OBJECTIVE AND METHODS: To assess the role of alcohol in drowning associated with recreational aquatic activity by reviewing the English language literature published up to October 2003.
FINDINGS: Alcohol is widely used in association with recreational aquatic activity in the United States, but there is minimal information regarding the extent of use elsewhere. A priori and anecdotal evidence suggests that alcohol is an important risk factor for drowning associated with recreational aquatic activity. Specific studies provide good evidence supporting this, but the extent of increased risk associated with alcohol use, and the attributable risk due to alcohol use, is not well characterised. Drowning appears to be the overwhelming cause of death associated with recreational aquatic activity with alcohol detected in the blood in 30%-70% of persons who drown while involved in this activity. The few relevant studies on degree of increased risk suggest persons with a blood alcohol level of 0.10 g/100 ml have about 10 times the risk of death associated with recreational boating compared with persons who have not been drinking, but that even small amounts of alcohol can increase this risk. The population attributable risk seems to be in the range of about 10%-30%.
COMMENTS: Alcohol consumption significantly increases the likelihood of immersions resulting in drowning during aquatic activities. However, more information is required if appropriate prevention activities are to be planned, initiated, and evaluated. This includes better information on alcohol use, and attitudes to alcohol use, in association with recreational aquatic activity, and the nature and extent of increased risk associated with alcohol use. Evaluation of interventions is also needed.
This is one of a pair of editorials in the April 10, 2004 issue of the British Medical Journal on the public health impact of traffic-related injuries. The authors comment on the attention given by public health professionals to the road traffic injury problem. They also comment upon the World Health Organization report, "The World Report on Road Traffic Injury Prevention," issued this week for World Health Day. (A summary of the WHO report is included under the Transportation Issues heading below.)
This is the second of two editorials in the April 10, 2004 issue British Medical Journal inspired by the theme of World Health Day (Road safety is no accident). Pless endorses the systems approach recommended by the WHO authors. He points out that this places less of the safety responsibility upon the victim and more on the architects of the transportation system and the vehicle manufacturers. (A summary of the WHO report is included under the Transportation Issues heading below.)
Women living within a violent relationship suffer from a multitude of somatic and psychological complaints. The constant erosion of their self-esteem undermines their confidence and decision-making abilities, eventually leading to a learned helplessness and apathy. In association with this is the significant deleterious effect on the psychological and physical health of any children witnessing this abuse within the home. Community health care providers such as district nurses, practice nurses and GPs are in close contact with the family and can observe the family dynamics. They are often the only health care professionals in a position to be able to build a rapport with the family. Consequently a survivor of domestic abuse may confide in them, enforcing the health professional to play a pivotal role in empowerment and the initiation of essential support services. This article highlights the detrimental effects of domestic abuse and the necessity to raise awareness within the community forum.
Survival and cost analysis of fatalities of the Kobe earthquake in Japan.
- Aoki N, Nishimura A, Pretto EA, Sugimoto K, Beck JR, Fukui T. Prehosp Emerg Care 2004; 8(2): 217-222.
Correspondence: Noriaki Aoki, FJSIM, School of Health Information Sciences, University of Texas Health Science Center-Houston, 7000 Fannin, UCT-600, Houston, TX 77030, USA; (email: noriaki.aoki@uth.tmc.edu).
OBJECTIVES: The authors investigated the dying patterns, and cause and preventability of deaths in a major earthquake disaster, and estimated the cost needed to enhance emergency medical services (EMS) response to prevent "unnecessary" deaths.
METHODS: The authors reviewed autopsy data in the Hanshin-Awaji (Kobe) earthquake of 1995. A survival analysis was performed to determine the time course and pattern of dying of these deaths. A cost analysis to estimate acceptable cost for EMS to reduce fatalities was also performed. Potentially salvageable life-years based on expected life-years among fatalities were calculated and used to simulate an acceptable cost for an enhanced EMS disaster response.
FINDINGS: The authors analyzed 5,411 fatalities. More than 80% of these patients died within three hours. There were statistically significant differences in survival/dying patterns among causes of death. Thirteen percent of victims experienced a protracted death, which could have been prevented with earlier medical or surgical intervention. The monetary cost of these lost lives was estimated at approximately $600 million US.
COMMENTS: Survival analysis revealed a significant population of potentially salvageable patients if more timely and appropriate medical intervention had been available immediately after the earthquake. Based on our cost analysis, and assuming a 1% annual probability of an earthquake and a 30% enhanced lifesaving capability of the EMS effort, approximately $2 million annually could be a reasonable expenditure to achieve the goal of reducing preventable deaths in disasters.
Heat-waves: risks and responses.
- Koppe C, Kovats S, Jendritzky G, Menne B. World Health Organization, Health and Global Environmental Change Series, Number 2. Geneva, Switzerland: World Health Organization.
Correspondence: Christina Koppe, Human Biometeorology, Deutscher Wetterdienst, Stefan-Meier-Str 4, D-79104 Freiburg, GERMANY; (email: christina.koppe@dwd.de).
High air temperatures can affect human health and lead to additional deaths even under current climatic conditions. Heatwaves occur infrequently in Europe and can significantly affect human health, as witnessed in summer 2003. This report reviews current knowledge about the effects of heat-waves, including the physiological aspects of heat illness and
epidemiological studies on excess mortality, and makes recommendations for preventive action. Measures for reducing heatrelated mortality and morbidity include heat health warning systems and appropriate urban planning and housing design. More heat health warnings systems need to be implemented in European countries. This requires good coordination between health and meteorological agencies and the development of appropriate targeted advice and intervention
measures. More long-term planning is required to alter urban bioclimates and reduce urban heat islands in summer. Appropriate building design should keep indoor temperatures comfortable without using energy-intensive space cooling. As heat-waves are likely to increase in frequency because of global climate change, the most effective interventions,
measures and policies to protect the health of vulnerable Europeans need to be developed and evaluated.
Correspondence: Kathryn A. Hamel, Department of Physical Therapy and Rehabilitation Science, University of California at San Francisco, San Francisco, California, USA; (email: unavailable).
OBJECTIVE: To examine specific behaviors used by older adults while ascending and descending stairs and to assess the relationships between confidence and stair performance.
METHODS: Cross-sectional.
SETTING: Center for Locomotion Studies, The Pennsylvania State University.
PARTICIPANTS: Sixteen male (mean age=82.7, range= 77-89) and 16 female (mean age=82.2, range=77-87) community-dwelling adults.
MEASUREMENTS: A stair self-efficacy (SSE) test was created to assess individuals' confidence in their safety on stairs. Observational stair performance measures, measures of walking speed on stairs, and the total SSE score were examined for differences due to sex, and the relationships between SSE and specific stair behaviors were assessed.
RESULTS: There was a significant relationship between SSE and the safety precautions taken during stair negotiation. Those with lower SSE were more likely to ascend and descend the stairs at a slower speed, use the handrail to a greater extent, and position themselves closer to the rail. The women had lower domain-specific SSE and tended to use the handrail to a greater extent than men even though there were no sex differences in self-reported functional ability or general falls and mobility confidence. A small group of subjects exhibited characteristics of instability, particularly during stair descent, yet most of this group had high SSE scores and failed to use the handrail.
COMMENTS: It appears that confidence related to stair negotiation plays a major role in determining risk-taking propensity during stair use in older adults.
A computational study on the use of balconies to reduce flame spread in high-rise apartment fires.
- Mammoser JH, Battaglia F. Fire Saf J 2004; 39(4): 277-296.
Correspondence: John H. Mammoser, Fire Resistive Construction, Fire Protection Division, Underwriters Laboratories, Inc., 333 Pfingsten Rd., Northbrook, IL 60062, USA; (email: john.mammoser@us.ul.com).
High-rise apartment fires are perhaps the most dangerous residential fires. Within high-rise buildings, flames and smoke can travel through ductwork, between interior walls, and up elevator shafts and stairwells. One of the fastest ways a fire spreads to other floors is along the exterior of the building due to open windows. Flame spread up vertical walls has been studied experimentally and computationally for years in the US and abroad. A numerical study has been undertaken to examine the reduction of vertical flame spread due to the presence of a balcony. The depth and geometry of the balcony greatly affects the vertical movement of fire. By varying the balcony depth and geometry, the aim of this study is to find an optimum configuration that reduces vertical fire spread on the external wall.
Do smoke alarms still function a year after installation? A follow-up of the get-alarmed campaign.
- Thompson CJ, Jones AR, Davis MK, Caplan LS. J Community Health 2004; 29(2): 171-181.
Correspondence: Corleen J. Thompson, 3704 Quail Hollow Road, Albany, GA 31721-2810, USA; (email: esfunccjt@mybluelight.com).
The Get-Alarmed Campaign Follow-up Study was the second phase of an initiative to assure that homes of families at high risk of fire-related injury and death had functioning smoke alarms. Smoke alarms and/or batteries were installed in over 94 percent of 454 participating households in Schley and Henry Counties, Georgia, in 2000. Before the study began, 60.6 percent of these homes had smoke alarms, but only 36.6 percent had functioning smoke alarms. The follow-up study was designed to determine the experiences of participants with smoke alarms and whether participating households had functioning smoke alarms a year after baseline. Participants were phoned or visited and asked about their experiences with smoke alarms since the baseline study. During the interview, they were asked to test a smoke alarm, the results of which could frequently be heard. Respondents included 237 from Schley County and 113 from Henry County, for an overall 77.1 percent response rate. While 80.3 percent of respondents had a smoke alarm that was heard by the interviewer when it was tested, 6.6 percent reported that their smoke alarm had been disabled or had a dead battery. Over 75 percent of respondents had smoke alarm sound offs in the prior year, predominately due to cooking smoke, but only about 5 percent reported removing the battery or otherwise disabling it to prevent sound offs. However, the measures taken may render a household unprotected at a critical time. Efforts to increase protection with smoke alarms should be augmented with programs to insure adequate and timely testing and maintenance of existing smoke alarms.
Work-related tetraplegia: cause of injury and annual medical costs.
- Webster B, Giunti G, Young A, Pransky G, Nesathurai S. Spinal Cord 2004; 42(4): 240-247.
Correspondence: Barbara Webster, Liberty Mutual Center for Disability Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA; (email: unavailable).
OBJECTIVE: To describe the demographics, cause of injury, and annual-paid medical costs for the 5 years following injury for cases of work-related tetraplegia.
STUDY DESIGN: Descriptive study.
SETTING: A single United States workers' compensation (WC) claims database.
METHODS: Tetraplegia cases with initial date of injury from 1 January 1989 to 31 December 1999 were selected by cross-referencing word search terms pertaining to body part injured and nature of injury. The main outcome measures were injury causes and annual-paid medical payments (adjusted to year 2000 medical consumer price index) of work-related tetraplegia by injury group for each year postinjury over a 5-year time period.
FINDINGS: A total of 62 claimants with work-related tetraplegia injured between 1 January 1989 and 31 December 1999. The vast majority of those identified were male claimants (92%) and more than a quarter worked in the construction industry (26%). Other highly represented industries included transportation and retail (15% each), manufacturing (13%), and agriculture and utility (11% each). The majority of injuries were the result of falls (36%) and vehicular accidents (34%). The mean Year 1 cost was $560 524 for those with a high-level tetraplegia (C2-4 ASIA A-C), $431 033 for a low-level injury (C5-8 ASIA A-C), and $178 041 for those with an ASIA D tetraplegia injury. The mean cost of subsequent years (Years 2-5) was $130 992 for a high-level, $129 250 for a low-level, and $34 352 for an ASIA D tetraplegia injury.
COMMENTS: Mean costs for Year 1 postinjury in WC cases are similar to previously published estimates. Comparing the current results with those of previous spinal cord injury cost studies suggests that those with work-related tetraplegia may receive more injury-related paid medical benefits after the first year postinjury than cases who do not receive WC-supported benefits.
The epidemic of pediatric traffic injuries in South Florida: a review of the problem and initial results of a prospective surveillance strategy.
- Hameed SM, Popkin CA, Cohn SM, Johnson EW; The Miami Pediatric Traffic Injury Task Force. Am J Public Health 2004; 94(4): 554-556.
Correspondence: Stephen M. Cohn, Ryder Trauma Center, Daughtry Family Department of Surgery, University of Miami School of Medicine, 1800 NW 10th Ave, Suite 227, Miami, FL 33136, USA; (email: stephen.cohn@miami.edu).
This study identified specific regional risk factors for the high rate of pediatric pedestrian trauma in Florida. Of the 29 cases studied prospectively, 3 (10%) occurred near ice cream trucks and 13 (45%) involved "dart-outs"; mean hospital charges were $24 478 +/-$43 939. Recommendations included an engineering change for a dangerous intersection, and a population-based recommendation was to equip ice cream trucks with extending stop signs.
Correspondence: Kevin C. Osterhoudt, Section of Medical Toxicology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA; (email: osterhoudtk@email.chop.edu).
OBJECTIVES: Vomiting frequently complicates the administration of activated charcoal. The incidence of such vomiting is not defined precisely in the pediatric population. Little is known about the patient-, poison-, or procedure-specific factors that contribute to emesis of charcoal. This study aimed to estimate the incidence of vomiting subsequent to therapeutic administration of charcoal to poisoned children < or =18 years of age and to examine the relative contributions of several risk factors to the occurrence of vomiting.
METHODS: Data were collected on a prospective cohort of 275 consecutive children who were treated with activated charcoal for acute poisoning exposure. The study was set in the emergency department of an urban, tertiary-care children's hospital. Sorbitol content of the charcoal was alternately assigned. Potential risk factors for vomiting were recorded prospectively, and the occurrence of vomiting within 2 hours of charcoal administration was measured.
FINDINGS: A total of 56 (20.4%) of 275 patients vomited. Median time to vomiting was 10 minutes.Previous vomiting (relative risk: 3.41; 95% CI: 1.48-7.85) and nasogastric tube administration (relative risk: 2.40; 95% CI: 1.13-5.09) were found to be the most significant independent risk factors for vomiting. The increased risk among children >12 years of age, compared with younger children, approached significance. Sorbitol content, large charcoal volumes, or fast administration rates did not increase vomiting risk significantly.
COMMENTS: One of every 5 children who are given activated charcoal within our pediatric emergency department vomited. Children with previous vomiting or nasogastric tube administration were at highest risk, and these factors should be accounted for in future investigation of antiemetic strategies. Sorbitol content of charcoal was not a significant risk factor for emesis.
Effectiveness of rugby headgear in preventing soft tissue injuries to the head: a case-control and video cohort study.
- Jones SJ, Lyons RA, Evans R, Newcombe RG, Nash P, McCabe M, Palmer SR. Br J Sports Med 2004; 38(2): 159-162.
Correspondence: Sarah Jones, Department of Epidemiology, Statistics and Public Health, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, Wales, UK; (email: jonessj3@cardiff.ac.uk).
OBJECTIVE: To determine if headgear use by rugby players was associated with a reduced risk of head or facial laceration, abrasion, or fracture.
METHODS: An emergency department based case-control study in South Wales, UK, with cases being rugby players treated for superficial head and facial injuries and controls being their matched opponents during the game. A review of videos of the 41 games in the 1999 Rugby World Cup was also carried out to compare with the case-control study. Odds ratios (OR) and 95% confidence intervals (95% CI) were used to measure association between exposure (headgear wearing) and outcome (head and facial injuries).
FINDINGS: In the case-control study, 164 pairs were analysed, with headgear worn by 12.8% of cases and 21.3% of controls. Headgear use was associated with substantial but non-significant reductions in superficial head (OR = 0.43, 95% CI 0.13 to 1.19) and facial (OR = 0.57, 95% CI 0.21 to 1.46) injuries. The video study followed 547 players over 41 games, during which there were 47 bleeding injuries to the head. Headgear use significantly reduced the risk of bleeding head injury in forwards (OR = 0.14, 95% CI 0.01 to 0.99, p = 0.02), but not in backs. There was also a higher risk of facial injury among forwards, but this was not significant.
COMMENTS: The combined results suggest that headgear can prevent certain types of superficial head injuries in players at all levels of the game, but the evidence is strongest for superficial head injury in elite forwards. A randomised controlled trial would be the best way to study this further.
OBJECTIVE: Young skiers are at increased risk for injury, however, epidemiological data on skiing related fatal injuries among child skiers are scarce. This study aimed to provide information needed to develop injury control and prevention programs.
METHODS: Study subjects came from Colorado, USA and were identified using a death certificate based surveillance system. Fatal injuries were limited to events that occurred at established commercial ski resorts in Colorado, and subjects were classified as child skiers (0-17 years) or adult skiers (>/=18 years).
MAIN OUTCOME MEASURE: Type and external cause, time, and week day of injury, gender and residency of the decedents.
FINDINGS: During the study period from 1980-2001, 149 fatal injuries associated with downhill skiing were identified; 21 (14.1%) occurred among child skiers aged </=17 years. The age of the youngest decedent was 7 years. In females the proportion of fatal injuries among child skiers was nearly three times that of adults. Traumatic brain injuries were the leading cause of death (67% of all deaths) among children, while multiple internal injuries and traumatic brain injuries accounted for almost equal proportions of fatal injuries among adults. Collision was the leading external mechanism of fatal injuries, accounting for more than two thirds of fatal injuries in both child and adult skiers.
COMMENTS: Traumatic brain injury was the leading cause and collision was the leading external injury mechanism of fatal injuries associated with downhill skiing among child skiers. This underscores the importance of brain injury prevention strategies, including the use of ski helmets and prevention of collisions on ski slopes.
Incomplete and biased perpetrator coding among hospitalized assaults for women in the United States.
- Weiss HB, Ismailov RM, Lawrence BA, Miller TR. Inj Prev 2004; 10(2): 119-121.
Correspondence: Harold Weiss, Center for Injury Research and Control, University of Pittsburgh, 200 Lothrop St, Suite B400, Pittsburgh, PA 15213, USA; (email: hw@injurycontrol.com).
BACKGROUND: Since 1997, hospital discharge data have included external cause of injury (E codes) for designating perpetrator relationship in assaults. For intentional injuries, guidelines require using two E codes; one for the injury mechanism and another (E967.n) identifying perpetrator relationship. Completeness and characteristics of the use of these codes have not been studied on a multistate level among states with complete E coding.
METHODS: Hospital discharge data for 1997 were solicited from states with good E coding completeness. Data were received from 19 states (51.9% of women in the United States, ages 15-49). For assaulted women, a regression model was constructed to identify factors associated with perpetrator code assignment using age, payment source, pregnancy status, race, and severity as covariates.
FINDINGS: Among 137,887 injured hospitalized women age 15-49, there were 7402 assaults (5.4%). Among all assaults to women, perpetrator coding was poor (8.8%). Among those that were perpetrator coded, 83.7% were spouse/partner related. Age was positively associated with probability of having a perpetrator code (p<0.001). Those paid by a private source were 42.9% more likely to have a perpetrator code (p = 0.007). Pregnant women were seven times more likely to have a perpetrator code (p<0.001). Non-white women were 66.8% less likely to have a perpetrator code (p<0.001) than white women.
COMMENTS: The poor use of perpetrator codes in hospital discharge data minimizes their usefulness for surveillance of serious injury from intimate partner violence. An implication of this research is the need to understand the gaps and strengthen the completeness of perpetrator documentation and coding. The findings suggest caution when interpreting the results from existing hospital discharge data based intimate partner violence surveillance systems.
BACKGROUND: Many studies have recently noted a shift in the causative mechanism of facial injuries away from traffic accident to assaults.
OBJECTIVE: Our study aimed to investigate patterns of facial injuries in trauma patients during 13 months study of trauma patients in six general hospitals in Tehran.
METHODS: Trauma patients who were hospitalized for more than 24 hours and had sustained injuries within seven days from admission were included in the study. Of the 8000 trauma patients, four hundred (5%) sustained facial injuries.
FINDINGS: Male to female ratio was 4.5:1. Among them, 53.3% were aged 11-30 years. Traffic accidents were by the far the commonest cause of injury. Motorcyclists who wore a helmet sustained facial fractures less often during traffic accident than those patients who did not wear helmet. Soft tissue injury and facial bone fracture comprised 43.3% and 40.8% of facial injuries, respectively. The majority of Soft tissue injuries (79%) were located extra orally. The mandible and nasal bone were the most commonly fractured facial bones. Victims of assault sustained more severe injuries compared to those involved in falls and traffic accidents.
COMMENTS: Use of helmets by motorcyclists and the separation of pedestrians routes from motor vehicles could reduce the number of victims and consequently injuries due to road traffic accidents. For implementation of effective prevention programs for reduction of facial injuries due to assault, it seems to be necessary to conduct studies investigating causes and pattern of injuries resulting in assault.
The economic burden of hospitalizations associated with child abuse and neglect.
OBJECTIVES: This study assessed the economic burden of child abuse-related hospitalizations.
METHODS: We compared inpatient stays coded with a diagnosis of child abuse or neglect with stays of other hospitalized children using the 1999 National Inpatient Sample of the Healthcare Costs and Utilization Project.
RESULTS: Children whose hospital stays were coded with a diagnosis of abuse or neglect were significantly more likely to have died during hospitalization (4.0% vs 0.5%), have longer stays (8.2 vs 4.0 days), twice the number of diagnoses (6.3 vs 2.8), and double the total charges ($19 266 vs $9513) than were other hospitalized children. Furthermore, the primary payer was typically Medicaid (66.5% vs 37.0%).
CONCLUSION: Earlier identification of children at risk for child abuse and neglect might reduce the individual, medical, and societal costs.
Airway obstruction in children aged less than 5 years: The prehospital experience.
- Vilke GM, Smith AM, Ray LU, Steen PJ, Murrin PA, Chan TC. Prehosp Emerg Care 2004; 8(2): 196-199.
Correspondence: Gary M. Vilke, Department of Emergency Medicine, UC San Diego Medical Center, 200 West Arbor Drive Mailcode #8676, San Diego, CA 92103, USA; (email: gmvilke@ucsd.edu).
BACKGROUND: Treatment of choking in children has been well studied, but few data are available on the various causes of the choking episodes in the pediatric population.
OBJECTIVES: To assess frequency and to stratify etiologies of children less than 5 years of age who had a 911 advanced life support (ALS) ambulance response for airway obstruction.
METHODS: A prehospital database was searched and information was collected defining type of obstruction, age of the child, parents' action, paramedic treatment, and incident outcome.
FINDINGS: There were 182 patients with airway obstruction under 5 years of age, of whom 99 (55%) were less than 1 year old. Liquid obstructions (i.e., formula, juices) were most common in the youngest children, whereas solid food and nonfood solid obstructions were most prevalent in children over 1 year old. One hundred seven (59%) of these obstructions resolved before paramedic arrival (69% of liquid obstructions, 72% of food, and 36% of nonfood solid objects). Interventions used by parents included bulb suction (3%), finger sweeps (6%), Heimlich maneuver (3%), and back blows (12%). Paramedics used ALS skills in only three cases. After paramedic evaluation, 47% of parents refused transport against medical advice (AMA).
COMMENTS: Although most episodes of pediatric airway obstruction will have been resolved by the time of paramedic arrival, age-specific and item-specific treatment skills need to be reinforced with parents and prehospital providers.
Social disparities in housing and related pediatric injury: a multilevel study.
- Shenassa ED, Stubbendick A, Brown MJ. Am J Public Health 2004; 94(4): 633-639.
Correspondence: Edmond D. Shenassa, Brown Medical School, Department of Community Health and Centers for Behavioral and Preventive Medicine, One Hoppin Street, Suite 500, Providence, RI 02903, USA; (email: edmond_shenassa@brown.edu).
OBJECTIVES: We conducted an ecologic analysis to determine whether housing characteristics mediate the associations between concentration of poverty and pediatric injury and between concentration of racial minorities and pediatric injury and whether the association between housing conditions and pediatric injury is independent of other risks.
METHODS: We created a hierarchical data set by linking individual-level data for pediatric injury with census data. Effect sizes were estimated with a Poisson model.
FINDINGS: After adjustment for owner occupancy and the percentage of housing built before 1950, the association between concentration of poverty and pediatric injury was attenuated. For concentration of racial minorities, only percentage of owner occupancy had some mediating effect. In hierarchical models, housing characteristics remained independent and significant predictors of pediatric injury.
COMMENTS: The association between community characteristics and pediatric injury is partially mediated by housing conditions. Risk of pediatric injury associated with housing conditions is independent of other risks.
Falls and fall-related injuries among the elderly: a survey of residential-care facilities in a Swedish municipality.
- Sadigh S, Reimers A, Andersson R, Laflamme L. J Community Health 2004; 29(2): 129-140.
Correspondence: Siv Sadigh, Karolinska Institutet, Department of Public Health Sciences, Division of Social Medicine, Norrbacka, SE-171 76 Stockholm, SWEDEN; (email: siv.sadigh@smd.sll.se).
Injurious falls among the elderly are an increasing public-health problem in Sweden. One group particularly vulnerable to falls consists of elderly people living in residential-care facilities. The purpose of this study was to investigate the extent to which falls lead to injury within a defined population of elderly people in institutionalized care. All the elderly persons living in residential-care facilities in an urban Swedish municipality during the year 1997 (n = 469 institutional places). Falls and fall-related injuries were registered over a one-year period. Data were gathered by personnel at the time of the falls, using a form specifically designed for surveillance purposes. Of the 865 falls reported during the study period, 375 were among men, with an average age of 82 years, and 490 among women, with an average age of 85 years. Men were subject to falling to a greater extent than women. The most common location was the individual's own bedroom. Injuries were incurred in approximately one in four falls, and the head was the body part most frequently injured. Only 24 falls (2.8%) resulted in a fracture, of which 18 were hip fractures. Although elderly people living in residential-care facilities fall fairly often, serious injuries, in the form of fractures, are incurred to a relatively limited extent.
The magnitude of major trauma in Oklahoma.
- Garwe T, Mallonee S, Stewart K, Hays-Moore P. J Okla State Med Assoc 2004; 97(2): 70-74.
Correspondence: Tabitha Garwe, Oklahoma State Department of Health, Injury Prevention Service, Oklahoma City 73117-1299, USA; (email: tabithag@health.state.ok.us).
BACKGROUND: Injuries are the third leading cause of death in Oklahoma and the leading cause of death and disability among persons 1-44 years. In 2001, participation in the Oklahoma trauma system became mandatory, and all licensed acute care hospitals were required to submit data to the Oklahoma Trauma Registry (OTR). The objective of this study was to describe the magnitude of major trauma occurring in Oklahoma from 2001-2002.
METHODS: Data were collected from all licensed acute care hospitals in Oklahoma. Only patients meeting the major trauma criteria were included in the study. Mortality was used as the main outcome measure.
FINDINGS: A total of 5,760 major trauma patients were reported. The mean age was 38 years (range: 5 days-100 years). Over two-thirds of major trauma cases were male. Blacks had the highest rate of injury (89.5/100,000 population). The leading cause of injury was motor vehicle crashes among persons < 65 years and falls among persons 65 years or older. Overall mortality was 16%; after controlling for age, males were significantly more likely to die than females (O.R 1.3; CI 1.1-1.5). Persons injured by firearms were nearly 5 times more likely to die (CFR=42%) than persons injured by all other causes (CFR=14%) (Odds Ratio 4.5; CI 3.6, 5.5). Excluding deaths in the emergency department (ED), patients were hospitalized an average of 9 days (median: 5 days; range 1-204 days). Over two-thirds (69%) of survivors were discharged home and 14% were discharged to a rehabilitation facility.
COMMENTS: There are noted demographic and etiological differences in the burden of major trauma. Understanding these differences may be useful in enhancing existing prevention practices in Oklahoma and for generating new research to lower this burden. The OTR is relatively new and still maturing; hence, further studies will be required to increase understanding of other factors that influence the incidence and outcome of trauma.
OBJECTIVE: This study aimed to identify self report questionnaire measures of parent attributes and behaviors that have relevance for understanding injury risk among children 2-5 years of age, and test a new Parent Supervision Attributes Profile Questionnaire (PSAPQ) that was developed to measure aspects of protectiveness and parent supervision.
METHODS: Naturalistic observations were conducted of parents' supervision of children on playgrounds, with questionnaires subsequently completed by the parent to measure parent education, family income, parent personality attributes, attributes relevant to parent supervision, and beliefs about parents' control over the child's health status. These measures were then related to children's risk taking and injury history.
FINDINGS: Visual supervision, auditory supervision, and physical proximity were highly intercorrelated, indicating that parents employed all types of behaviors in service of supervision, rather than relying predominantly on one type of supervisory behavior. Physical proximity was the only aspect of supervision behavior that served a protective function and related to children's risk taking behaviors: parents who remained close to their children had children who engaged in less risk taking. On questionnaires, parents who reported more conscientiousness, protectiveness, worry about safety, vigilance in supervision, confidence in their ability to keep their child safe, and belief in control over their child's health had children who showed less risk taking and/or experienced fewer injuries. The new PSAPQ measure was associated with specific aspects of supervision as well as children's risk taking and injury history.
COMMENTS: This study reveals several parent attributes and behaviors with relevance for child injury risk that can be measured via self report questionnaires, including the new PSAPQ.
OBJECTIVE: To estimate the incidence of ocular injury in rural Nepal and identify details about these injuries that predict poor visual outcome.
METHODS: Reports of ocular trauma were collected from 1995 through 2000 from patients presenting to the only eye care clinic in Sarlahi district, Nepal. Patients were given a standard free eye examination and interviewed about the context of their injury. Follow up examination was performed 2-4 months after the initial injury.
FINDINGS: 525 cases of incident ocular injury were reported, with a mean age of 28 years. Using census data, the incidence was 0.65 per 1000 males per year, and 0.38 per 1000 females per year. The most common types of injury were lacerating and blunt, with the majority occurring at home or in the fields. Upon presentation to the clinic, 26.4% of patients had a best corrected visual acuity worse than 20/60 in the injured eye, while 9.6% had visual acuity worse than 20/400. 82% were examined at follow up: 11.2% of patients had visual acuity worse than 20/60 and 4.6% had vision worse than 20/400. A poor visual outcome was associated with increased age, care sought at a site other than the eye clinic, and severe injury. 3% of patients were referred for further care at an eye hospital at the initial visit; 7% had sought additional care in the interim between visits, with this subset representing a more severe spectrum of injuries.
COMMENTS: The detrimental effects of delayed care or care outside of the specialty eye clinic may reflect geographic or economic barriers to care. For optimal visual outcomes, patients who are injured in a rural setting should recognise the injury and seek early care at a specialty eye care facility. Findings from our study suggest that trained non-ophthalmologists may be able to clinically manage many eye injuries encountered in a rural setting in the "developing" world, reducing the demand for acute services of ophthalmologists in remote locations of this highly agricultural country.
The use of coping strategies by Danish children classed as bullies, victims, bully/victims, and not involved, in response to different (hypothetical) types of bullying.
The coping strategies employed in response to different types of bullying, by 305 Danish children (142 boys, 163 girls) in school years four to nine (aged 10-15 years), were investigated. Children were classed into four bully-victim status types. A revised version of the Olweus Bully/Victim Questionnaire was used for the classification of children, and a Self-Report Coping Measure for the investigation of coping strategies. The coping strategy of Externalizing was used significantly more by children classed as bully/victims compared with victims and not involved children: Seeking Social Support and Internalizing were preferred significantly more by girls, whereas Externalizing was preferred significantly more by boys; Distancing, Seeking Social Support, and Internalizing were favored significantly more by children in years four to six compared with children in years seven to nine. Looking at coping strategies in response to different types of bullying, Seeking Social Support was used significantly more in response to attack on property relative to verbal bullying, social exclusion, and indirect bullying, and Distancing was used significantly less in response to attack on property compared with any of the other types of bullying. The results are discussed in relation to implications for educational practice.
History of deliberate self-harm and its association with mood fluctuation.
- Sampson E, Mukherjee S, Ukoumunne OC, Mullan N, Bullock T. J Affect Disord 2004; 79(1-3): 223-227.
Correspondence: Elizabeth Sampson, Dementia Research Group, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK; (email: l.sampson@dementia.ion.ucl.ac.uk).
BACKGROUND: It is known that mental illness is associated with increased suicide risk. It has been postulated that suicidality may be an independent clinical phenomenon and we investigate whether variability of mood may be a mediator of this.
METHOD: Fifty-three psychiatric inpatients were assessed on the Montgomery-Asberg depression rating scale, once weekly, over a 4-week period. The SCID II was administered to diagnose co-morbid personality disorder. Hostility was measured with the Hostility and Direction of Hostility questionnaire. A Fluctuation Index score was calculated to measure variability of mood.
FINDINGS: Unadjusted analyses suggested that patients with a history of deliberate self-harm showed greater variability in mood as measured by the fluctuation index (mean difference=13.4; 95% CI=4.3 to 22.6; P=0.005) though this relationship was no longer significant at the 5% level after adjustment (mean difference=13.4; 95% CI=-2.0 to 28.8; P=0.09).
LIMITATIONS: There was a high initial dropout rate from the study and a small sample size. A prospective study would have more power in determining the effect of mood fluctuations.
COMMENTS: Mood fluctuation may be a useful indicator of risk of deliberate self-harm and attempted suicide.
Suicide attempts and suicidal ideation: links with psychiatric comorbidity in eating disorder subjects.
- Milos G, Spindler A, Hepp U, Schnyder U. Gen Hosp Psychiatry 2004; 26(2): 129-135.
Additional psychiatric disorders in eating disorders patients may contribute to the risk of suicide and suicide attempts. The aim of this study was to examine associations between Axes I and II comorbidity and suicidality in a large sample of women currently suffering from an eating disorder (ED). In a sample of 288 women (87 anorexia nervosa, 158 bulimia nervosa, 43 eating disorders not otherwise specified) psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview for DSM-IV. Histories of attempted suicide were explored in a structured interview. Suicidal ideation was determined by means of the SCL-90. Past suicide attempts were reported by 26%. Subjects with a purging type ED more frequently had a history of attempted suicide than subjects with a nonpurging type ED. A history of suicide attempts was associated with higher levels of Axes I and II comorbidity, in particular with affective disorders and Cluster B personality disorders. Current suicidal ideation was generally linked with higher levels of all types of Axes I and II comorbidity. Eating disorders are serious psychiatric disorders associated with high levels of comorbidity and suicidality. Incorporating a comprehensive psychiatric evaluation into the clinical assessment of ED patients is important for the assessment of suicidality and for the provision of adequate treatments.
Suicides in young people in rural southern India.
- Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad J, Minz S, Abraham VJ, Bose A. Lancet 2004; 363(9415): 1117-1118.
Correspondence: Anuradha Bose, Department of Community Health, Christian Medical College, Vellore 632002, INDIA; (email: abose@cmcvellore.ac.in).
Different rates of suicide have been reported in India. In Vellore, southern India, we have noted that the rates of suicides are several fold higher than those reported anywhere in the world, especially in young women. The department of community health at the Christian Medical College, Vellore, has obtained data prospectively on births, deaths, and morbidity in a population of 108?000. We used the verbal autopsy method to assign cause of death. The mortality rates were analysed for 10 years, from 1992 to 2001, for the age-group 10-19 years. Suicides accounted for about a quarter of all deaths in young men and between 50% and 75% of all deaths in young women. The average suicide rate for young women was 148 per 100?000, and for young men 58 per 100?000. We believe that our findings are reliable. The system of surveillance is well established and the verbal autopsy method has been validated. These very high rates of suicide need urgent intervention.
Road traffic injuries are a major but neglected public health challenge that requires concerted efforts for effective and sustainable prevention. Of all the systems with which people have to deal every day, road traffic systems are the most complex and the most dangerous. Worldwide, an estimated 1.2 million people are killed in road crashes each year and as many as 50 million are injured. Projections indicate that these figures will increase by about 65% over the next 20 years unless there is new commitment to prevention. Nevertheless, the tragedy behind these figures attracts less mass media attention than other, less frequent types of tragedy.
The World report on road traffic injury prevention is the first major report being jointly issued by the World Health Organization (WHO) and the World Bank on this subject. It underscores their concern that unsafe road traffic systems are seriously harming global public health and development. It contends that the level of road traffic injury is unacceptable and that it is largely avoidable.
Preventing road traffic injury: a public health perspective for Europe.
- Racioppi F, Eriksson L, Tingvall C, Villaveces A. World Health Organization. Geneva: World Health Organization, 2004.
Correspondence: Francesca Racioppi, Technical Officer, Transport, Environment and Health, WHO European Centre for Environment and Health, Via Francesco Crispi 10, I-00187 Rome, ITALY; (email: frr@who.it).
This 100 page report is available online: ( Download Report ).
Road traffic injuries in the WHO European Region represent a major public health problem. About 127 thousand people are killed and about 2.4 million injured every year. The cost of road traffic injuries to society is an estimated 2% of a country�s gross domestic product. About one third of the victims are aged 15�29 years. Nevertheless, effective preventive strategies exist and need to be applied through multisectoral approaches, and the health sector has a unique role to play. This publication has been prepared for World Health Day 2004 to raise awareness among the general public and enhance commitment among policy-makers to take immediate action towards preventing road traffic injury. The publication builds on and complements the World report on road traffic injury prevention, analysing in depth the burden of disease from road traffic injury in the European Region, framing the issue in the context of sustainable mobility, presenting a comprehensive systems approach to road safety based on successful experiences developed by some Member States in the Region and highlighting opportunities for the health sector to play a broader role. The publication calls for a multisectoral and evidence-based approach to preventing road traffic injuries, with public health playing an important role, emphasizes the importance of a strong political commitment at all levels of government and makes recommendations for action.
Raised Speed Limits, Speed Spillover, Case-Fatality Rates, and Road Deaths in Israel: A 5-Year Follow-Up.
- Richter ED, Barach P, Friedman L, Krikler S, Israeli A. Am J Public Health 2004; 94(4): 568-574.
Correspondence: Elihu D Richter, Unit of Occupational and Environmental Medicine, Hebrew University-Hadassah Medical School, Jerusalem 91120, ISRAEL; (email: elir@cc.huji.ac.il).
OBJECTIVES: We assessed the 5-year, nationwide impact on road deaths of the raise in the speed limit (November 1, 1993) on 3 major interurban highways in Israel from 90 to 100 kph.
METHODS: We compared before-after trends in deaths as well as case fatality-an outcome independent of exposure (defined as vehicle-kilometers traveled).
FINDINGS: After the raise, speeds rose by 4.5%-9.1%. Over 5 years, there was a sustained increase in deaths (15%) and case fatality rates (38%) on all interurban roads. Corresponding increases in deaths (13%) and case fatality (24%) on urban roads indicated "speed spillover."
COMMENTS: Immediate increases in case fatality predicted and tracked the sustained increase in deaths from increased speeds of impact. Newtonian fourth power models predicted the effects of "small" increases in speed on large rises in case fatality rates. Countermeasures and congestion reduced the impact on deaths and case-fatality rates by more than half.
Motor vehicle crash deaths related to police pursuits in the United States.
Correspondence: Fred Rivara, Harborview Injury Prevention and Research Center, Box 359960, 325 Ninth Ave, Seattle, WA 98104, USA; (email: fpr@u.washington.edu).
OBJECTIVE: To determine the number and characteristics of motor vehicle crash deaths related to police pursuits in the United States.
METHODS: Analysis of the Fatality Analysis Reporting System and the Crashworthiness Data System of the National Highway Traffic Safety Administration for the years 1994-2002.
FINDINGS: There were 2654 fatal crashes involving 3965 vehicles and 3146 fatalities during the nine year study period. Of these, 1088 were to people not in the fleeing vehicle. These crashes often occurred at high speed, in the night, on local roads. Most of the pursued drivers had prior motor vehicle related convictions.
COMMENTS: Many deaths related to police pursuits are to innocent victims. Given that most of the pursued drivers had prior convictions, alternative means of detaining them should be explored.
Improving surveillance for injuries associated with potential motor vehicle safety defects.
OBJECTIVE: To improve surveillance for deaths and injuries associated with potential motor vehicle safety defects.
METHODS: Vehicles in fatal crashes can be studied for indications of potential defects using an "early warning" surveillance statistic previously suggested for screening reports of adverse drug reactions. This statistic is illustrated with time series data for fatal, tire related and fire related crashes. Geographic analyses are used to augment the tire related statistics.
FINDINGS: A statistical criterion based on the Poisson distribution that tests the likelihood of an expected number of events, given the number of events that actually occurred, is a promising method that can be readily adapted for use in injury surveillance.
COMMENTS: Use of the demonstrated techniques could have helped to avert a well known injury surveillance failure. This method is adaptable to aid in the direction of engineering and statistical reviews to prevent deaths and injuries associated with potential motor vehicle safety defects using available databases.
This study provides the first systematic research of homicide-suicide (HS) in a Chinese society. Data were drawn from the HK Homicide Monitoring Data-base computer file derived from investigation and death reports held by the HK Police Force and the Coroner's Court. During the 10-year study period, 56 events involving 133 deaths were identified. The majority of offenders were males (75%) and most victims were female (64%). The mean age of offenders and victims were 41.9 and 32.3 years, respectively. Spouses and lovers comprised the majority of victims (46.4%) followed by child victims (36%). Most HS events were motivated by separation or termination of marital or sexual relations (39%), economic reasons (25%) and other domestic disputes (20%). The most frequent modes of killing were strangulation/suffocation (26%), stabbing/chopping (24%), followed by gassing/poisoning (14%) and falling from height (14%). The commonest of suicide was falling from height (48%). It was followed by gassing/poisoning (22%) and strangulation/suffocation (13%). Depression (18.3%) was found to be the commonest mental disorder. Most offenders were from low-socio-economic background. Two-third were unemployed and 76.6% had 9 or less years of education. HS in HK were distinguished from those reported in the western literature in respect to the high relevance of economic factors, the absence of mercy killing between old couples, a higher percentage of pedicide-suicides and the infrequent use of firearms.
Domestic violence: prevalence in pregnant women and associations with physical and psychological health.
Correspondence: Gillian Mezey, St. George's Hospital Medical School, Department of Forensic Psychiatry, Jenner Wing, Ground Floor, Cranmer Terrace, London SW17 ORE, UK; (email: gmezey@sghms.ac.uk).
OBJECTIVES: To examine the prevalence of domestic violence (DV) and its associations with obstetric complications and psychological health in women on antenatal and postnatal wards.
METHODS: A cross-sectional survey conducted in an inner-London teaching hospital. Two hundred English-speaking women aged 16 and over, were interviewed between July 2001 and April 2002. The Abuse Assessment Screen was used to assess for experiences of DV. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS). The analysis of predictors of obstetric complications grouped together those known to be associated with DV.
FINDINGS: 23.5% of women had lifetime experience of DV, 3% during the current pregnancy. Women with a history of DV were significantly more likely to be single, separated or in non-cohabiting relationship and to have smoked in the year prior to and/or during pregnancy. Higher EPDS scores were significantly associated with DV, single, separated or non-cohabiting status, and obstetric complications. Both a history of DV and increased EPDS scores were significantly associated with obstetric complications after controlling for other known risk factors.
COMMENTS: Domestic violence is regarded as an important risk marker for the development of obstetric complications and depressive symptomatology. This finding of itself justifies training and education of maternity health professionals to raise awareness.
Protection Orders and Intimate Partner Violence: An 18-Month Study of 150 Black, Hispanic, and White Women.
- McFarlane J, Malecha A, Gist J, Watson K, Batten E, Hall I, Smith S. Am J Public Health 2004; 94(4): 613-618.
Correspondence: Judith McFarlane, Texas Woman's University, College of Nursing, 1130 John Freeman Blvd,Houston, TX 77030, USA; (email: jmcfarlane@twu.edu).
OBJECTIVES: We compared types and frequencies of intimate partner violence experienced by women before and after receipt of a 2-year protection order.
METHODS: Participants were 150 urban English- and Spanish-speaking Black, Hispanic, and White women who qualified for a 2-year protection order against an intimate partner.
FINDINGS: One woman committed suicide 6 weeks into the study. The remaining 149 women completed all interviews. Results showed significant reductions in threats of assault, physical assault, stalking, and worksite harassment over time among all women, regardless of receipt or nonreceipt of a protection order.
COMMENTS: Abused women who apply and qualify for a 2-year protection order, irrespective of whether or not they are granted the order, report significantly lower levels of violence during the subsequent 18 months.
Parental social determinants of risk for intentional injury: a cross-sectional study of Swedish adolescents.
- Engstrom K, Diderichsen F, Laflamme L. Am J Public Health 2004; 94(4): 640-645.
Correspondence: Karin Engstrom, Karolinska Institutet, Department of Public Health Sciences, Division of Social Medicine, Norrbacka, S-171 76 Stockholm, SWEDEN; (email: karin.engstrom@phs.ki.se).
OBJECTIVES: We investigated the effect of family social and economic circumstances on intentional injury among adolescents.
METHODS: We conducted a cross-sectional register study of youths aged 10 to 19 years who lived in Sweden between 1990 and 1994. We used socioeconomic status, number of parents in the household (1- or 2-parent home), receipt of welfare benefits, parental country of birth, and population density as exposures and compiled relative risks and population-attributable risks (PARs) for self-inflicted and interpersonal violence-related injury.
FINDINGS: For both genders and for both injury types, receipt of welfare benefits showed the largest crude and net relative risks and the highest PARs. The socioeconomic status-related PAR for self-inflicted injury and the PAR related to number of parents in the household for interpersonal violence-related injury also were high.
COMMENTS: Intentional-injury prevention and victim treatment need to be tailored to household social circumstances.
Assessing the Long-Term Effects of the Safe Dates Program and a Booster in Preventing and Reducing Adolescent Dating Violence Victimization and Perpetration.
- Foshee VA, Bauman KE, Ennett ST, Linder GF, Benefield T, Suchindran C. Am J Public Health 2004; 94(4): 619-624.
Correspondence: Vangie Foshee, Department of Health Behavior and Health Education, 317 Rosenau Hall, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7440, USA; (email: foshee@email.unc.edu).
OBJECTIVES: This study determined 4-year postintervention effects of Safe Dates on dating violence, booster effects, and moderators of the program effects.
METHODS: We gathered baseline data in 10 schools that were randomly allocated to a treatment condition. We collected follow-up data 1 month after the program and then yearly thereafter for 4 years. Between the 2- and 3-year follow-ups, a randomly selected half of treatment adolescents received a booster.
FINDINGS: Compared with controls, adolescents receiving Safe Dates reported significantly less physical, serious physical, and sexual dating violence perpetration and victimization 4 years after the program. The booster did not improve the effectiveness of Safe Dates.
COMMENTS: Safe Dates shows promise for preventing dating violence but the booster should not be used.
See item 2 under Risk Factor Prevalence, Injury Occurrence and Costs
