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• The relationship between alcohol use and mortality rates from injuries: a comparison of measures.

  Mann RE, Suurvali HM, Smart RG. Am J Drug Alcohol Abuse 2001; 27(4):737-747.
  
  Centre for Addiction and Mental Health, Addiction Research Foundation Division, Toronto, Ontario, Canada. Robert_Mann@camh.net

  Per capita consumption of alcohol has traditionally been considered to be the leading indicator of population levels of alcohol problems. However, some recent research suggests that this relationship may be weakening, and that drinking pattern measures may be preferable to per capita consumption as problem-level indicators. We compared the ability of per capita alcohol consumption and survey-based measures of alcohol use to predict deaths from injuries in Ontario, Canada, for the period 1977-1996. Per capita consumption and percentage of daily drinkers were significantly related to injury mortality, but percentage of drinkers and percentage of episodic heavy drinkers (those who drank five or more drinks on a drinking occasion) were not. Of the measures we examined, per capita consumption was the strongest indicator of mortality rates from injuries. However, the survey-derived measure of percentage of daily drinkers was similar to per capita consumption in ability to predict problem levels.

• The World Trade Center Attack: Observations from New York's Bellevue Hospital.

  Roccaforte JD. Crit Care 2001; 5(6):307-309.
  
  Correspondence: J. David Roccaforte, Department of Anesthesiology, Bellevue Hospital Center, 215 Bowery 5R, New York, NY 10002 USA. jdavidr@mail.com

  This report describes selected aspects of the response by Bellevue Hospital Center to the World Trade Center attack of 11 September 2001. The hospital is 2.5 miles (4 km) from the site of the attack. These first-hand observations and this analysis may aid in future preparations. Key issues described relate to communication, organization, injuries treated, staffing, and logistics.

• Role of Snoring and Daytime Sleepiness in Occupational Accidents.

  Lindberg E, Carter N, Gislason T, Janson C. Am J Respir Crit Care Med 2001; 164(11):2031-2035.
  
  Correspondence: E. Lindberg, Department of Medical Sciences, Respiratory Medicine and Allergology, and Department of Medical Sciences, Occupational and Environmental Medicine, Akademiska Sjukhuset, Uppsala, Sweden

  OBJECTIVES: To establish whether snoring and excessive daytime sleepiness (EDS), the main symptoms of obstructive sleep apnea syndrome, influence the risk of occupational accidents.
  
  METHODS: a population-based, prospective study was performed. In 1984, 2,874 men aged 30-64 answered questions on snoring and EDS. Ten years later 2,009 (73.8% of the survivors) responded to a follow-up questionnaire including work-related questions and potential confounders. Information on occupational accidents during 1985-1994 was obtained from national register data. A total of 345 occupational accidents were reported by 247 of the men (12.3%).
  
  RESULTS: Multivariate analysis revealed that men who reported both snoring and EDS at baseline were at an increased risk of occupational accidents during the following 10 yr, with an adjusted odds ratio of 2.2 (95% CI 1.3-3.8) after adjusting for age, body mass index, smoking, alcohol dependence, years at work, blue-collar job, shift work, and exposure to noise, organic solvents, exhaust fumes, and whole-body vibrations. However, no significant increased risk was found for snorers without EDS or nonsnorers with EDS.
  
  CONCLUSIONS: The researchers conclude that sleepy, male snorers have an increased risk of occupational accidents. The results indicate that early identification and treatment of sleep-disordered breathing may reduce the number of injuries at work.

• Concussions in hockey: there is cause for concern.

  Goodman D, Gaetz M, Meichenbaum D. Med Sci Sports Exerc 2001; 33(12): 2004-2009.
  
  Correspondence: David Goodman, Human Motor Systems Laboratory, Simon Fraser University, Burnaby, B.C., CANADA; and Department of Psychiatry, University of British Columbia, Vancouver, B.C., CANADA. (E-mail: david_goodman@sfu.ca).

  OBJECTIVES: The purpose of the study was to document various aspects of concussion in Canadian Amateur hockey including demographics, causes, treatment, and prevention in order to guide future recommendations on how to reduce injury.
  
  METHODS: A detailed prospective and retrospective concussion history was obtained from British Columbia Junior Hockey League players over the course of two seasons (1998-2000).
  
  RESULTS: Higher rates of concussions occur in games versus practice, and there was an overrepresentation of forwards injured versus defensemen or goaltenders. There was between 4.63 and 5.95 concussions per 1000 player/game hours with the average age of the first hockey-related concussion in the 15th year. The greatest cause of concussion was contact with the ice and/or the boards. Fighting was not a major cause of concussion, although other illegal actions such as elbowing were.
  
  CONCLUSIONS: The primary recommendation to reduce the number and severity of concussions is to eliminate plays where there is a demonstrable intent to injure another player. Concussions in hockey are of considerable concern; however, there is now encouraging information with respect to the treatment of these injuries.

• An operational model to investigate contact sports injuries.

  Gissane C, White J, KERR K, Jennings D. Med Sci Sports Exerc 2001; 33(12): 1999-2003.
  
  Correspondence: Conor Gissane, Department of Health Studies, Brunel University, Osterley Campus, Isleworth, Middlesex, TW5 7DU, UNITED KINGDOM; (E-mail: conor.gissane@brunel.ac.uk).

  BACKGROUND: In sports injury research, investigations often attempt to identify a unique risk factor that distinguishes an injured player. However, a wide variety of factors can contribute to a sports injury occurring, and an understanding of the cause of injury is important to advance knowledge.
  
  OBJECTIVES: A cyclical operational model is proposed to examine the interrelationship of a number of factors that are involved in sports injury epidemiology.
  
  METHODS: The proposed model identifies a healthy/fit player initially, although the player may exhibit a number of intrinsic risk factors for sports injury. Before exposure to extrinsic risk factors, there is the opportunity for implementation of prevention strategies by coaching personnel and the sports medicine team. These strategies might include, among others, appropriate warm-up, adequate hydration, wearing protective equipment, and prophylactic taping. Additionally, preventative screening could take place to assess the various intrinsic and extrinsic risk factors that could lead to sports injury.
  
  RESULTS: Two examples of how the operational model relates to contact sports injury cases are presented. Participating in sport inevitably exposes the player to external risk factors that predispose toward injury. The treatment of the injured player aims to restore the player to preinjury playing status and to prevent the injury from becoming chronic.
  
  CONCLUSIONS: It is suggested that the application of this proposed cyclical model may lead to greater success in understanding the multifaceted nature of sports injuries and furthermore help minimize injury risk and support the rehabilitation of injured contact sports participants.

• The CRASH trial: the first large-scale, randomized, controlled trial in head injury.

  Roberts I. Crit Care 2001; 5(6):292-293.
  
  Correspondence: Ian Roberts, CRASH Trial Management Group, CRASH Co-ordinating Centre, London School of Hygiene and Tropical Medicine,49-51 Bedford Square London WC1B 3DP, UK. Ian.Roberts@lshtm.ac.uk

  The global epidemic of head injuries is just beginning. Many are caused by road traffic crashes. It is estimated that, by 2020, road traffic crashes will have moved from its present position of ninth to third in the world disease burden ranking, as measured in disability adjusted life years. In developing countries, it will have moved to second. The Corticosteroid Randomization After Significant Head Injury (CRASH) trial is a large-scale, randomized, controlled trial, among adults with head injury and impaired consciousness, of the effects of a short-term infusion of corticosteroids on death and on neurological disability. Following a successful pilot phase, which included over 1000 randomized participants, the main phase of the trial is now underway. Over the next 5 years, the trial aims to recruit a total of 20,000 patients. Such large numbers will only be possible if hundreds of doctors and nurses can collaborate in emergency departments all over the world. The trial is currently recruiting, and new collaborators are welcome to join the trial (see www.crash.lshtm.ac.uk).

• See report under Violence

• Psychological autopsy studies - a review.

  Isometsa ET. Eur Psychiatry 2001; 16(7): 379-385.
  
  Correspondence: E. T. Isometsa, Mood Disorders and Suicide Research Unit, Department of Mental Health and Alcohol Research, National Public Health Institute, Mannerheimintie 166 FIN-00300, Helsinki, Finland

  Psychological autopsy is one of the most valuable tools of research on completed suicide. The method involves collecting all available information on the deceased via structured interviews of family members, relatives or friends as well as attending health care personnel. In addition, information is collected from available health care and psychiatric records, other documents, and forensic examination. Thus a psychological autopsy synthesizes the information from multiple informants and records. The early generation of psychological autopsies established that more than 90% of completed suicides have suffered from usually co-morbid mental disorders, most of them mood disorders and/or substance use disorders. Furthermore, they revealed the remarkable undertreatment of these mental disorders, often despite contact with psychiatric or other health care services. More recent psychological autopsy studies have mostly used case-control designs, thus having been better able to estimate the role of various risk factors for suicide. The future psychological autopsy studies may be more focused on interactions between risk factors or risk factor domains, focused on some specific suicide populations of major interest for suicide prevention, or combined psychological autopsy methodology with biological measurements.

• Head injury-related road crash mortality in rural Western Australia.

  Stella J, Sprivulis P, Cooke C. ANZ J Surg 2001; 71(11):665-668.
  
  Correspondence: Julien Stella, Emergency Department, Fremantle Hospital, Fremantle, WA, AUSTRALIA

  BACKGROUND: The aim of the present paper was to assess the incidence of, and identify factors associated with road crash (RC)-related fatal head injuries in rural and metropolitan Western Australia.
  
  METHODS: Examination of demographics, driving behavior and RC characteristics for RC fatalities involving a head injury (Abbreviated Injury Scale (AIS) >/= 2) between 1 January 1998 and 31 December 1999 was carried out using the State Coronial -Database.
  
  RESULTS: There were 328 deaths. The median age was 28 years and 74.1% of cases were male. Seventy per cent died at the scene. Of scene survivors, 89% were transferred to a metropolitan hospital before dying. Sixty per cent of total RC and 65% of at-scene deaths occurred in rural areas. Single-vehicle crashes comprised 45% of total crashes, of which 72.8% occurred in rural locations. Poor driver behavior was identified in 53% of deaths. Ethanol was implicated in 29.8% of deaths, other intoxicating drugs were implicated in 19.2%, speeding was implicated in 19.5%, and lack of safety restraints/devices was implicated in 22%. Poor driver behavior was identified in 72% of single-vehicle deaths, compared with 38% of multivehicle crashes (P < 0.001). Rural people comprised 61% of rural crash victims. Ninety-one per cent of rural victims died in rural crashes. The incidence of RC death associated with head injury in the rural population is 13.4 deaths/100 000 per year, more than double that for the metropolitan population (6.4 deaths/100 000 per year; P < 0.001).
  
  CONCLUSIONS: The rural population of Western Australia is overrepresented in head injury-related RC deaths. Single-vehicle crashes where unsafe driving behavior is implicated comprise a large proportion of these. Strategies to reduce unsafe driving practices aimed at rural drivers are necessary.

• Local television news coverage of traumatic deaths and injuries.

  McArthur DL, Magana D, Peek-Asa C, Kraus JF. West J Med 2001; 175(6): 380-384.
  
  Southern California Injury Prevention Research Center UCLA School of Public Health 10833 Le Conte Ave Los Angeles, CA 90095-1772.

  OBJECTIVES: To assess how local television news programs' reporting of injuries and deaths from traumatic causes compares with coroners' records of deaths and the estimated incidence of injuries in the same geographic area during the same time.
  
  METHODS: Using epidemiologic methods, we identified the underlying cause of death or injury in each of 828 local television news stories broadcast in Los Angeles during late 1996 or early 1997 that concerned recent (<3 days) traumatic injuries or deaths in Los Angeles County. Odds ratios were computed using deaths by homicide or injuries sustained in assaults as the referent group.
  
  RESULTS: The number of persons depicted as dead amounted to 47.8% of the actual total number of traumatic deaths occurring in Los Angeles County during the study period. In contrast, the number depicted as injured represented only 3.4% of injuries due to traumatic causes. Both injuries and deaths due to fires, homicides, and legal interventions were proportionally well represented. However, injuries and deaths from accidental poisoning, falls, and suicide were significantly underrepresented.
  
  CONCLUSIONS: Some types of events receive disproportionately more news coverage than others. Local television news tends strongly to present only those events concerned with death or injury that are visually compelling. We discuss reasons for concern about the effect that this form of information bias has on public understanding of health issues and possible counteractions that physicians can take.

• School-Associated Violent Deaths in the United States, 1994-1999

  Anderson M, Kaufman J, Simon TR, Barrios L, Paulozzi L, Ryan G, Hammond R, Modzelesko W, Feucht T, Potter L, and the School-Associated Violent Deaths Study Group. JAMA 2001; 286(21): 2695-2702.
  
  Correspondence: Mark Anderson, MD, MPH, Division of Violence Prevention, Centers for Disease Control and Prevention, Mailstop K-60, 4770 Buford Hwy NE, Atlanta, GA 30341 (e-mail: mea6@cdc.gov).

  BACKGROUND: Despite the public alarm following a series of high-profile school shootings that occurred in the United States during the late 1990s, little is known about the actual incidence and characteristics of school-associated violent deaths.
  
  OBJECTIVES: To describe recent trends and features of school-associated violent deaths in the United States.
  
  METHODS: Design, Setting, and Subjects- Population-based surveillance study of data collected from media databases, state and local agencies, and police and school officials for July 1, 1994, through June 30, 1999. A case was defined as a homicide, suicide, legal intervention, or unintentional firearm-related death of a student or nonstudent in which the fatal injury occurred (1) on the campus of a public or private elementary or secondary school, (2) while the victim was on the way to or from such a school, or (3) while the victim was attending or traveling to or from an official school-sponsored event. Main Outcome Measures- National estimates of risk of school-associated violent death; national trends in school-associated violent deaths; common features of these events; and potential risk factors for perpetration and victimization.
  
  RESULTS: Between 1994 and 1999, 220 events resulting in 253 deaths were identified; 202 events involved 1 death and 18 involved multiple deaths (median, 2 deaths per multiple-victim event). Of the 220 events, 172 were homicides, 30 were suicides, 11 were homicide-suicides, 5 were legal intervention deaths, and 2 were unintentional firearm-related deaths. Students accounted for 172 (68.0%) of these deaths, resulting in an estimated average annual incidence of 0.068 per 100 000 students. Between 1992 and 1999, the rate of single-victim student homicides decreased significantly (P = .03); however, homicide rates for students killed in multiple-victim events increased (P = .047). Most events occurred around the start of the school day, the lunch period, or the end of the school day. For 120 (54.5%) of the incidents, respondents reported that a note, threat, or other action potentially indicating risk for violence occurred prior to the event. Homicide offenders were more likely than homicide victims to have expressed some form of suicidal behavior prior to the event (odds ratio [OR], 6.96; 95% confidence interval [CI], 1.96-24.65) and been bullied by their peers (OR, 2.57; 95% CI, 1.12-5.92).
  
  CONCLUSIONS: Although school-associated violent deaths remain rare events, they have occurred often enough to allow for the detection of patterns and the identification of potential risk factors. This information may help schools respond to this problem.

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Rev. 12-Dec-2001 at 20:34 hours.