 stalkers referred to a forensic service, those who had committed acts of serious violence (homicide and serious assaults) were compared with those who had not on preselected clinical, demographic, and criminological variables. Associations of serious violence were found to differ from those reported for general violence. In particular, serious violence was significantly associated with an absence of criminal convictions and the presence of employment. There was no association with substance abuse, previous convictions for violence, or personality disorder. Different degrees of violence have different associations. This has implications for the development of violence prediction instruments and for violence prevention in stalking.
OBJECTIVE: To determine (1) the nature and frequency of threatening or violent events in the NICU workplace, (2) whether nurses feel confident in their ability to recognize and deal with these events, (3) whether there is an association between violence training and confidence in the ability to recognize and manage violence, and (4) whether NICU nurses report and document these events. DESIGN: A descriptive, self administered questionnaire.
SAMPLE: A nonprobability sample comprised of 68 RNs employed in a Level III NICU in a midwestern metropolitan-area hospital.
MAIN OUTCOME VARIABLES: Types and frequencies of threatening or violent events in the NICU; nurses' confidence in their ability to recognize/manage these events; nurses' reporting/documentation of these events. RESULTS: Fifty-four percent of the sample experienced threatening or violent workplace events; 83.8 percent of the sample felt confident in their ability to recognize violent situations; 69.1 percent felt confident in their ability to manage violent situations. Various means were reported for documenting and reporting such events, but 27 percent neither reported nor documented violent events.
Homicide victim/offender relationship in Florida Medical Examiner District 8.
This study examined the correlations between victim/offender relationship and three variables: motive, weapon choice, and number of injuries inflicted. Empirical relationship and motive categories were used. The sample consisted of 57 intentional homicide cases from Florida Medical Examiner District 8 between the years 1992 and 1996. Relationships were divided into primary and secondary categories. Primary relationships included intimates, relatives, and friends; secondary relationships included acquaintances and strangers. Motives were classified as romantic dispute, argument/conflict, revenge, or felony type; weapons as firearm or contact; and number of injuries inflicted as single or multiple. A significant correlation was found between victim/offender relationship and homicide motive; however, the revenge and felony type motive categories did not differ. Unexpectedly, no correlation was found between victim/offender relationship and either weapon choice or number of injuries inflicted. Further study is needed of the interactions between homicide victim/offender relationship and motive, weapon selection, and number of injuries inflicted.
Age 14 starts a child's increased risk of major knife or gun injury in Washington, DC.
- Freed HA, Milzman DP, Holt RW, Wang A. J Natl Med Assoc 2004; 96(2): 169-174.
Correspondence: Chip Freed, Department of Emergency Medicine, Howard University Hospital, Howard University College of Medicine, Washington, DC 20060, USA; (email: chipfreed@aol.com).
This retrospective review of eight years of trauma registry data at an inner-city level-1 trauma center was undertaken to discover at what age urban children start to become at high risk of being victims of either a major gunshot wound or stabbing. We reviewed data from 2,191 patients who were the victim of either a gunshot wound or stabbing, were 18 years of age or under, and met pre-established criteria to qualify as a major trauma victim. There was a rise and subsequent fall in both overall crime and intentional injury rates during the eight-year period. Nevertheless, in each of the eight years studied, the risk of being a victim of a major gunshot wound or stabbing rose abruptly at age 14 (p<0.01) and the incidence continued to rise sharply through age 18.
Mentoring to reduce antisocial behaviour in childhood.
- Roberts H, Liabo K, Lucas P, DuBois D, Sheldon TA. BMJ 2004; 328(7438): 512-514.
Correspondence: Helen Roberts, Child Health Research and Policy Unit, Institute of Health Sciences, City University, London EC1A 7QN, UK; (email: h.roberts@city.ac.uk).
The effects of social interventions need to be examined in real life situations as well as studies.
Politicians and policy makers are increasingly interested in evidence based decision making. They are under pressure to look to research for solutions to policy problems and justify programmes by reference to the knowledge base. It is tempting for policy makers to grasp any research on seemingly intractable social problems, however slim, in the hope of finding simple solutions. Rolling out national programmes based on inadequate evidence can, however, do more harm than good. We use the example of mentoring for young people with, or at risk of, antisocial behaviour problems to show the potential dangers of running ahead of the evidence.
Social interventions aimed at children
Public health interventions to improve outcomes for children are an example of policy and research evolving in tandem.1-3 Interventions such as Highscope, Headstart, parenting education, home visiting, and mentoring have been well designed and robustly evaluated, some of them by randomised controlled trials.4-10 Nevertheless, parent education, home visiting, and mentoring, as their proponents and evaluators would be the first to agree, largely remain black boxes with a great many unanswered questions about what specific forms of intervention are effective and under which conditions.
Mentoring for antisocial behaviour in childhood
Antisocial behaviour in childhood and adolescence is a problem for young people and their families, for health and welfare professionals planning multidisciplinary services, and for general practitioners approached by fraught parents.12 13 Behaviour problems in childhood can presage more serious problems in later life.14 Antisocial behaviour in young people is also a problem for the police, communities, and politicians. This makes finding a solution a political as well as a therapeutic imperative -- a potent driver for action.
One approach is through mentoring schemes, which a meta-analysis has shown to have benefits.10 In a typical non-directive mentoring programme, a mentor will be a volunteer who provides support or guidance to someone younger or less experienced. The mentor aims to offer support, understanding, experience, and advice. Mentoring is non-invasive and does not require drug treatment. It is easy to see why it might work, and why it is attractive to politicians and policy makers.
In February 2003, Lord Filkin, then a minister in the Home Office, announced £850 000 ($1.6m; 1.26m) of funding for mentoring schemes in England: "Mentors can make a real difference to... some of the most vulnerable people... and help to make our society more inclusive. There are... excellent examples of schemes which really work."15
There is equal enthusiasm in the United States. In his state of the union address in January 2003, President Bush announced plans for a $450m (£238m; 352m) initiative to expand the availability of mentoring programmes for young people. This included $300m for mentoring at risk pupils and $150m to provide mentors to children of prisoners.16
What does the research show?
One problem with interventions that become politically attractive, and to which large sums are attached, is that research may be used for support rather than illumination. Robust research does indicate benefits from mentoring for some young people, for some programmes, in some circumstances, in relation to some outcomes.8-10 But there are also good descriptive evaluations suggesting that those young people who stay on in programmes are inclined to report favourably on the experience.17 18
We examined the existing reviews (see bmj.com) and concluded that research on mentoring programmes does not provide evidence of measurable gains in outcomes such as truanting or other antisocial behaviours.19 When improvements have been reported, such as in reports of the Big Brothers Big Sisters mentoring programme,8 critical examination suggests flaws that weaken the conclusions.8 Although this study was well conducted, it failed to report on changes observed from administrative records. A comprehensive meta-analysis on mentoring found no effect in studies using more objective measuring tools than self report and non-blinded reports of behaviour change.10
Mentoring programmes for vulnerable young people may have a negative impact, and adverse effects associated with breakdowns of relationships with mentors have been reported.20 Worryingly, a three year follow up study of one well designed scheme found that a subgroup of mentored young people, some of whom had previously been arrested for minor offences, were more likely to be arrested after the project than those not mentored.21 On the basis of these findings, we concluded that non-directive mentoring programmes delivered by volunteers cannot be recommended as an effective intervention for young people at risk of or already involved in antisocial behaviour or criminal activities.
We are not suggesting that mentoring cannot work. There are many different kinds of mentoring, and some show better evidence of effect than others.10 Our current state of knowledge on the effectiveness of mentoring is similar to that of a new drug that shows promise but remains in need of further research and development. There is no equivalent of the National Institute for Clinical Excellence or Food and Drug Administration for mentoring. If there were, no more than a handful of programmes might have realistic hopes of qualifying. And even then, it would have to be acknowledged that we lack full understanding of the safeguards needed to ensure that young people are not harmed by participation. For some of the most vulnerable young people, mentoring programmes as currently implemented may fail to deliver on their promises.
How should we respond to the evidence?
Showing that something works (or not) is one thing, and difficult enough. But what happens next in real life settings? We summarised the research findings and presented them to practitioners and planners who were implementing mentoring. Unsurprisingly, their response was not to abandon the projects. Instead, they asked how they could make it work.
They asked for evidence on what seemed to have a more positive effect for the group of children with whom they were working. The research suggests that cognitive behaviour therapeutic approaches are effective in attaining some of the outcomes sought, including when these are delivered through a mentoring-like component.22, 23 The practitioners therefore decided to include a directive element in their approach. They also drew on practices that seem to be associated with stronger benefits for young people, such as ongoing training for volunteer mentors and involvement of parents.10 Of course, without implementing such innovations in a trial setting, we will never know whether new approaches are better, worse, or much the same.
Conclusion
Social interventions are complex and are capable of doing as much or even more harm than medical ones. They need to be as thoroughly evaluated before and after implementation.
Those of us who have been pushing policy makers and practitioners to adopt evidence based practice need to be careful that we do not sell it as a simple way to solve problems. We need a lot more work on how to help policy makers deal with complex interventions and evidence. Research and development in health and social care needs huge investment if we are to develop adequate social interventions for big problems. At present, practitioners, parents, and children and young people themselves, looking for good research evidence on common problems, will find the evidence cupboard disappointingly bare.
Young people have the right to evidence based interventions. We know from the past that many well meaning attempts to do good resulted in harm, but we now have the means through systematic review, trials, sound evaluations, and good qualitative work, to do better.
Meanwhile, a climate has been created in which it is widely held that these interventions are effective and national programmes are being established. Questions about who delivers the service, the kind of young people who might benefit, and the content of services likely to be effective can be lost in the drive to get the programmes running.11 These programmes can gain momentum because they have strong face validity: they look like the sort of things that should work, our instincts tell us that they will work, and we want them to work. This can not only result in premature roll out on the basis of insufficient evidence but also make it difficult to stop or change direction.
