3 November 2003


Alcohol and Other Drugs

The influence of alcohol, age and number of passengers on the night-time risk of driver fatal injury in New Zealand.

- Keall MD, Frith WJ, Patterson TL. Accid Anal Prev 2004; 36(1): 49-61.

Correspondence: Michael D. Keall, Land Transport Safety Authority, Research and Statistics, P.O. Box 2840, Wellington, NEW ZEALAND; (email: mdk@ltsa.govt.nz).

(Copyright © 2003, Elsevier Publishing)

Breath alcohol measurements and other data collected at randomly selected roadside sites were combined with data on fatally injured drivers in crashes occurring on the same weekdays and times (Friday and Saturday nights) at locations matched by the size of the nearest town. A logistic model was fitted to these data for the years 1995-2000 to estimate the effects of alcohol, driver's age and the influence of passengers carried on the risk of driver fatal injury in New Zealand. The estimated risks increased steeply with increasing blood alcohol concentration (BAC), closely following an exponential curve at levels below about 200mg/dl (i.e. 0.2%) and increasing less than exponentially thereon. The model fitted to data for drivers under 200mg/dl showed that risks at all BAC levels were statistically significantly higher for drivers aged under 20 (over five times) and for drivers aged 20-29 (three times) than for drivers aged 30 and over. Further, controlling for age and BAC level, driving with a single passenger was associated with approximately half the night-time risk of driver fatal injury relative to driving either solo or with two or more passengers. According to a recent travel survey, the types of passengers carried at the times of night and days of week studied appear to differ significantly from the types of passengers carried generally, which may lead to different passenger effects on driver behavior. The high relative risk of teenage drivers means that they reach high risk levels commonly regarded as unacceptable in the field of road safety even at their current legal limit of 30mg/dl, particularly when more than one passenger is carried in the car.

Secondhand effects of alcohol use among university students: computerized survey.

- Langley JD, Kapri K, Stephenson SCR. BMJ 2003; 327(7422): 1023-1024.

Correspondence: John D Langley, Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin 9000, NEW ZEALAND; (email: john.langley@ipru.otago.ac.nz).

(Copyright © 2003, BMJ Publishing Group)

BACKGROUND: "Secondhand effects" -- negative experiences directly resulting from someone else's drinking -- are among the problems associated with heavy drinking. Secondhand effects regularly receive attention from the media, and this probably shapes public opinion on alcohol policies and how individuals behave -- for example, avoiding high risk situations -- although no empirical studies have examined this. Also, studies of the incidence of secondhand effects are rare. One survey about drinking among college students has found that secondhand effects -- including interruptions to study or sleep, having to take care of a drunk student, and being insulted or humiliated -- were common.

METHODS: We invited a random sample of 1910 students (aged 16-29 years) at the University of Otago to complete an internet based questionnaire (http://ipru.otago.ac.nz/ausdemo), and 1564 (82%) responded. We asked the students which of 11 secondhand effects they had experienced in the previous four weeks. Responses were none, once, two or three times, or at least four times. We assessed whether the respondent was a heavy drinker by asking how often they drank six or more drinks on a single occasion. We obtained complete data from 1524/1564 (97%) respondents. Non-heavy drinkers included 62 abstainers and 191 drinkers who consumed fewer than six drinks on any single occasion.

FINDINGS: Incidence of any secondhand effect increased with the tendency to drink heavily. Logistic regression with adjustment for sex showed that, relative to 16-19 year olds, 20-24 year olds had similar odds of experiencing at least one secondhand effect (odds ratio 0.80; 95% confidence interval 0.58 to 1.09), and 25-29 year olds were at lower risk (0.17; 0.11 to 0.26). We found that being pushed, hit, or assaulted was 1.6 times more common (9% v 15%), unwanted sexual advances were 1.4 times more common (20% v 28%), and damage to property was 1.3 times more common (15% v 20%).

COMMENTS: Secondhand effects due to drinking alcohol are more common among university students than previously thought. For example, a tenth of women and a fifth of men were assaulted at least once in the four weeks preceding our survey, and one fifth of students had their property damaged. Even non-heavy drinkers experienced several effects, some serious.

Strengths of this study include the random sampling, the high response rate, and using a computerized questionnaire, a method known to increase reporting of high risk behavior. Limitations include imprecision -- for example, the seriousness of "crimes" is unspecified -- reliance on respondents to attribute responsibility for the effect, and our focus on students alone.

The needs of the many non-drinkers and moderate drinkers who are harmed by heavy drinkers should be considered when devising local and national alcohol policies. Universities and colleges should tackle environmental risk factors for hazardous drinking -- for example, the availability and promotion of alcohol on and around campus -- and should provide screening and intervention services for students with patterns of hazardous drinking.

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Commentary and Editorials

No reports this week

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Community-based Prevention

Community-based assessment of unintentional injuries: a pilot study in rural Vietnam.

- Hang HM, Ekman R, Bach TT, Byass P, Svanstrom L. Scand J Public Health 2003; 31(Suppl 62): 38-44.

Correspondence: Hoang Minh Hang, Department of Biostatistics, Hanoi Medical University Hanoi Vietnam, VIETNAM; (email: unavailable).

(Copyright © 2003, Taylor & Francis)

CONTEXT: Although unintentional injuries are recognized as a major public health problem globally, little is known about their patterns and rates at the community level in most low-income countries. Rapid social development, leading to increased traffic and industrialization, may be changing patterns of injury. Injuries within the home environment have not so far been recognized to the same extent as traffic and work-related injuries in Vietnam, largely because they have not been effectively counted. This study took place in northern Vietnam, in the context of a longitudinal community surveillance site called FilaBavi, as a pilot project aiming to determine the community incidence of unintentional injury and to explore appropriate methods for community-based injury surveillance.

METHODS: An initial study population of 23,807 was identified and asked about their experience of injury in the preceding three months.

FINDINGS: Overall 450 new injuries were detected over 5,952 person-years, a rate of 76 per 1,000 person-years. Males were injured at 1.6 times the rate of females, and home and road traffic accidents were most common. Most injuries occurred during unpaid household tasks. Cutting and crushing injuries occurred most frequently. Of 221 deaths from all causes in the FilaBavi population during 1999 among 43,444 person-years, 25 were attributed to unintentional injuries and two to suicide. Unintentional injury was the third leading cause of death in this community, with a case-fatality rate of 0.8%.

COMMENTS: The findings suggest that greater attention needs to be directed toward the prevention of injuries occurring in the home in rural Vietnam. On the basis of this pilot study, a one-year study using the same approach is under way to characterize the patterns of unintentional injury in more detail, including any seasonal variation.

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Disasters

Terrorism preparedness in state health departments --- United States, 2001--2003.

- Shipp G, Dickson J, Quinlisk P, Lohff C, Franklin N. MMWR 2003; 52(43): 1051-1053.

Complete report with tables, references, and editorial comments available online ( DOWNLOAD DOCUMENT ).

The anthrax attacks in fall 2001 highlighted the role of infectious disease (ID) epidemiologists in terrorism preparedness and response. Beginning in 2002, state health departments (SHDs) received approximately $1 billion in new federal funding to prepare for and respond to terrorism, infectious disease outbreaks, and other public health threats and emergencies. This funding is being used in part to improve epidemiologic and surveillance capabilities. To determine how states have used a portion of their new funding to increase ID epidemiology capacity, the Iowa Department of Public Health's Center for Acute Disease Epidemiology and the Iowa State University Department of Microbiology conducted two surveys of U.S. state epidemiologists during September 2000--August 2001 and October 2002--June 2003. This report summarizes the results of these surveys, which determined that although the number of SHD epidemiology workers assigned to ID and terrorism preparedness increased by 132%, concerns remained regarding the ability of SHDs to hire qualified personnel. These findings underscore the need to develop additional and more diverse training venues for current and future ID epidemiologists. All 50 SHDs responded to both surveys. A total of 47 SHDs reported adding or expecting to add ID epidemiologists, who were assigned various responsibilities (e.g., terrorism preparedness, ID and terrorist agent surveillance, outbreak and possible terrorist threat investigation, public health worker and health-care provider training, and grant writing). Overall, during 2001--2003, the number of epidemiology workers employed in ID and terrorism preparedness increased by 132%, from 366 to 848. Despite these hiring increases, the surveys identified multiple challenges, including problems 1) allocating time for planning (66% of responding SHDs); 2) establishing disease surveillance systems (55%); and 3) hiring qualified ID epidemiologists (57%). Other challenges to preparedness included the complexity of food-security issues, state hiring freezes and budget deficits, political and public policy considerations, and difficulty allocating the necessary time and resources for the pre-event smallpox vaccination program.

Local preparedness and response to terrorism with biological and chemical agents -- present status in United States.

- Nogi EK. Int J Disaster Med 2003; 1(1): 51-55.

Correspondence: Eric K. Noji, Office of the US Surgeon General, US Public Health Service, 200 Independence Avenue, Washington, DC 20201, USA; (email: Eric.Noji@hhs.gov).

(Copyright © 2003, Taylor & Francis)

Over the past decade, acts of terrorism have ranged from dissemination of aerosolized anthrax spores, intentional food product contamination, release of chemical weapons in major metropolitan subway systems and suicide attacks using explosive devices. Unfortunately, predicting when and how such attacks might occur has proven to be very difficult. Since the bombing attacks at the World Trade Center in New York in 1993 and 2001, the Federal Building in Oklahoma City in 1995, the US Embassies in Kenya and Tanzania in 1998 and just recently in Saudi Arabia and Morocco, and the release of impressively weaponized anthrax spores in the US Postal System during the autumn of 2001, large scale terrorist attacks on civilian populations using weapons of mass destruction no longer seem in the realm of the fantastic. At their worst, the New York, Oklahoma City, and Tokyo attacks may represent the crossing of a grim threshold, weakening long-standing taboos and increasing the likelihood of analogous attacks in the future. Preparing the medical community to address these threats is a formidable challenge, but the consequences of being unprepared could be devastating. The medical and healthcare infrastructure must be prepared to both prevent and treat illnesses and injury that would result from CBRNE terrorism, especially a covert terrorist attack.

This article outlines steps for strengthening medical and public health capacity to protect against these dangers that have been taken in the USA. Investments in scientific knowledge, public health and hospital and healthcare systems provide the best defense against terrorism and will improve our ability to successfully respond to other public health threats that will emerge in the twenty-first century.

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Distraction and attentional issues

No reports this week

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Injuries at Home

Modification of the home environment for the reduction of injuries.

- Lyons R, Sander L, Weightman A, Patterson J, Jones SL, Rolfe B, Kemp A, Johansen A. Cochrane Database Syst Rev 2003; 4: CD003600.

Correspondence: R. Lyons, Swansea Clinical School, University of Wales Swansea, Grove Bldg, Singleton Park, Swansea, UK; (email: unavailable).

(Copyright © 2003, The Cochrane Collaboration)

CONTEXT: Injury in the home is extremely common, accounting for around a third of all injuries. The majority of injuries of children under five and people aged 75 and over occur at home. Multi-factorial injury prevention interventions have been shown to reduce injuries in the home. However, few studies have focussed specifically on the impact of physical adaptations to the home environment and the effectiveness of such intervention needs to be ascertained.

OBJECTIVES: To review the evidence for the effect on injuries of modification of the home environment with a primary focus on interventions to reduce physical hazards.

SEARCH STRATEGY: We searched the following databases: APId, ASSIA, British Nursing Index, CINAHL, Cochrane Library databases, Dissertation Abstracts, EMBASE, HealthSTAR, ICONDA, ISI Science (and Social Science) Citation Index, MEDLINE, National Research Register, PREMEDLINE, SIGLE and Urbadisk. Conference proceedings and reference lists were scanned. Experts in the field and trialists were contacted. Searches were not restricted to English language. Handsearching of relevant journals was not conducted.

SELECTION CRITERIA: Randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted time series studies.

DATA COLLECTION AND ANALYSIS: All abstracts were screened by two reviewers for relevance, outcome and design. Two reviewers independently evaluated methodological quality and extracted data from each eligible study.

FINDINGS: We found 28 published trials and one unpublished study. Trials were not sufficiently similar to allow for the combination of data by statistical analyses, so this review takes a narrative form. Studies were divided into three groups based on the primary population sample: children, older people and the general population. None of the 11 childhood studies demonstrated a reduction in injuries that might have been due to environmental adaptation in the home. One study reported a reduction in injuries and in hazards but the two could not be linked. The majority of studies used hazard reduction as the outcome. Of the 15 studies in older people, none demonstrated a reduction in injuries due to hazard reduction, although two demonstrated a reduction in falls that could be due to hazard reduction. In the mixed age group there were two trials; neither demonstrated an effect on injuries.

COMMENTS: There is insufficient evidence to determine the effects of interventions to modify environmental home hazards. Further interventions to reduce hazards in the home should be evaluated by adequately designed randomized controlled trials measuring injury outcomes. Recruitment of large study samples to measure effect may be a major consideration for future trials.

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Occupational Issues

Reduction in injury rates in nursing personnel through introduction of mechanical lifts in the workplace.

- Evanoff B, Wolf L, Aton E, Canos J, Collins J. Am J Ind Med 2003; 44(5): 451-457.

Correspondence: Bradley Evanoff, Division of General Medical Sciences, Department of Internal Medicine, Campus Box 8005, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (email: bevanoff@im.wustl.edu).

(Copyright © 2003, John Wiley & Sons)

CONTEXT: Health care workers incur frequent injuries resulting from patient transfer and handling tasks. Few studies have evaluated the effectiveness of mechanical lifts in preventing injuries and time loss due to these injuries.

METHODS: We examined injury and lost workday rates before and after the introduction of mechanical lifts in acute care hospitals and long-term care (LTC) facilities, and surveyed workers regarding lift use.

FINDINGS: The post-intervention period showed decreased rates of musculoskeletal injuries (RR = 0.82, 95% CI: 0.68-1.00), lost workday injuries (RR = 0.56, 95% CI: 0.41-0.78), and total lost days due to injury (RR = 0.42). Larger reductions were seen in LTC facilities than in hospitals. Self-reported frequency of lift use by registered nurses and by nursing aides were higher in the LTC facilities than in acute care hospitals. Observed reductions in injury and lost day injury rates were greater on nursing units that reported greater use of the lifts.

COMMENTS: Implementation of patient lifts can be effective in reducing occupational musculoskeletal injuries to nursing personnel in both LTC and acute care settings. Strategies to facilitate greater use of mechanical lifting devices should be explored, as further reductions in injuries may be possible with increased use.

Fatal injuries to teenage construction workers in the US.

- Suruda A, Philips P, Lillquist D, Sesek R. Am J Ind Med 2003; 44(5): 510-514.

Correspondence: Anthony Suruda, Rocky Mountain Center for Occupational & Environmental Health, 75 South 2000 East, Salt Lake City, UT 84112-5120, USA; (email: tonysuruda@aol.com).

(Copyright © 2003, John Wiley & Sons)

CONTEXT: The construction industry is second only to agriculture in the annual number of fatal injuries in workers less than 18 years of age. We examined fatal injury reports for youth and adult workers to determine risk factors for injury and applicability of existing child labor regulations.

METHODS: The US Occupational Safety & Health Administration (OSHA) investigation data for fatal work injuries from 1984 through 1998 were reviewed with respect to type of event, employer characteristics, and apparent violations of existing child labor laws under the Fair Labor Standards Act (FLSA). We also examined whether the employer met exemption criteria for federal enforcement of child labor or OSHA regulations.

FINDINGS: The fatality rate for teenage construction workers age 19 and younger was 12.1 per 100,000 per year, slightly less than for adult workers. Teenage workers who were fatally injured were more likely than adults to have been employed at non-union construction firms (odds ratio (OR) = 4.96, P < 0.05), firms with fewer than 11 employees (OR = 1.72, P < 0.05), and their employers were more likely to have been cited by OSHA for safety violations (OR = 1.66, P < 0.05) than for firms which were investigated because of a fatality in an adult worker. Fatalities in teenagers were more likely to occur in special construction trades such as roofing. Among fatalities in workers less than 18 years of age, approximately one-half (49%) of the 76 fatal injuries were in apparent violation of existing child labor regulations. We estimated that in 41 of the 76 cases (54%) the employer's gross annual income exceeded the $500,000 threshold for federal enforcement of child labor laws. Only 28 of 76 cases (37%) were at construction firms with 11 or more employees, which are subject to routine OSHA inspections.

COMMENTS: Fatal injuries in teenage construction workers differed from those in adults in that they were more likely to be at small, non-union firms of which a substantial proportion were exempt from federal enforcement of child labor laws and from routine OSHA inspections. Safety programs for young construction workers should include small, non-union construction firms and those in special construction trades such as roofing. We did not identify specific areas for new regulation but the number of fatalities reviewed was small.

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Pedestrian and Bicycle Issues

Trauma to adult bicyclists: a growing problem in the urban environment.

- Rosenkranz KM, Sheridan RL. Injury 2003; 34(11): 825-829.

Correspondence: Robert L. Sheridan, Department of Surgery, Dartmouth Hitchcock Medical Centre, 02114, Boston, MA, USA; (email: rsheridan@partners.org).

(Copyright © 2003, Elsevier Publishing)

The proportion of adults involved in serious bicycle accidents has increased in the last two decades. The majority of the bicycle injury prevention efforts, however, are directed toward child riders. The authors performed a retrospective review of injury statistics from the Massachusetts Hospital Discharge Data Set, 1994-1999, the Massachusetts Emergency Department Injury Surveillance System, 1999, and the trauma registry of an Urban Level I Trauma Center, 1993-2000. Massachusetts's state-wide injury data reveals a 30% increase in hospital charges between 1994 and 1999 for adults following bicycle falls and collisions with concomitant stability in the charges for children. In the years 1993-2000, 60% of patients requiring inpatient care at the Study Center for Bicycle Related Injuries were over 16 years of age. Fifty-one percent of patients were without a helmet. Positive blood alcohol tests were present in 35 (16%) of the 222 patients. Forty-six (75%) of patients suffering closed head injury were not helmeted. Adult bicycle trauma is a significant health and financial problem in the urban state of Massachusetts. Bicycle education and legislation emphasizing safe bicycling practice, the protective effects of helmets, and the danger of cycling under the influence of alcohol may help alleviate this problem.

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Poisoning

Plant poisonings in children in the Czech Republic, 1996-2001.

- Vichova P, Jahodar L. Hum Exp Toxicol 2003; 22(9): 467-472.

Correspondence: Ludek Jahodar, Department of Pharmaceutical Botany and Ecology, Faculty of Pharmacy, Charles University in Prague, CZECH REPUBLIC; (email: jahodar@faf.cuni.cz).

(Copyright © 2003, Arnold)

Ingestion of or exposure to potentially poisonous plants is a relatively common presenting complaint in hospital pediatric departments, especially amongst toddlers. We present a retrospective study conducted to review the hospital admissions following acute childhood poisoning with plants in the Czech Republic over a 6-year period from 1996 to 2001. Six university hospital pediatric departments and two local hospital pediatric departments were involved in the study. Information and complete data on the cases were collected on the basis of all hospital medical records and internal hospital database outcomes. A total of 174 plant exposures were analyzed to tabulate the list of top species involved in plant poisonings. The aims were to provide classification according to agent frequency, clinical presentations, severity of symptoms expressed, affected age groups and gender of patients and to evaluate the treatment according to patient outcome. The most frequent ingestions were of thorn apple seeds (14.9%), followed by dumb cane exposures (11.5%) and common yew (9.8%). Thorn apple, dumb cane, golden chain and raw beans caused the most serious symptoms. There were no fatalities reported out of the reviewed medical records. Complete data on plant poisoning in children from all over the territory of the Czech Republic are not available; however, we believe that the frequency of causes and the rank of plant species commonly involved are properly reflected in our study.

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Recreation and Sports

Patterns of injury and outcomes associated with motocross accidents.

- Gorski TF, Gorski YC, McLeod G, Suh D, Cordero R, Essien F, Berry D, Dada F. Am Surg 2003; 69(10): 895-898.

Correspondence: Tito F. Gorski, Department of Surgery, Inland Valley Regional Medical Center, Wildomar, California, USA; (email: unavailable).

(Copyright © 2003, Southeastern Surgical Congress)

Motocross has become a popular recreation activity in Southern California, particularly in the Inland Empire area. In order to evaluate the patterns of injury and outcomes associated with motocross accidents, the Trauma Registry data and charts of all patients with motocross-related injuries from January 2000 to December 2001 were reviewed. Of the 270 patients studied, 265 were males and 5 were females, with a mean age of 26 years (range, 5-61). The mean Injury Severity Score was 6.8 (range, 1-38). Injuries involved extremity trauma in 52 per cent of patients closed head injuries in 33 per cent, blunt chest trauma in 23 per cent, abdominal trauma in 15 per cent, spinal trauma in 14 per cent, and pelvic trauma in 8 per cent. Surgery was required in 96 patients (36%), most commonly for treatment of orthopedic injuries. After initial evaluation, 179 patients were admitted (66%), 60 were discharged home (22%), 29 were transferred for higher level of care (11%), and two expired (1%). The mean hospital length of stay was 2.3 days (range, 1-9). Motocross accidents are most commonly associated with extremity injuries and closed head trauma. Although the overall mortality is low, the morbidity is high, with a large proportion of patients requiring surgery.

Equestrian injuries in New Zealand, 1993-2001: knowledge and experience.

- Northey G. N Z Med J 2003; 116(1182): U601.

Correspondence: Glenda Northey, Injury Prevention Research Centre, University of Auckland, Auckland, NEW ZEALAND; (email: g.northey@auckland.ac.nz).

(Copyright © 2003, New Zealand Medical Association)

CONTEXT: The aims of this study were to investigate the extent of equestrian injuries in New Zealand and provide a range of prevention interventions.

METHODS: An examination of New Zealand Health Information Service (NZHIS) morbidity data for 1993 to 2001 and mortality data for 1993 to 1999 was undertaken. Recent studies on equestrian injuries were evaluated.

FINDINGS: NZHIS data indicated that as a result of horse-related injuries 5,613 people were hospitalized between 1993 and 2001 and there were 16 fatalities between 1993 and 1999. Horse-related injuries were most prevalent in young females aged 10 to 19 years. Among Maori (the indigenous people of New Zealand), men predominated in horse-related injury numbers. Overall, half of equestrian injuries occurred in those under the age of 19 years. The major injury site was the arm. High equestrian-injury rates were recorded in rural regions.

COMMENTS: The findings indicate that age and regionally specific practical injury prevention strategies, health promotion messages and educational programs are required. In particular, clear rules and regulations on protective and safety clothing are likely to enhance safety. Education in horse behavior is required to facilitate safer environments on and around horses. A code of practice for horse riding and trekking establishments could decrease the risk of injury to those who hire horses.

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Research Methods

The worst injury predicts mortality outcome the best: rethinking the role of multiple injuries in trauma outcome scoring.

- Kilgo PD, Osler TM, Meredith W. J Trauma 2003; 55(4): 599-606.

Correspondence: Patrick D. Kilgo, Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1063, USA; (email: pkilgo@wfubmc.edu).

(Copyright © 2003, Lippincott, Williams & Wilkins)

CONTEXT: The prediction of outcome after injury must incorporate measures of injury severity, but there is no consensus on how many injuries should be used in calculating these measures. Initially, the single worst injury was used to predict outcome, but the introduction of the Injury Severity Score allowed up to three injuries to contribute to outcome prediction. Subsequently, other outcome prediction approaches used many (New Injury Severity Score [NISS]) or all (ICISS and Trauma Registry Abbreviated Injury Scale Score [TRAIS], which use International Classification of Diseases, Ninth Revision [ICD-9] and Abbreviated Injury Scale [AIS] survival risk ratios [SRRs], respectively) of a patient's injuries. The ability of only the most severe injury in predicting mortality has never been studied. Our objective was to determine the ability of a patient's worst injury to predict mortality.

METHODS: A 10-fold cross-validation design was used to compute six scores for each of 160,208 patients from a large trauma database (the National Trauma Data Bank [NTDB]). The scores were ICISS, TRAIS, ICISS1 (only a patient's worst ICD-9 SRR), TRAIS1 (only a patient's worst AIS SRR), NISS (sum of squares of worst three AIS severity measures), and MAXAIS (worst AIS severity measure). Discrimination was assessed using the area under the receiver operating characteristic curve. Logistic regression R2 gauged the proportion of variance each score explained. The Akaike information criterion, a deviance statistic (lower is better), assessed model fit.

FINDINGS: The receiver operating characteristic curve, R2, and Akaike information criterion statistics (NC_ICISS and NC_ICDSRR1 represents scores derived from the original North Carolina Hospital Discharge Database SRRs) are summarized in tabular form in the Results section.

COMMENTS: Regardless of scoring type (ICD/AIS SRRs or AIS severity), a patient's worst injury discriminates survival better, fits better, and explains more variance than currently used multiple injury scores.

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RISK FACTOR PREVALENCE

Alaska Native mortality, 1979-1998.

- Day GE, Lanier AP. Public Health Rep 2003; 118(6): 518-530.

Correspondence: Gretchen Ehrsam Day, Office of Alaska Native Health Research, 4201 Tudor Centre Dr., Ste. 105, Anchorage, AK 99508, USA; (email: day747@gci.net).

(Copyright © 2003, Association of Schools of Public Health)

OBJECTIVES: This study compares mortality patterns for the Alaska Native population and the U.S. white population for 1989-1998 and examines trends for the 20-year period 1979-1998.

METHODS: The authors used death certificate data and Indian Health Service population estimates to calculate mortality rates for the Alaska Native population, age-adjusted to the U.S. 1940 standard million. Data on population and mortality for U.S. whites, aggregated by 10-year age groups and by gender, were obtained from the National Center for Health Statistics, and U.S. white mortality rates were age-adjusted to the U.S. 1940 standard million.

FINDINGS: Overall, 1989-1998 Alaska Native mortality rates were 60% higher than those for the U.S. white population for the same period. There were significant disparities for eight of 10 leading causes of death, particularly unintentional injury, suicide, and homicide/legal intervention. Although declines in injury rates can be documented for the period 1979-1998, large disparities still exist. Alaska Native death rates for cancer, cerebrovascular disease, chronic obstructive pulmonary disease, and diabetes increased from 1979 to 1998. Given decreases in some cause-specific mortality rates in the U.S. white population, increased rates among Alaska Natives have resulted in new disparities.

COMMENTS: These data indicate that improvements in injury mortality rates are offset by marked increases in chronic disease deaths.

Patient age and outcome following severe traumatic brain injury: an analysis of 5,600 patients.

- Hukkelhoven CW, Steyerberg EW, Rampen AJ, Farace E, Habbema JD, Marshall LF, Murray GD, Maas AI. J Neurosurg 2003; 99(4): 666-673.

Correspondence: Chantal W. P. M. Hukkelhoven, Center for Clinical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, THE NETHERLANDS; (email: c.hukkelhoven@erasmusmc.nl).

(Copyright © 2003, American Association of Neurological Surgeons)

CONTEXT: Increasing age is associated with poorer outcome in patients with closed traumatic brain injury (TBI). It is uncertain whether critical age thresholds exist, however, and the strength of the association has yet to be investigated across large series. The authors studied the shape and strength of the relationship between age and outcome, that is, the 6-month mortality rate and unfavorable outcome based on the Glasgow Outcome Scale.

METHODS: The shape of the association was examined in four prospective series with individual patient data (2664 cases). All patients had a closed TBI and were of adult age (96% < 65 years of age). The strength of the association was investigated in a metaanalysis of the aforementioned individual patient data (2664 cases) and aggregate data (2948 cases) from TBI studies published between 1980 and 2001 (total 5612 cases). Analyses were performed with univariable and multivariable logistic regression. Proportions of mortality and unfavorable outcome increased with age: 21 and 39%, respectively, for patients younger than 35 years and 52 and 74%, respectively, for patients older than 55 years. The association between age and both mortality and unfavorable outcome was continuous and could be adequately described by a linear term and expressed even better statistically by a linear and a quadratic term. The use of age thresholds (best fitting threshold 39 years) in the analysis resulted in a considerable loss of information. The strength of the association, expressed as an odds ratio per 10 years of age, was 1.47 (95% confidence interval [CI] 1.34-1.63) for death and 1.49 (95% CI 1.43-1.56) for unfavorable outcome in univariable analyses, and 1.39 (95% CI 1.3-1.5) and 1.46 (95% CI 1.36-1.56), respectively, in multivariable analyses. Thus, the odds for a poor outcome increased by 40 to 50% per 10 years of age.

COMMENTS: An older age is continuously associated with a worsening outcome after TBI; hence, it is disadvantageous to define the effect of age on outcome in a discrete manner when we aim to estimate prognosis or adjust for confounding variables.

The evaluation of patients admitted to a burn center in Turkey.

- Duzgun AP, Senel E, Ozmen MM, Kulacoglu H, Isik Y, Coskun F. Ulus Travma Derg 2003; 9(4): 250-256.

Correspondence: Arife P. Duzgun, Ankara Numune Teaching and Research Hospital Department of Surgery, Ankara, TURKEY; (email: apolatduzgun@yahoo.com).

(Copyright © 2003, Turkish Association of Trauma and Emergency Surgery)

CONTEXT: Burns constitute an important part of accident-related deaths due to high morbidity and mortality.

METHODS: The medical records of 778 (279 female) patients who were treated during last three years period were retrospectively analyzed concerning age, gender, the cause of the burn, the month when the burn occurred, admission date, duration of the hospital stay, area of the burn. The relationship between these parameters and the mortality was analyzed.

FINDINGS: The average age of the patients was 20 years. The burns were related to accidents in 87% patients, abuse in 8%, co-morbid diseases in 3% and suicidal attempts in 2%. In 48% of the cases there were hot fluid burns and in 37% (284) fire-flames. The burns were due to electrical burns in 13% patients and to other reasons in the remaining 2%. One hundred and seventy - two patients had fatal courses. The mortality rate was 75% in 12 patients who were above 60 years. Average burn area was 24% (10-100) and average hospital stay was 13 days.

COMMENTS: As most of the burns were due to accidents, the number of burns might be reduced by prioritizing preventive measures and better results could be obtained when the quality and the number of the burn centers is increased.

Fatal accidental burns in married women.

- Kumar V, Tripathi CB. Leg Med 2003; 5(3): 139-145.

Correspondence: Virendra Kumar, Department of Forensic Medicine, KMC, Manipal, 576119, Karnataka, INDIA; (email: drvkr_2001@yahoo.com).

(Copyright © 2003, Elsevier Publishing)

Burning incidents amongst women are a major concern in India as it has become pervasive throughout all social strata and geographical areas. They may be homicidal, suicidal or accidental in nature. Here, in the study, the main objective is to present the different epidemiological and medicolegal aspects of accidental burns in the married women. In a cohort of 152 burned wives, 70 (46%) were accidental victims and these cases were analyzed accordingly for their different medicolegal and epidemiological aspects. Data were collected from personal interview and from examining the different documents related to death. In this series, most of the women were illiterate Hindu housewives hailing from joint families (i.e. multigenerational groups of related individuals living under a single roof) of rural community. The majority (60%) of the affected wives were 16-25 years of age at the time of the accident and sustained less than 90% total body surface area burn injury. Most had the survival period more than 1 day, and more than half of them died of septicemia.

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Risk Perception and Communication

Risk terminology: a platform for common understanding and better communication.

- Christensen FM, Andersen O, Duijm NJ, Harremoes P. J Hazard Mater 2003; 103(3): 181-203.

Correspondence: Frans Møller Christensen, Danish Toxicology Centre, Health and Innovation, Horsholm, DENMARK; (email: frans.christensen@jrc.it).

(Copyright © 2003, Elsevier Publishing)

The sciences of analyzing and describing risks are relatively new and developing, and the associated terminologies are developing as well. This has led to ambiguity in the use of terms, both between different risk sciences and between the different parties involved in risk debates. Only recently, major vocabularies have been compiled by authoritative agencies. Some of these vocabularies are examined and explained based on a division into fundamental and action oriented risk terms. Fundamental terms are associated with description and characterization of the chemical, biological and physical processes leading from risk source(s) to possible consequences/effects. The approach to these terms is based on a cause-effect skeleton. The action oriented terms cover administrative, scientific, sociological, etc. processes associated with the work of identifying, characterizing, regulating and communicating risks in the society, and their internal connection and iterative character have been illustrated. Focus is laid on engineering and toxicological risks, but to some extent, the thoughts presented may be extrapolated to other areas. Differences in applied terminology probably cannot be eliminated, but they can be identified and clarified for better understanding. With the present paper, the authors hope to contribute to reducing the probability of derailing risk discussions from the risk issue itself.

When cultures meet in general practice: intercultural differences between GPs and parents of child patients.

- Harmsen H, Meeuwesen L, van Wieringen J, Bernsen R, Bruijnzeels M. Patient Educ Couns 2003; 51(2): 99-106.

Correspondence: Hans Harmsen, Department of General Practice, Erasmus University Rotterdam, Room Ff 323, P.O. Box 1738, 3000 DR, Rotterdam, THE NETHERLANDS; (email: j.harmsen@bmg.eur.nl).

(Copyright © 2003, Elsevier)

Although health care professionals in The Netherlands are increasingly confronted with diverse immigrant groups, medical counseling and treatment of these groups has not been the subject of extensive research yet. From other studies it is well known that intercultural differences can have serious consequences for health care, e.g. in terms of risk of incorrect diagnoses or non-compliance. Eighty-seven autochthonous Dutch and immigrant (mainly from Turkey and Surinam) parents of child patients and their general practitioners (GPs) were recruited to investigate the influence of cultural differences on mutual understanding and patient compliance. Analyses of questionnaires and home interviews revealed that there is a relation between the cultural background of the patient and effectiveness of communication. Communication in consultations between GPs and persons from ethnic minorities is less effective than in consultations with Dutch persons: there is more misunderstanding, and also more non-compliance. In general, mutual understanding between GP and patient proves to be a strong predictor for patient compliance. These findings hold especially true for patients living in two worlds, i.e. a mixture of traditional and western cultures. The results are discussed in terms of methodological issues and practical implications for the health care providers.

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Rural and Agricultural Issues

Sick leave analysis among self-employed Dutch farmers.

- Hartman E, Oude Vrielink HH, Huirne RB, Metz JH. Occup Med 2003; 53(7):461-468.

Correspondence: Esther Hartman, Farm Management Group, Institute for Risk Management in Agriculture, Wageningen University, PO 9101, 6700 HB Wageningen, THE NETHERLANDS; (email: esther.hartman@wur.nl)

(Copyright © 2003, Society of Occupational Medicine, Published by Oxford University Press)

CONTEXT: Agriculture is one of the most physically demanding and risky industries. Aim The objective of this study was to provide baseline data on the diagnoses, occurrence and duration of sick leave of self-employed Dutch farmers.

METHOD: A database of 22 807 sick leave claims of 12 627 farmers during the period 1994-2001 was analyzed.

FINDINGS: Most of the claims (61%) were for musculo-skeletal injuries and disorders. The mean cumulative incidence (CI) was 10.2 claims per year per 100 farmers and did not change over time. However, it varied per agricultural sector and per age category, being lowest in arable farming and in the youngest age category and highest in mushroom farming and in the oldest age category. The duration of sick leave depended both on diagnosis and age category: the slowest recovery from sick leave was seen in farmers with respiratory diseases and farmers in the oldest age category.

COMMENTS: The results make it easier to identify groups of farmers to be targeted to prevent sick leave. To reduce the occurrence of sick leave in agriculture, the strategy should be to prevent musculo-skeletal injuries and disorders. Furthermore, a sector-specific approach is recommended, so that preventive actions can be focused on working conditions-specifically on workload and work safety. Efforts to shorten the duration of sick leave will also be valuable to obtain a reduction of sick leave.

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School Issues

Motor ability: protective or risk for school injuries?

- Gofin R, Donchin M, Schulrof B. Accid Anal Prev 2004; 36(1): 43-48.

Correspondence: Rosa Gofin, Department of Social Medicine, Hadassah University Hospital, Ein Karem, 91120, Jerusalem, ISRAEL; (email: gofin@cc.huji.ac.il).

(Copyright © 2003, Elsevier Publishing)

The study aims were to assess the independent contribution of motor ability to the incidence of school injuries. The study included 2057 pupils in grades 3-6 of primary schools in a city in the north of Israel. A surveillance system gathered information about injuries that occurred on school premises or during school related activities and required medical treatment or caused limitation of usual activities. Children provided information on sensation seeking, self-appraisal of health, academic performance, physical activity, and dominant hand; anthropometric measurements and motor ability tests were performed. The incidence of injury events was 4% (95% CI=3.2-5.0). Injuries increased with increased balance and agility, but there were no differences according to reaction time. No other study variables were associated with the incidence of injuries. Our findings of an increase in the incidence of injuries with better motor ability may express differences in exposure to risk situations between children with better and poorer motor abilities.

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Sensing and Response Issues

Attentional modulation of threshold sensitivity to first-order motion and second-order motion patterns.

- Allen HA, Ledgeway T. Vision Res 2003; 43(27): 2927-2936.

Correspondence: Harriet A. Allen, McGill Vision Research Unit, 687 Pine Avenue West, Rm. H4-14, H3A 1A1, Montreal, Quebec, CANADA; (email: h.a.allen@bham.ac.uk).

(Copyright © 2003, Elsevier Publishing)

Previous studies [e.g. Vision Research 40 (2000) 173] have shown that when observers are required to selectively attend to one of two, spatially-adjacent patches containing either first-order (luminance-defined) or second-order (contrast-defined) motion, threshold sensitivity for identifying the direction of second-order motion, but not first-order motion, is enhanced for the attended stimuli. The processing of second-order motion, unlike first-order motion, may, therefore, require attention. However, other studies have found little evidence for differential effects of attention on the processing of first-order and second-order motion [Investigative Ophthalmology and Visual Science 42(4) (2001) 5061]. We investigated the effects of attention instructions on the ability of observers to identify the directions and spatial orientations of luminance-defined and contrast-defined motion stimuli. Pairs of motion stimuli were presented simultaneously and threshold performance was measured over a wide range of drift temporal frequencies and stimulus durations. We found: (1) direction discrimination thresholds for attended motion stimuli were lower than those for unattended stimuli for both types of motion. The magnitude of this effect was reduced when the observers were not given prior knowledge of which patch of motion (attended or unattended) they had to judge first. (2) Direction discrimination for first-order motion was similarly affected at all temporal frequencies and durations examined, but for second-order motion the effects of attention depended critically on the drift temporal frequency and stimulus duration used. (3) Orientation discrimination showed little or no influence of attention instructions. Thus, whether or not attention influences the processing of second-order motion depends crucially on the precise stimulus parameters tested. Furthermore under appropriate conditions the processing of first-order motion is also influenced by attention, albeit to a lesser extent than second-order motion.

Collinear contextual suppression.

- Herzog MH, Schmonsees U, Fahle M. Vision Res 2003; 43(27): 2915-2925.

Correspondence: Michael H. Herzog, Human Neurobiology and Center for Advanced Imaging, University of Bremen, Argonnenstrasse 3, 28211, Bremen, GERMANY; (email: mherzog@uni-bremen.de).

(Copyright © 2003, Elsevier Publishing)

The context of a target can modulate behavioral as well as neural responses to that target. For example, target processing can be suppressed by iso-oriented surrounds whereas it can be facilitated by collinear contextual elements. Here, we present experiments in which collinear elements exert strong suppression whereas iso-oriented contextual surrounds yield no contextual modulation--contrary to most studies in this field. We suggest that contextual suppression depends strongly on the spatial arrangement of the context pointing to the influence of Gestalt factors in contextual modulation.

The shape and size of crowding for moving targets.

- Bex PJ, Dakin SC, Simmers AJ. Vision Res 2003; 43(27): 2895-2904.

Correspondence: Peter J. Bex, Institute of Ophthalmology, University College London, 11-43 Bath Street, EC1V 9EL, London, UK; (email: p.bex@ucl.ac.uk).

(Copyright © 2003, Elsevier Publishing)

Our ability to identify alphanumeric characters can be impaired by the presence of nearby features, especially when the target is presented in the peripheral visual field, a phenomenon is known as crowding. We measured the effects of motion on acuity and on the spatial extent of crowding. In line with many previous studies, acuity decreased and crowding increased with eccentricity. Acuity also decreased for moving targets, but the absolute size of crowding zones remained relatively invariant of speed at each eccentricity. The two-dimensional shape of crowding zones was measured with a single flanking element on each side of the target. Crowding zones were elongated radially about central vision, relative to tangential zones, and were also asymmetrical: a more peripheral flanking element crowded more effectively than a more foveal one; and a flanking element that moved ahead of the target crowded more effectively than one that trailed behind it. These results reveal asymmetrical space-time dependent regions of visual integration that are radially organized about central vision.

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Suicide

State firearm laws and rates of suicide in men and women.

- Conner KR, Zhong Y. Am J Prev Med 2003; 25(4): 320-324.

Correspondence: Kenneth R. Conner, University of Rochester Medical Center, Department of Psychiatry, Center for the Study and Prevention of Suicide, Rochester, New York, USA; (email: Kenneth_conner@urmc.rochester.edu).

(Copyright © 2003, Elsevier Publishing)

CONTEXT: To evaluate the associations of state laws restricting firearms and incidence rates of suicide in men and women using a cross-sectional design.

METHODS: States were divided into three categories based on the restrictiveness of their firearm laws: restrictive (n =8); modest (n =22); and unrestrictive (n =20). State suicide incidence rates stratified by gender were compared using Poisson regression analyses that controlled for measures of race/ethnicity, income, and urbanization. Analyses were based on 2000 census data and state suicide data from 1999 and 2000.In the analysis of women, compared to states with restrictive firearm laws, there were higher suicide incidence rate ratios (IRR) in states with modest (IRR=1.64; 95% confidence interval [CI], 1.34-2.01) and unrestrictive laws (IRR=1.55; 95% CI, 1.23-1.95). The analysis of men showed comparable results: modest firearm laws (IRR=1.51; 95% CI, 1.27-1.79); unrestrictive firearm laws (IRR=1.49; 95% CI, 1.23-1.82).

RESULTS: Results support the hypothesis that state restrictions on firearms have the potential to reduce the suicide rate. FINDINGS: Findings do not support a hypothesis that greater firearm restrictions are associated with the substitution of alternative methods of suicide. Firearms appear to be a comparable exposure for suicide in men and women. Although men are more likely to use firearms in suicide than women, this difference may merely reflect more frequent gun ownership among men.

Suicidal behavior in adolescents: risk factors (bibliography review and descriptive-analytical study).

- Vairo MC, Ruiz M, Blanco M, Matusevich D, Finkelsztein C. Vertex 2003; 14(53): 179-189.

Correspondence: Carolina Vairo, Hospital Italiano de Buenos Aires, ARGENTINA; (email: carovairo@hotmail.com).

(Copyright © 2003, Polemos)

CONTEXT: In the United States suicide is the third cause of death among adolescents. Suicidal behavior has increased a hundred percent over the last three decades; it is one of the most frequent psychiatric emergencies and the first cause of admission among inpatients between 15 and 24 years.

OBJECTIVE: This paper is divided in two parts. The first one is made up of a review about risk factors for suicidal behavior in adolescents. The objective of the second part study is to estimate the frequency of risk factors for suicidal behavior in a sample of inpatients and to correlate them with high lethality suicidal attempts.

METHOD: This is a retrospective, observational, descriptive, analytic transversal study based on information from 23 medical records. Variables were processed by bivariate analysis; relative risk was obtained considering high lethality suicidal attempt as dependent variable.

FINDINGS: Statistically significant relationships were found between high lethality suicidal attempt and no Axe II diagnosis and with the appearance of hopelessness.

COMMENTS: Suicidal attempts in adolescents with an Axe II diagnosis could be more related to self-harming than to a wish to die. Hopelessness can be considered an independent variable that determines the lethality of the suicidal attempt.

Life on the seesaw: a qualitative study of suicide resiliency factors for young gay men.

- Fenaughty J, Harre N. J Homosex 2003; 45(1): 1-22.

Correspondence: Niki Harre, University of Auckland, Department of Psychology, University of Auckland, Auckland, NEW ZEALAND; (email: n.harre@auckland.ac.nz).

(Copyright © 2003, Haworth Press)

While considerable research has highlighted the factors that increase gay youth suicide risk, there has been much less emphasis on protective factors. Using grounded theory methodology, we explored the suicide resiliency in eight young gay men in Aotearoa/New Zealand. Common themes emerged, including positive social norms and conditions, high levels of support, identification with role models and high self-esteem. These were integrated with "known" risk factors to form the Seesaw Model of Gay Male Suicide. This model demonstrates that the balance between risk and resiliency may be the key to gay suicide. Depending on the balance of these factors, youth might either be resilient, attempt suicide, or teeter somewhere in between. The current findings indicate that gay youth suicide prevention requires efforts to increase resiliency factors for this group.

Characteristics of self-immolation attempts in Akita Prefecture, Japan.

- Nakae H, Zheng YJ, Wada H, Tajimi K, Endo S. Burns 2003; 29(7): 691-696.

Correspondence: Hajime Nakae, Department of Emergency and Critical Care Medicine, Akita University School of Medicine, 1-1-1 Hondo, 010-8543, Akita, JAPAN; (email: nakaeh@doc.med.akita-u.ac.jp).

(Copyright © 2003, Elsevier Publishing)

Akita Prefecture has had the highest suicide rate in Japan for the past 9 years. To obtain further information on suicide attempts by self-immolation in Akita, we performed a statistical analysis of patients in this prefecture who attempted to burn themselves. Over the past 6 years, 541 patients suffering from burns were transferred to medical emergency units. Of these, 35 (6.5%) attempted self-immolation, most of whom were between 20 and 60 years of age. Women over 50 years of age outnumbered men in the same age group. All 35 patients sustained flame burns. The total burn surface area (TBSA), burn index (BI), rate of inhalation injury, and mortality rate were all significantly higher in the patients who attempted self-immolation than in those with nonsuicidal burns. Most (68.6%) of the self-immolation attempts were made indoors. Because the Japanese are not generally a very religious people, training to help them cultivate a philosophy of life and educating them in moral science to help them form a personal view of life and death may be necessary to prevent suicides.

Risk of suicide and spouse's psychiatric illness or suicide: nested case-control study.

- Agerbo E. BMJ 2003; 327(7422): 1025-1026.

Correspondence: Esben Agerbo, National Centre for Register-based Research, University of Aarhus, DK-8000 Aarhus C, DENMARK; (email: ea@ncrr.dk).

(Copyright © 2003, BMJ Publishing Group)

BACKGROUND: Suicides cluster in families with histories of psychiatric disorders and suicides. Genetic and environmental factors may play a role in the familial aggregation of suicides but are inseparable in most studies. Because married couples are usually genetically unrelated, studying them can identify environmental factors and means of protection. Your spouse dying or your spouse having a psychiatric disorder is stressful; mortality is increased in the surviving spouse. I investigated the association between a spouse's psychiatric illness, suicide, and other causes of death and own suicide.

METHODS:I got data by linking population based registers using unique personal identification numbers, which are assigned to all people living in Denmark. Until 1993, suicide was defined as ICD-8 (international classification of diseases, 8th revision) codes E950-E959; after 1994, ICD-10 codes X60-X84. I matched each person aged 25 to 60 years who had committed suicide during 1982-97 to a random subsample of 20 people stratified by sex and year of birth. I only enrolled people who had been living in Denmark for the past two years. I identified all spouses and children who were living with these people on 31 December two years before the suicide. I got admission and discharge dates and diagnoses from the Danish psychiatric central register, which has monitored all facilities for inpatients since 1969.1 2 I analyse the data with conditional logistic regression.

FINDINGS: I identified 9011 suicides, 180 220 controls, and 111 172 spouses (table). People whose spouse had ever been admitted with a psychiatric disorder were at greater risk of committing suicide, particularly if the first admission had been recent (risk ratio 5.09; 95% confidence interval 3.53 to 7.35). People whose spouse had died, especially by suicide (21.69; 11.10 to 42.37), were also at a greater risk of committing suicide. An adjusted analysis found weaker associations, but a spouse's suicide remained indicative of own suicide (P = 0.01).

COMMENTS: A greater risk of committing suicide was associated with a spouse who had been admitted to hospital with a psychiatric disorder or had died, particularly if the cause was suicide. Both spouses having been admitted was not associated with any additional effect.

Risk of suicide was particularly great in people whose spouse had been first admitted within the previous two years, which advocates a causal relationship. A severe mental illness can have an impact on other family members' social life, leisure time, and economy. Shared environmental factors may put cohabiting partners at risk of the same diseases. That the effect of assortative mating, measured here as both spouses previously admitted, however, did not further increase the suicide risk is striking. This finding suggests that behavioral traits associated with some psychiatric disorders, or that the admission itself, increase the suicide risk in spouses.

Research based on routine registers has limitations -- for example, data about episodes of illness that did not lead to admission and attempted suicides are unavailable. Conjugal bereavement has an impact on mortality among surviving spouses, and bereavement due to suicide increases own risk of suicide more than bereavement after other modes of death. Suicide may induce particularly difficult grief, and suicide of a spouse increases the other spouse's awareness of suicide as a possible means to end grief. Assortative mating for suicidal behavior is less likely because preference for mating between people with psychiatric illness did not increase the risk of suicide.

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Transportation

Road traffic injuries in an urban area in Mexico. An epidemiological and cost analysis.

- Hijar M, Arredondo A, Carrillo C, Solorzano L. Accid Anal Prev 2004; 36(1): 37-42.

Correspondence: Martha Hijar, National Institute of Public Health, Mexico (INSP) Center for Research in Health Systems, Avenue Universidad 655, Col. Sta. Ma, Ahuacatitlan, Mor., Cuernavaca, MEXICO; (email: mhijar@correro.insp.mx).

(Copyright © 2003, Elsevier Publishing)

The objective of this study was to do an epidemiological and costs analysis of the impact of road traffic injuries on the demand for emergency room services at hospitals located in the city of Cuernavaca, Mexico. The studied population included injured people who demanded medical attention at the emergency room for injuries due to events in public places, occurring between February and April 2001. Trained interviewers collected the data at the emergency room, 24h a day. The statistical analysis included simple and bivariate analysis using chi(2) odds ratio (OR), and a confidence interval of 95%. The costs analysis included the expenses during the process of searching for and finding care for injuries. There were 433 injured people, 233 (54%) were victims of road traffic accidents, 72% of crashes, and 28% were injured pedestrian and cyclists. Variables associated with the demand of emergency care due to road traffic injuries in comparison with other accidents, were: severity of injuries (OR 2.60, CI 1.44-4.71), and thorax injury (OR 4.64, CI 1.03-20.89). Pedestrians had higher costs for health care and 80% of them had to pay out-of-pocket (P<0.05). Differences between patients injured by crashes or as a pedestrian, were: age under 14 years (OR 5.9, CI 2.5-13.9), being unemployed (OR 2.1, CI 1.20-3.96), and being an elementary school student (OR 13.9, CI 3.08-63.13). The present study is, so far, the only one in Mexico to include an epidemiological and costs analysis in approaching the problem of road traffic injuries. Similar methods must be used, especially in developing countries, to reduce this important public health problem.

Neck strains and sprains among motor vehicle occupants-United States, 2000.

- Quinlan KP, Annest JL, Myers B, Ryan G, Hill H. Accid Anal Prev 2004; 36(1): 21-27.

Correspondence: Kyran P. Quinlan, Department of Pediatrics, Childrens' Hospital, University of Chicago, MC 6082, 5841 South Maryland Avenue, 60637, Chicago, IL, USA; (email: kquinlan@peds.bsd.uchicago.edu).

(Copyright © 2003, Elsevier Publishing)

CONTEXT: Motor vehicle (MV)-related injury is a leading cause of death and emergency department visits in the US. Information has been limited regarding the magnitude and types of injuries suffered by the survivors of MV crashes.

OBJECTIVE: To estimate the incidence and patterns of neck strain/sprain injury among MV occupants treated in US hospital emergency departments.

DESIGN AND PARTICIPANTS: Descriptive epidemiologic analysis of persons treated at a stratified, probability sample of US hospital emergency departments from 1 July to 31 December 2000.

MAIN OUTCOME MEASURES: Annualized national estimates of number and rate of neck strain/sprain injury among MV occupants overall and by patient's age and sex. Rates were calculated per 100,000 population as well as per billion person miles traveled.

FINDINGS: In 2000, an estimated 901,442 (95% CI 699,283-1,103,601) persons with neck strain/sprain injury were treated in US hospital emergency departments. For MV occupants, neck strain/sprain was the most frequent type of injury, comprising 27.8% of all injuries to MV occupants treated in emergency departments that year. The incidence (per 100,000 population) of neck strain/sprain was significantly lower in younger children and peaked in the 20-24-year age group. The incidence (per billion person miles traveled) peaked in the 15-19-year age group. Females tended to have a higher incidence of emergency department-treated neck strain/sprain than males.

COMMENTS: Neck strain/sprain is the most common type of injury to MV occupants treated in US hospital emergency departments. Based on emergency department visits, these estimates suggest that the problem of neck injury may be larger than has been previously demonstrated using other surveillance tools. Further research is needed to determine contributory factors and prevention measures to reduce the risk of neck injury among MV occupants especially among those at higher risk such as females, older teenagers and young adults.

Measuring transport injuries in a developing country: an application of the capture-recapture method.

- Tercero F, Andersson R. Accid Anal Prev 2004; 36(1): 13-20.

Correspondence: Ragnar Andersson, Department of Preventive Medicine, National Autonomous University of Nicaragua, Leon, NICARAGUA; (email: ragnar.andersson@kau.se).

(Copyright © 2003, Elsevier Publishing)

CONTEXT: The purposes of this study are to provide an estimation of the incidence of transport injuries in a defined local community in Nicaragua by using the capture-recapture method, and to compare results using this method when data at different levels of severity are utilized.

METHODS: hospital data (inpatient and outpatient) and traffic police records. Characteristics available for matching included name, age, sex, and date of occurrence. The methodology of capture-recapture was used to estimate the ascertainment degree of both sources of data and the estimate mortality and incidence rates. Estimates were calculated both when all hospital data were taken into account (inpatient and outpatient combined) and when only inpatient records were matched against police records.

RESULTS: First, including police records and all hospital data, the mortality and morbidity estimates were 35.5/100000 and 43.7/1000 per year, respectively. Second, when outpatients were excluded from the analysis, the corresponding estimates were 28.6/100000 and 7.5/1000, respectively. In non-fatal cases, the ascertainment-corrected coverage through police records was 2.6% and through hospital surveillance 19.0% when both inpatients and outpatients were included. In fatal cases, the corresponding rates were 56.1 and 22.8%, respectively.

COMMENTS: The combined data set pointed out pedestrians and cyclists as the main risk groups. Most fatalities were due to head injuries. Our results show that neither police records nor hospital records nor the aggregate database provided acceptable coverage of transport-related injuries. Combining police and hospital data by means of capture-recapture analysis produces more valid estimates, but caution must be given to the issue of severity heterogeneity between the two sources.

Safety as perceived by wheelchair-seated passengers in special transportation services.

- Wretstrand A, Petzall J, Stahl A. Accid Anal Prev 2004; 36(1): 3-11.

Correspondence: Anders Wretstrand, Department of Technology and Society, Lund University, Box 118, SE-221 00, Lund, SWEDEN; (email: anders.wretstrand@tft.lth.se).

(Copyright © 2003, Elsevier Publishing)

The aim of this study was to gain a better understanding of, and to help form a more complete picture of, the perceived safety of wheelchair-seated passengers using special transportation services (STS). A questionnaire was sent out and completed by 801 respondents in five Swedish regions. Additional information was acquired by means of 15 subsequent in-depth interviews. It was found that 5% reported personal incident-related injuries during the period that they had been eligible for STS. Injuries were most likely to occur during normal driving, but the passengers were also exposed to risks during boarding and alighting procedures. Nevertheless, 80% of the passengers were basically satisfied with the degree of safety. A large majority (97%) reported that they always use tie-down systems, and 78% always use safety belts. These results indicate that, despite general satisfaction with the STS system as such, malfunction of the existing safety equipment is a problem, since safety is especially critical for STS passengers-a vulnerable road-user group with few alternative travel modes. Therefore, there is a need for wheelchair tie-down and occupant restraint systems (WTORS) that are easier to handle by the operators and more suitable for the passengers and their wheelchairs. A low-floor vehicle concept might also reduce injury risks related to boarding and alighting procedures.

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Violence and Weapons

Screening for domestic violence in the pediatric office: a multipractice experience.

- Siegel RM, Joseph EC, Routh SA, Mendel SG, Jones E, Ramesh RB, Hill TD. Clin Pediatr (Phila) 2003; 42(7): 599-602.

Correspondence: Robert M. Siegel, Cincinnati Pediatric Research Group, Division of General and Community Pediatrics, Children's Hospital Medical Center, Cincinnati, Ohio, USA; (email: unavailable).

(Copyright © 2003, Westminister Publications)

The purpose of our study was to screen for domestic violence (DV) in 4 different pediatric practice settings. Women who accompanied their children to well-child visits were eligible. The women were screened with a 6-question tool previously piloted by our group, which included questions on partner abuse, child abuse, and pet abuse. Over a 1-year period, 435 women were screened. Of these women, 95 (22%) described DV at some point in their lives. Sixty-nine (16%) reported abuse longer than 2 years before the screen and 26 (6%) reported more recent abuse. While 11 of 117 women screened in the more affluent private practice reported a history of past abuse, no women in that group reported DV occurring within 24 months. The proportion of women reporting violence did not differ significantly by site, but the proportion of patients reporting new violence was significantly lower at the private practice site by Chi-square analysis. In conclusion, women screened in a variety of pediatric settings will disclose DV. Recent abuse is more likely to be reported in settings with indigent patients. All pediatricians should be screening for DV and have protocols in place to offer women the services they need if DV is revealed.

Nonintracranial fatal firearm injuries in children: implications for treatment.

- Nance ML, Branas CC, Stafford PW, Richmond T, Schwab CW. J Trauma 2003; 55(4): 631-635.

Correspondence: Michael L. Nance, Department of Surgery, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA; (email: nance@email.chop.edu).

(Copyright © 2003, Lippincott, Williams & Wilkins)

CONTEXT: Understanding the injury characteristics of nonintracranial fatal (NIF) gunshot wounds in children treated in a statewide trauma system will help guide effective treatment strategies.

METHODS: This study was a retrospective analysis of children fatally injured with firearms. The review included demographic information, firearm injury characteristics, and outcome. The setting included trauma centers participating in a statewide trauma registry. Patients were all children (age < 18 years) treated in trauma centers for NIF gunshot wounds from January 1988 through December 2000. The main outcome measures were characteristics of fatal firearm injuries in children.

FINDINGS: Over the 13-year period, there were 1,954 children with firearm injuries including 368 (18.8%) children with fatal wounds. Of the fatally wounded children, 177 (48.1%) had no intracranial injury. The NIF injury population was 90.4% male, with a mean age of 14.9 years (range, <1-17 years) and an Injury Severity Score of 38.2 (range, 9-75). Over 95% of deaths in this group occurred within 24 hours of admission. Although injuries to the thorax were most common (78.5%), 48.6% of the NIF cohort had injuries to multiple body regions, including 31% with injuries in both the abdomen and thorax. Compared with all children wounded by firearms, NIF firearm injury patients had, on average, more body regions injured (1.6 vs. 1.1, p < 0.001) and a greater total number of injuries (6.0 vs. 3.5, p < 0.001). Patients with an NIF injury were more likely to suffer a major vascular injury (54.8% vs. 13.8%, p < 0.001), lung injury (56.5% vs. 12.9%, p < 0.001), or cardiac injury (44.6% vs. 4.6%, p < 0.001) than all children with a firearm injury.

COMMENTS: Most children who arrive at trauma centers alive and subsequently die from NIF firearm injuries do so rapidly from major vascular and thoracic injury. Almost half of these children have injuries to multiple body regions, further complicating management. Innovative, aggressive treatment approaches should be sought to improve survival in this extremely injured cohort of children.

The pattern of gunshot injuries in a communal clash as seen in two Nigerian teaching hospitals.

- Aderounmu AO, Fadiora SO, Adesunkanmi AR, Agbakwuru EA, Oluwadiya KS, Adetunji OS. J Trauma 2003; 55(4): 626-630.

Correspondence: A. O. A. Aderounmu, Department of Surgery, Ladoke Akintola Univeristy of Technology, Oshogbo, NIGERIA; (email: atilola17@yahoo.com).

(Copyright © 2003, Lippincott, Williams & Wilkins)

CONTEXT: The pattern of gunshot injury in the Ife-Modakeke communal clash between March 3 and May 23, 1999 was analyzed in this study.

METHODS: The history was recorded for each patient presenting at the hospital with gunshot injuries from the clash. Each was examined and followed up through subsequent treatment in the wards and clinics.

FINDINGS: The study included 185 patients. The male-to-female ratio was 22.1 to 1, and 45.9% of the patients ranged in age from 21 to 30 years. The mean age was 28.3 +/- 11.2 years, and the mortality rate was 8.6%. There were 120 warriors and 65 noncombatants. Government workers and students made up most of the noncombatants (42.5%), whereas drivers and farmers constituted the vast majority of the warriors (23.3%). Injury to the lower limbs was the most commonly seen injury (54.6%). Sustained fractures and femoral fractures were the most common fracture (n = 100, 54.1%). Head and colonic injuries were the greatest cause of mortality.

COMMENTS: For civilian gunshot injuries, morbidity and mortality rates are high in the less developed countries because of inadequate prehospital and hospital care. Efforts should be made to improve these facilities.

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