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Background To describe and analyze the involvement of fentanyl and fentanyl analogs (FAs) in drug-related deaths in West Virginia (WV), United States. Methods Retrospective analyses of all WV drug-related deaths from 2005 to 2017 were performed, including comparisons of demographic and toxicological characteristics among total deaths, deaths in which fentanyl/FAs were present, deaths in which they were absent, heroin-related deaths, and prescription opioid-related deaths. Results Most of the 8813 drug-related deaths were overdoses, with about 11% resulting from transportation/other injuries in which drugs were contributors. Prescription opioid presence (without fentanyl) decreased by 75% from 2005–14 to 2015–17 (3545 deaths to 859 deaths, respectively), while fentanyl involvement in the deaths increased by 122% between these periods (487 to 1082 deaths). Ten FAs were identified (427 instances) after 2015. Alprazolam and ethanol were among the top five most frequently identified substances across years. Fentanyl, heroin and cocaine replaced oxycodone, diazepam and hydrocodone in the top five beginning in 2015. Few decedents had a prescription for fentanyl after 2015, with fewer prescriptions also present for other controlled substances identified. Conclusions Fentanyl, rapidly emerging FAs, and other illicit drugs in recent years pose a serious health threat even though prescription opioid-related deaths decreased over the same time period.

Purpose The relationship between cellphone use while driving legislation and self-reported adolescent driver behavior is poorly understood, especially across demographic subgroups. This study investigated the relationship between statewide cellphone legislation and cellphone use behaviors across adolescent driver subgroups, including age (16/17 vs. 18), sex, race/ethnicity (white non-Hispanic and others), and rurality (urban or rural). Methods Data from the 2011–2014 Traffic Safety Culture Index Surveys were combined with state legislation. The outcomes were self-reported texting and handheld cellphone conversations. The exposure was the presence of a texting or handheld cellphone ban applicable to all drivers (i.e., universal) in the drivers' state of residence. A multilevel, modified Poisson regression model was used to estimate the risk of engaging in these behaviors. Results Approximately 34% of respondents reported to have driven while conversing, and 37% texted and drove in the 30 days before the survey. Universal handheld calling bans were associated with lower occurrences of cellphone conversations across all groups except rural drivers. Overall, handheld cellphone bans were associated with 55% lower (adjusted risk ratio .45, 95% confidence interval .32–.63) occurrences of cellphone conversations. However, universal texting bans were not associated with fewer texting behaviors in any subgroup. Conclusions Universal handheld calling bans may discourage adolescents from engaging in handheld phone conversations, whereas universal texting bans may not fully discourage texting behaviors. More interventional or educational work is necessary, particularly addressing texting while driving.

Background: Traumatic brain injury (TBI) is a significant public health concern for older adults. Small-scale human studies have suggested pre-TBI statin use is associated with decreased in-hospital mortality following TBI, highlighting the need for large-scale translational research. Objective: To investigate the relationship between pre-TBI statin use and in-hospital mortality following TBI. Methods: A retrospective study of Medicare beneficiaries 65 and older hospitalized with a TBI during 2006 to 2010 was conducted to assess the impact of pre-TBI statin use on in-hospital mortality following TBI. Exposure of interest included atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin. Beneficiaries were classified as current, recent, past, and nonusers of statins prior to TBI. The outcome of interest was in-hospital mortality. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs) comparing current, recent, and prior statin use to nonuse. Results: Most statin users were classified as current users (90%). Current atorvastatin (OR = 0.88; 95% = CI 0.82, 0.96), simvastatin (OR = 0.84; 95% CI = 0.79, 0.91), and rosuvastatin (OR = 0.79; 95% CI = 0.67, 0.94) use were associated with a significant decrease in the risk of in-hospital mortality following TBI. Conclusions: In addition to being the most used statins, current use of atorvastatin, rosuvastatin, and simvastatin was associated with a significant decrease in in-hospital mortality following TBI among older adults. Future research must include clinical trials to help exclude the possibility of a healthy user effect in order to better understand the impact of statin use on in-hospital mortality following TBI.

BackgroundMotor vehicle collisions comprise the majority of occupational-related fatalities in the United States and West Virginia has one of the highest occupational-related fatality rates in the nation. The purpose of this study was to compare work and non-work-related collisions, crash locations, and the characteristics of in-state and out-of-state drivers ≥18 years of age who were fatally injured in work-related collisions in West Virginia.MethodologyData were from the 2000-2017 Fatality Analysis Reporting System. Work and non-work-related crashes and characteristics in-state vs. out-of-state drivers were compared using binary and multivariable logistic regression analyses. Crash locations were compared via spatial analyses using kernel density estimations.ResultsAmong the 5,835 individuals fatally injured in crashes, 209 were designated 'at work'. The odds of being a work-related crash were 85% lower [Odds Ratio (OR) = 0.15; 95% confidence interval (CI): 0.04, 0.49] among those testing positive for alcohol, but 2.5 times greater (OR = 2.56; 95% CI: 1.16, 5.65) among those holding a commercial driver's license. The odds of being an in-state driver were 75% lower (OR = 0.25; 95% CI: 0.12, 0.53) among those wearing a safety belt, but 2.7 times greater among workers testing drug positive (OR = 2.67; 95% CI: 1.10, 6.52). In-state drivers were also less likely to be driving a large truck or be involved in single vehicle collisions and less likely to experience crashes on weekends, nights, or on highways. Spatial patterns of crash locations varied slightly between workers and non-workers.ConclusionsWork-related crashes differed greatly from non-work-related crashes in West Virginia. Stark differences existed between in-state and out-of-state workers and their crashes. Various avenues for workplace safety interventions exist, including seatbelt initiatives and drug testing policies for non-commercial drivers, which could help mitigate West Virginia's elevated, occupational-related, traffic fatality rate.

Background Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care. Methods/design Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Māori compared with non-Māori). Discussion If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking. Trial registration Universal Trial Number (UTN) U1111-1134-0028. ACTRN12612001220853 . Submitted 8 November 2012 (date of enrolment of first participant); Version 1 registration confirmed 19 November 2012. Retrospectively registered.

Background Racial disparities in trauma outcomes occur, but disparities in fall mortality are unknown. The objective of this study was to determine inhospital and 1-year fall mortality among patients discharged from an urban trauma center. Methods We conducted a retrospective analysis of fall patients in our trauma registry (1997 to 2008) linked to the National Death Index to determine postdischarge mortality. Statistical analysis included chi-square tests, multivariable logistic regression, and Cox proportional hazards models. Results There were 7,541 fall admissions. There was no clinically significant difference in inhospital mortality between blacks and whites with age stratification. One year after discharge, blacks younger than 65 years were more likely to die of disease (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.62). Conclusions Although rates of inhospital mortality are similar, blacks younger than 65 years have a higher risk of dying after discharge due to disease when stratified by age highlighting the need for continued medical follow-up and prevention efforts.

Objective. Despite successes in the 1980s and early 1990s, progress in reducing impaired driving fatalities in the United States has stagnated in recent years. Since 1997, the percentage of drivers involved in fatal crashes with illegal blood alcohol concentration (BAC) levels has remained at approximately 20% to 22%. Many experts believe that public complacency, competing social and public health issues, and the lack of political fortitude have all contributed to this stagnation. The number of alcohol-related crashes, injuries, and fatalities is still unacceptable, and most are preventable. The public needs to be aware that the problem presented by drinking drivers has not been solved. Political leaders need guidance on which measures will affect the problem, and stakeholders need to be motivated once again to implement effective strategies. Methods. The National Academy of Sciences (NAS) Transportation Research Board (TRB) Alcohol, Other Drugs, and Transportation Committee (ANB50) sponsored a workshop held at the NAS facility in Woods Hole, MA, on August 24-25, 2015, to discuss the lack of progress in reducing impaired driving and to make recommendations for future progress. A total of 26 experts in research and policy related to alcohol-impaired driving participated in the workshop. The workshop began by examining the static situation in the rate of alcohol-impaired driving fatal crashes to determine what factors may be inhibiting further progress. The workshop then discussed eight effective strategies that have not been fully implemented in the United States. Workshop participants (16 of the 26) rated their top three strategies. Results. Three strategies received the most support: 1. Impose administrative sanctions for drivers with BACs = .05 to .08 g/dL.2. Require alcohol ignition interlocks for all alcohol-impaired driving offenders.3. Increase the frequency of sobriety checkpoints, including enacting legislation to allow them in the 11 states that currently prohibit them. Impose administrative sanctions for drivers with BACs = .05 to .08 g/dL. Require alcohol ignition interlocks for all alcohol-impaired driving offenders. Increase the frequency of sobriety checkpoints, including enacting legislation to allow them in the 11 states that currently prohibit them. Five other important strategies included the following: (a) increase alcohol taxes to raise the price and reduce alcohol consumption; (b) re-engage the public and raise the priority of impaired driving; (c) lower the illegal per se BAC limit to .05 for a criminal offense; (d) develop and implement in-vehicle alcohol detection systems; and (e) expand the use of screening and brief interventions in medical facilities. Conclusions. Each of these strategies is proven to be effective, yet all are substantially underutilized. Each is used in some jurisdictions in the United States or Canada, but none is used extensively. Any one of the three strategies implemented on a widespread basis would decrease impaired driving crashes, injuries, and fatalities. Based on the research, all three together would have a substantial impact on the problem.

Older adults have the highest rates of hospitalization and mortality from traumatic brain injury (TBI), yet outcomes in this population are not well studied. In particular, contradictory reports on the protective effect of female sex on mortality following TBI may have been related to age differences in TBI and other injury severity and mechanism. The objective of this study was to determine if there are sex differences in mortality following isolated TBI among older adults and compare with findings using all TBI. A secondary objective was to characterize TBI severity and mechanism by sex in this population.This was a retrospective cohort study conducted among adults aged 65 and older treated for TBI at a single large Level I trauma center from 1996 to 2012 (n = 4,854). Individuals treated for TBI were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Isolated TBI was defined as an Abbreviated Injury Scale score of 0 for other body regions. Our primary outcome was mortality at discharge.Among those with isolated TBI (n = 1,320), women (45% of sample) were older (mean [SD], 78.9 [7.7] years) than men (76.8 [7.5] years) (p0.001). Women were more likely to have been injured in a fall (91% vs. 84%; p0.001). Adjusting for multiple injury severity measures, female sex was not significantly associated with decreased odds of mortality following isolated TBI (odds ratio, 1.01; 95% confidence interval, 0.66-1.54). Using all TBI cases, adjusted analysis found that female sex was significantly associated with decreased odd of mortality (odds ratio, 0.73; 95% confidence interval, 0.59-0.89).We found no sex differences in mortality following isolated TBI among older adults, in contrast with other studies and our own analyses using all TBI cases. Researchers should consider isolated TBI in outcome studies to prevent residual confounding by severity of other injuries.Prognostic/epidemiologic study, level IV.

Background To quantify how alcohol, polysubstance use and other factors influence opioid concentrations in drug-related deaths in West Virginia (WV), United States. Methods Multiple linear regression models were employed to identify relationships among alcohol, other factors, and the concentrations of four commonly identified opioids (fentanyl, hydrocodone, oxycodone, methadone), accounting for demographic, toxicological and comorbid characteristics in WV drug-related deaths from 2005 to 2018. Results Alcohol concentrations of 0.08% or above were associated with significant reductions in blood concentrations of fentanyl (27.5%), hydrocodone (30.5%) and methadone (32.4%). Significantly lower predicted concentrations of all opioids studied were associated with multiple opioid vs. single opioid presence, with predicted concentration reductions ranging from 13.7% for fentanyl to 65–66% for hydrocodone and oxycodone. Benzodiazepine presence was associated with small, non-statistically significant changes in opioid concentrations, while stimulant presence was associated with statistically significant reductions in hydrocodone and oxycodone concentrations. Conclusions Co-ingestion of alcohol, multiple opioids or stimulants were associated with significantly decreased predicted concentrations of commonly identified opioids in drug deaths. Further evidence is provided for enhanced risks from polysubstance use with opioids, which has important public health implications.

Introduction: We aimed to investigate in-hospital outcomes of traumatic brain injury (TBI) based on blood alcohol concentration (BAC) and mechanism of injury (MOI). Methods: We conducted a retrospective study for patients admitted with TBI between 2010 and 2014. Based on BAC, patients were classified into [negative (-BAC) and positive (+BAC) group]. Data were analyzed and compared according to the MOI. Results: Out of 8141 trauma patients, 946 (11.6%) were diagnosed with TBI and 681 (72%) were subjected to BAC screening. One out of seven TBI was related to alcohol consumption with a mean age of 32 years. Gender, age, and Injury Severity Scores (ISS) were comparable in the two groups. However, the proportion of patients with polytrauma was significantly higher in -BAC than +BAC group regardless of the MOI except for the fall-related TBI. The median BAC was higher in fall-related followed by pedestrians and MVC victims [55 mmol/L (10–101), 49(9–71), and 31(1–69), respectively], p = 0.001. Overall hospital mortality was comparable between the two groups except for the pedestrian-related TBIs in which (+BAC) had significantly fewer mortality. Conclusions: Screening for BAC among patients with TBI increases substantially regardless of the MOI. The high BAC value in Fall-related TBI needs more attention to set appropriate preventive measures.

Objective Vast amounts of injury narratives are collected daily and are available electronically in real time and have great potential for use in injury surveillance and evaluation. Machine learning algorithms have been developed to assist in identifying cases and classifying mechanisms leading to injury in a much timelier manner than is possible when relying on manual coding of narratives. The aim of this paper is to describe the background, growth, value, challenges and future directions of machine learning as applied to injury surveillance. Methods This paper reviews key aspects of machine learning using injury narratives, providing a case study to demonstrate an application to an established human-machine learning approach. Results The range of applications and utility of narrative text has increased greatly with advancements in computing techniques over time. Practical and feasible methods exist for semiautomatic classification of injury narratives which are accurate, efficient and meaningful. The human-machine learning approach described in the case study achieved high sensitivity and PPV and reduced the need for human coding to less than a third of cases in one large occupational injury database. Conclusions The last 20 years have seen a dramatic change in the potential for technological advancements in injury surveillance. Machine learning of ‘big injury narrative data’ opens up many possibilities for expanded sources of data which can provide more comprehensive, ongoing and timely surveillance to inform future injury prevention policy and practice.

The purpose of this study is to assess the case rate of acute respiratory distress syndrome (ARDS) after near hanging and the secondary outcomes of traumatic and/or anoxic brain injury and death. Risk factors for the outcomes were assessed.The method is a single-center, statewide retrospective cohort study of consecutive patients admitted between August 2002 and September 2011, with a primary diagnosis of nonjudicial "hanging injury."Of 56 patients, 73% were male. The median age was 31 (Interquartile range (IQR), 16-56). Upon arrival, 9% (5/56) did not have a pulse, and 23% (13/56) patients were intubated. The median Glasgow Coma Scale (GCS) was 13 (IQR, 3-15); 14% (8/56) had a GCS = 3. Acute respiratory distress syndrome developed in 9% (5/56) of patients. Traumatic anoxic brain injury resulted in 9% (5/56) of patients. The in-hospital case fatality was 5% (3/56). Lower median GCS (3 [IQR, 3-7] vs 14 [IQR, 3-15]; P = .0003) and intubation in field or in trauma resuscitation unit (100% [5/5] vs 16% [8/51]; P = .0003) were associated with ARDS development. Risk factors of death were GCS = 3 (100% [3/3] vs 9% [5/53]; P = .002), pulselessness upon arrival of emergency medical services (100% [3/3] vs 4% [2/53]; P.001], and abnormal neurologic imaging (50% [1/2] vs zero; P = .04).The ARDS case rate after near hanging is similar to the general trauma population. Low GCS and intubation are associated with increased risk of ARDS development. The rate of traumatic and/or anoxic brain injury in this population is low.

Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.

Elevated blood alcohol content (BAC) is a risk factor for injury. Associations of BAC with adult respiratory distress syndrome (ARDS) have not been conclusively established.We evaluated the association of a BAC greater than 0 mg/dL with the intermediate outcomes, Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score, and their association with ARDS development.This is an observational retrospective cohort study of 26,305 primary trauma admissions to a statewide referral trauma center from July 11, 2003, to October 31, 2011. Logistic regression was performed to assess the relationship between admission BAC, ISS, GCS score, and ARDS development within 5 days of admission.The case rate for ARDS was 5.5% (1,447). BAC greater than 0 mg/dL was associated with ARDS development in adjusted analysis (odds ratio, 1.50; 95% confidence interval [CI], 1.33-1.71; p0.001). High ISS (≥16) had a stronger association with ARDS development (odds ratio, 17.99; 95% CI, 15.51-20.86), as did low GCS score (≤8) (odds ratio, 8.77; 95% CI, 7.64-10.07; p0.001). Patients with low GCS score and high ISS had the most frequent ARDS (33.6%) and the highest case-fatality rate without ARDS (24.7%).Elevated BAC is associated with ARDS development. In the analysis of alcohol exposure, ISS and GCS score occur after alcohol ingestion, making them intermediate outcomes. ISS and GCS score were strong predictors of ARDS and may be useful to identify at-risk patients. Elevated BAC may increase the frequency of the ARDS through influence on injury severity or independent molecular mechanisms, which can be discriminated only in experimental models.Epidemiologic study, level III.

Hangover is the most commonly reported negative consequence of heavy alcohol consumption. A large variety of symptoms have been reported the day after heavy drinking, which together are called the alcohol hangover. Frequently reported hangover symptoms include thirst, headache, drowsiness, and reduced alertness [1]. Although hangover is a common phenomenon in society and has serious socioeconomic consequences, it has received relatively little research attention. To increase research and international collaboration to examine the alcohol hangover, in 2010 the Alcohol Hangover Research Group (AHRG) was founded. This paper covers the research topics discussed at the 5th Alcohol Hangover Research Group meeting, held August 1–2, 2013 in Keele, UK.

Background Links between mental illness, self-inflicted injury and interpersonal violence are well recognised, but the association between poor mental health and unintentional injuries is not well understood. Methods We used the 2010 National Health Interview Survey to assess the association between psychological distress and unintentional non-occupational injuries among US adults. Psychological distress was measured by the Kessler Psychological Distress Scale, a symptom scale shown to identify community-dwelling persons with mental illness. Multivariable logistic regression was used to estimate adjusted ORs (AOR) and 95% CIs. Results Of the 26 776 individuals analysed, 2.5% reported a medically attended unintentional injury in the past 3 months. Those with moderate and severe psychological distress had 1.5 (1.2 to 1.8) and 2.0 (1.4 to 2.8) times higher odds of injury, respectively, as compared to those with low distress levels, after adjusting for age, sex, race, marital status, education level, alcohol use, physical functional limitation, medical comorbidity, employment status and health insurance status. Psychological distress was significantly associated with falls (AOR 1.4 (1.1 to 1.9)) and sprain/strain injuries (AOR 2.0 (1.5 to 2.8)), but not transportation-related injuries (AOR 1.2 (0.7 to 1.9)) or fractures (AOR 1.1 (0.8 to 1.6)). Conclusions Among community-dwelling US adults, psychological distress is significantly associated with unintentional non-occupational injury, and the magnitude of association increases with severity of distress. The association between psychological distress and injury may be particularly strong for falls and sprain/strain injuries. These findings draw attention to a large group of at-risk individuals that may merit further targeted research, including longitudinal studies.

Alcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of resuscitation in injured patients. We investigated whether acutely injured patients with positive blood alcohol content (+BAC) had less lactate clearance than sober patients.We conducted a retrospective cohort study of acutely injured patients treated at an urban Level 1 trauma centre between January 2010 and December 2012. Blood alcohol and venous lactate levels were measured on all patients at the time of arrival. Study subjects were patients transported directly from the scene of injury, who had an elevated lactate concentration on arrival (≥3.0mmol/L) and at least one subsequent lactate measurement within 24h after admission. Lactate clearance ([Lactate1-Lactate2]/Lactate1) was calculated for all patients. Chi-squared tests were used to compare values from sober and intoxicated subjects. Lactate clearance was plotted against alcohol levels and stratified by age and Injury Severity Score (ISS).Serial lactate concentration measurements were obtained in 3910 patients; 1674 of them had +BAC. Patients with +BAC were younger (mean age: 36.6 [SD 14.7] vs 41.0 [SD 19.9] years [p=0.0001]), were more often male (83.4% vs 75.9% [p=0.0001]), had more minor injuries (ISS9) (33.8% vs 27.1% [p=0.0001]), had a lower in-hospital mortality rate (1.4% vs 3.9% [p=0.0001]), but also had lower average lactate clearance (37.8% vs 47.6% [p=0.0001]). The lactate clearance of the sober patients (47.6 [SD 33.5]) was twice that of those with +BAC400 (23.5 [SD 6.5]). Lactate clearance decreased with increasing BAC irrespective of age and ISS.In a large group of acutely injured patients, a dose-dependent decrease in lactate clearance was seen in those with elevated BAC. This relationship will cause a falsely elevated lactate reading or prolong lactate clearance and should be taken into account when evaluating patients with +BAC.

Objective Pedestrians account for a third of the 1.2 million traffic fatalities annually worldwide, and men are overrepresented. We examined the factors that contribute to this male-female discrepancy: walking exposure (kilometres walked per person-year), vehicle-pedestrian collision risk (number of collisions per kilometres walked) and vehicle-pedestrian collision case fatality rate (number of deaths per collision). Design The decomposition method quantifies the relative contributions (RCs) of individual factors to death rate ratios among groups. The male-female ratio of pedestrian death rates can be expressed as the product of three component ratios: walking exposure, collision risk and case fatality rate. Data sources included the 2008–2009 US Fatality Analysis Reporting System, General Estimates System, National Household Travel Survey and population estimates. Setting USA. Participants Pedestrians aged 5 years and older. Main outcome measures Death rate per person-year, kilometres walked per person-year, collisions per kilometres walked and deaths per collision by sex. Results The pedestrian death rate per person-year for men was 2.3 times that for women. This ratio of male to female rates can be expressed as the product of three component ratios: 0.995 for walking exposure, 1.191 for collision risk and 1.976 for case fatality rate. The RCs of these components were 1%, 20% and 79%, respectively. Conclusions The majority of the male-female discrepancy in 2008–2009 pedestrian deaths in the US is attributed to a higher fatality per collision rate among male pedestrians.

Objectives. We have described national trends for the 5 leading external causes of injury mortality. Methods. We used negative binomial regression and annual underlying cause-of-death data for US residents for 2000 through 2009. Results. Mortality rates for unintentional poisoning, unintentional falls, and suicide increased by 128%, 71%, and 15%, respectively. The unintentional motor vehicle traffic crash mortality rate declined 25%. Suicide ranked first as a cause of injury mortality, followed by motor vehicle traffic crashes, poisoning, falls, and homicide. Females had a lower injury mortality rate than did males. The adjusted fall mortality rate displayed a positive age gradient. Blacks and Hispanics had lower adjusted motor vehicle traffic crash and suicide mortality rates and higher adjusted homicide rates than did Whites, and a lower unadjusted total injury mortality rate. Conclusions. Mortality rates for suicide, poisoning, and falls rose substantially over the past decade. Suicide has surpassed motor vehicle traffic crashes as the leading cause of injury mortality. Comprehensive traffic safety measures have successfully reduced the national motor vehicle traffic crash mortality rate. Similar efforts will be required to diminish the burden of other injury.

OBJECTIVES: Ladder falls comprise 16% of all US workplace fall-related fatalities, and ladder use may be particularly hazardous among older workers. This follow-back study of injured workers from a nationally representative sample of US emergency departments (ED) focused on factors related to ladder falls in three domains of the work environment: work equipment, work practices, and worker-related factors. Risk factors for fractures, the most frequent and severe outcome, were also evaluated. METHODS: Workers injured from a ladder fall, treated in one of the 65 participating ED in the occupational National Electronic Injury Surveillance System (NEISS) were asked to participate. The questionnaire included worker demographics, injury, ladder and work equipment and environment characteristics, work tasks, and activities. Multivariate logistic regression models estimated odds ratios and 95% confidence intervals of a work-related fracture. RESULTS: Three-hundred and six workers experiencing an injury from an – on average – 7.5-foot-fall from a step, extension, or straight ladder were interviewed primarily from construction, installation, maintenance, and repair professions. Injuries were most frequently to the arm, elbow or shoulder; head, neck, or face with diagnoses were primarily fracture, strain, sprain, contusion or abrasion. Workers were most frequently standing or sitting on the ladder while installing, hanging an item, or performing a repair when they fell. Ladder movement was the mechanism in 40% of falls. Environmental conditions played a role in

The objective of this study was to qualitatively evaluate young Egyptians' perceptions, attitudes, knowledge and behaviour towards injuries before implementation of an extensive questionnaire about injuries among Egyptian youth. In 2008, five focus groups of three to nine participants each were conducted in Cairo, Egypt in Arabic to evaluate young Egyptians' attitudes towards injuries, injury prevention, and their understanding of 'accidents' and fatalism. Participants were 14-26 years of age and were from medium to high socioeconomic status. Focus group participants noted that the concept of hadthah ('accident') signified an event determined by destiny, whereas esabah ('injury') was the result of human actions. The results of these focus groups indicate that young, educated Egyptians are interested in injury prevention programmes despite low confidence in the preventability of injuries.

The impact on health and safety of the combination of chronic sleep deficits and extended working hours has received worldwide attention. Using the National Health Interview Survey (NHIS), an in-person household survey using a multistage, stratified, clustered sample design representing the US civilian, non-institutionalized population, the authors estimated the effect of total daily self-reported sleep time and weekly working hours on the risk of a work-related injury. During the survey period 2004-2008, 177,576 persons (ages 18-74) sampled within households reported that they worked at a paid job the previous week and reported their total weekly work hours. A randomly selected adult in each household (n = 75,718) was asked to report his/her usual (average) total daily sleep hours the prior week; complete responses were obtained for 74,415 (98.3%) workers. Weighted annualized work-related injury rates were then estimated across a priori defined categories of both average total daily sleep hours and weekly working hours. To account for the complex sampling design, weighted multiple logistic regression was used to independently estimate the risk of a work-related injury for categories of usual daily sleep duration and weekly working hours, controlling for important covariates and potential confounders of age, sex, race/ethnicity, education, type of pay, industry, occupation (proxy for job risk), body mass index, and the interaction between sleep duration and work hours. Based on the inclusion criteria, there were an estimated 129,950,376 workers annually at risk and 3,634,446 work-related medically treated injury episodes (overall injury rate 2.80/100 workers). Unadjusted annualized injury rates/100 workers across weekly work hours were 2.03 (or =20 h), 3.01 (20-30 h), 2.45 (31-40 h), 3.45 (40-50 h), 3.71 (50-60 h), and 4.34 (60 h). With regards to self-reported daily sleep time, the estimated annualized injury rates/100 workers were 7.89 (5 h sleep), 5.21 (5-5.9 h), 3.62 (6-6.9 h), 2.27 (7-7.9 h), 2.50 (8-8.9 h), 2.22 (9-9.9 h), and 4.72 (10 h). After controlling for weekly work hours, and aforementioned covariates, significant increases in risk/1 h decrease were observed for several sleep categories. Using 7-7.9 h sleep as reference, the adjusted injury risk (odds ratio [OR] for a worker sleeping a total of5 h/day was 2.65 (95% confidence interval [CI]: 1.57-4.47), for 5-5.9 h 1.79 (95% CI: 1.22-2.62), and for 6-6.9 h 1.40 (95% CI: 1.10-1.79). No other usual sleep duration categories were significantly different than the reference; however, for10 h of usual daily sleep, the OR was marginally significantly elevated, 1.82 (95% CI: 0.96-3.47). These results suggest significant increases in work-related injury risk with decreasing usual daily self-reported sleep hours and increasing weekly work hours, independent of industry, occupation, type of pay, sex, age, education, and body mass.

PURPOSE:: To investigate the association of history of school suspension (HSS) to risky behaviors and injury history. METHODS:: Adult patients admitted to a Level I trauma center (n = 774) were assessed for demographics, socioeconomic status, educational history, risky behaviors (infrequent seat belt use, drinking and driving, binge drinking, and speeding for a thrill), substance abuse disorders, and prior injury history. Student's t test and chi statistics were used to compare subjects with and without a HSS in relation to risky behaviors and injury history (alpha = 0.05). Logistic regression models were constructed with each risky behavior and injury history as the outcome adjusting for demographics, socioeconomic status, and substance abuse disorders. RESULTS:: Patients with HSS (n = 260) were significantly younger, more likely to be male, not married, low income, Black, unemployed, smokers, and alcohol and drug dependent than patients without such history (n = 514). They had higher rates of binge drinking (66% vs. 33%), infrequent seat belt use (50% vs. 26%), drinking and driving (24% vs. 12%), and driving fast for a thrill (21% vs. 8%). Similarly, they had more frequent previous history of vehicular injuries (44% vs. 31%) and assaults (36% vs. 16%). Multivariate models revealed school suspension to be associated with infrequent seat belt use (Odds ratio [OR] = 2.02 [1.44-2.83]), binge drinking (OR = 1.95 [1.25-3.04]), speeding for a thrill (OR = 1.83 [1.15-2.92]), prior vehicular injuries (OR = 1.46 [1.06-2.02]), and assaults (OR = 1.67 [1.13-2.47]). CONCLUSION:: HSS is associated with risky behaviors, and history of prior vehicular crashes and assaults. Language: en

Sudden-onset injury results from a momentary energy exchange between an agent and host, producing immediately discernible tissue damage. These injuries are common in both occupational and nonoccupational settings; typical causes include falls, mechanical contact/crushing, exposure to temperature extremes, and exposure to electrical current. We review epidemiologic and engineering approaches to injury prevention and propose a process control model for describing risk-of-exposure to injury agents during the Pre-event phase of sudden-onset injury. Process control is a proactive approach to quality engineering that is based on the premise of preventing defective products from being manufactured in the first place, instead of relying on reactive inspections to detect defects at the end of the manufacturing process. Principles of process control can be applied by occupational health and safety professionals to prevent workplace injury. The proposed model describes how work activities (process inputs) cause risk-of-exposure to injury agents to fluctuate over the course of a work shift. Risk-of-exposure is a complex function with many input factors including: the nature/magnitude of hazards, the presence and effectiveness of engineering controls, safety climate, management attitudes and practices, the surrounding work environment, the physical and mental states of the worker, and the quality and quantity of supervision and training. Injury can occur only when this function crosses a certain threshold and the host is exposed to injurious energy via physical contact. Certain factors that contribute to risk-of-exposure are stable for extended time periods (weeks, months, years), whereas other factors are transient (durations of minutes or seconds). The model extends classical work by Haddon and others, provides preliminary insights to designing epidemiologic studies and developing fault-tolerant work systems, and illustrates how interdisciplinary approaches can improve our understanding of the etiology of sudden-onset injuries and advancing injury research.

To examine the association between occupational physical demands and risk of same-level falls resulting in fracture in female workers' compensation claimants.From workers' compensation claims for same-level falls, 7286 female workers from three age groups (18-49, 50-59 and 60-79 years) were randomly selected. Levels of occupational physical activity, standing and sitting were assigned using occupational codes. Fracture occurrence was determined using the International Classification of Diseases codes. Risks of same-level falls resulting in fracture were compared by quartiles of physical activity, standing and sitting.In the 18-49-year age group, physical activity, standing and sitting at work were not significantly associated with risk of same-level falls resulting in fracture (p value trend: 0.07, 0.18 and 0.10, respectively). In the 50-59 and 60-79-year age groups, increasing duration of standing and decreasing duration of sitting were associated with decreasing risk of same-level falls resulting in fracture (p value trend: standing0.001, 0.01; sitting0.001, 0.02). In the 50-59-year age group, the relative risks of same-level falls resulting in fracture were 0.53, 0.41 and 0.82 for the second, third and highest quartiles of physical activity, respectively, as compared with workers in the lowest quartile (95% confidence interval 0.35 to 0.80, 0.23 to 0.72, 0.56 to 1.21, respectively). In the 60-79-year age group, there was a similar, but not significant, U-shaped association between occupational physical activity and risk of same-level falls resulting in fracture.Moderate occupational physical demands may be associated with a decreased risk of same-level fall resulting in fracture in female workers' compensation claimantsor=50 years of age.

Pediatric poisonings represent a major and preventable cause of morbidity and mortality throughout the world. Epidemiologic information about poisoning among children in many lower- and middle-income countries is scarce. This study describes the epidemiology of acute poisonings in children presenting to Ain Shams University's Poisoning Treatment Center (ASU-PTC) in Cairo and determines the causative agents and characteristics of acute poisoning in several pediatric age groups.This retrospective study involved acutely poisoned patients, 0-18 years of age, who presented to the ASU-PTC between 1 January 2009 and 31 December 2013. Data were extracted from electronic records maintained by the ASU-PTC. Collected data included demographics, substance of exposure, circumstances of the poisoning, patient disposition, and outcome.During the 5-year study period, 38 470 patients meeting our criteria were treated by the ASU-PTC; 19 987 (52%) were younger than 6 years of age; 4196 (11%) were 6-12 years; and 14 287 (37%) were12 years. Unintentional poisoning accounted for 68.5% of the ingestions, though among adolescents 84.1% of ingestions were with self-harm intent. In all age groups, the most frequent causative drugs were non-opioid analgesics, antipyretics, and antirheumatics. The most common nonpharmaceutical agents were corrosives in preschool children and pesticides in adolescents. Most patients had no/minor effects (29 174 [75.8%]); hospitalization rates were highest among adolescents. There were 119 deaths (case fatality rate of 0.3), primarily from pesticide ingestion.Poisoning in preschool children is mainly unintentional and commonly due to nonpharmaceutical agents whereas poisoning in adolescents is mainly intentional (self-harm). Pesticides, mainly organophosphorous compounds and carbamates, were the most frequent agents leading to morbidity and mortality.

Most studies find strong evidence that motorcycle helmets protect against injury, but a small number of controversial studies have reported a positive association between helmet use and neck injury. The most commonly cited paper is that of Goldstein (1986). Goldstein obtained and reanalyzed data from the Hurt Study, a prospective, on-scene investigation of 900 motorcycle collisions in the city of Los Angeles. The Goldstein results have been adopted by the anti-helmet community to justify resistance to compulsory motorcycle helmet use on the grounds that helmets may cause neck injuries due to their mass. In the current study, we replicated Goldstein's models to understand how he obtained his unexpected results, and we then applied modern statistical methods to estimate the association of motorcycle helmet use with head injury, fatal injury, and neck injury among collision-involved motorcyclists. We found Goldstein's analysis to be critically flawed due to improper data imputation, modeling of extremely sparse data, and misinterpretation of model coefficients. Our new analysis showed that motorcycle helmets were associated with markedly lower risk of head injury (RR 0.40, 95% CI 0.31-0.52) and fatal injury (RR 0.44, 95% CI 0.26-0.74) and with moderately lower but statistically significant risk of neck injury (RR 0.63, 95% CI 0.40-0.99), after controlling for multiple potential confounders.

Reliable high quality traffic safety data has been essential for monitoring, developing and evaluating strategies to reduce the burden of injuries from traffic injuries. Information is often available in many different sources including police reports, ambulance/emergency medical service (EMS) run data, emergency department(ED) and hospital data, and mortality data from death certificates or medical examiner/coroner systems. However while each of these data systems has their own strengths and weakness, none can provide a comprehensive picture of traffic related injuries. Hospital trauma center records for example have extensive information on injuries and related medical problems but lack details on the mechanism of injury and crash and roadway characteristics. Often medical data cannot even distinguish drivers from pedestrians. Police or insurance crash reports on the other hand have considerable detail on the crash and circumstances surrounding it but have very poor data on the actual injuries sustained or their severity. This impedes targeting of prevention strategies towards serious injuries and fatalities. This presentation will use examples from current work on data linkage to demonstrate the value of linking traffic record data and explore how this approach can greatly advance traffic medicine and road safety in fast developing countries. In the United States linkage of crash data and medical data has been important for many traffic safety programs. One example is Maryland’s Crash Outcome Data Evaluation System (CODES) that uses probabilistic methodology to link police crash records to injury outcome records. CODES was established in an effort to improve highway safety through the use of linked motor vehicle crash data collected from police, EMS, hospitals (emergency department or inpatient admissions), and death certificates. This linked data have been used for a variety of statewide studies such as of injured motorcyclists, effectiveness of seat belts at preventing injuries, studies of older drivers, an analysis of mismatch collisions, geographic analysis of pedestrian injuries, patterns of injury in frontal collisions, costs and consequences of lower extremity injuries, the safety of newer vehicles, and the impact of casino gambling on alcohol-related crashes. A new project seeks to overcome the serious lack of reliable routine data on drug involvement in fatal crashes by linking detailed toxicology data from medical examiners with the Fatality Analysis Reporting System (FARS) in a sentinel group of states. Similar data linkage is also used in other countries such as a New Zealand study estimating underreporting of serious injuries by police reports. An Australian study noted that workers compensation datasets can identify most serious cases of occupational traffic injuries but lack valuable information on the circumstances and risk factors contributing to work-related crashes. Through linkage to police crash reports the study was able to identify high risk groups such as heavy vehicle drivers and the role played by fatigue and speeding. Many fast developing countries also have useful crash reports either from police or insurance reports. However only through linkage with medical data can their full potential for reducing the burden of serous traffic injuries be realized?

There are no clinical guidelines addressing the management of depression after traumatic brain injury (TBI). The objectives of this study were to (1) describe depression treatment patterns among Medicare beneficiaries with a diagnosis of depression post-TBI; (2) compare them with depression treatment patterns among beneficiaries with a diagnosis of depression pre-TBI; and (3) quantify the difference in prevalence of use. We conducted a retrospective analysis of Medicare beneficiaries hospitalized with TBI during 2006–2010. We created two cohorts: beneficiaries with a new diagnosis of depression pre-TBI (n=4841) and beneficiaries with a new diagnosis of depression post-TBI (n=4668). We searched for antidepressant medications in Medicare Part D drug event files and created variables indicating antidepressant use in each 30-day period after diagnosis of depression. We used provider specialty and current procedural terminology to identify psychotherapy in any location. We used generalized estimating equations to quantify the effect of TBI on receipt of depression treatment during the year after diagnosis of depression. Average monthly prevalence of antidepressant use was 42% among beneficiaries with a diagnosis of depression pre-TBI and 36% among those with a diagnosis post-TBI (p

Unintentional injuries are a leading cause of death among children, especially in developing countries. Lack of reliable data regarding primary health care professionals' role in childhood unintentional injury prevention hinders the development of effective prevention strategies. A survey of 99 family physicians and nurses from 10 family health centres sought to develop insight into their knowledge, attitudes, and practices regarding unintentional injury prevention for children15 in Cairo, Egypt. Approximately, 60% were familiar with the terms unintentional injuries and injury prevention. Falls and road traffic crashes were identified as primary causes of childhood injuries by 54.5%. While90% agreed injury prevention counselling (IPC) could be effective, only 50.5% provided IPC. Lack of time and educational materials were the leading barriers to provision of IPC (91.9% and 85.9%, respectively), while thinking counselling is not part of their clinical duties was the least perceived barrier (9.1%). There is a large disconnect between providers' knowledge, attitudes and practices regarding IPC, more training and provision of counselling tools are essential for improving IPC by Egyptian medical providers.

Most data regarding high blood alcohol concentrations (BAC) ≥400 mg/dL have been from alcohol poisoning deaths. Few studies have described this group and reported their alcohol consumption patterns or outcomes compared to other trauma patients. We hypothesised trauma patients with very high BACs arrived to the trauma centre with less severe injuries than their sober counterparts.Historical cohort of 46,222 patients admitted to a major trauma centre between January 1, 2002 and October 31, 2011. BAC was categorised into ordinal groups by 100 mg/dL intervals. Alcohol questionnaire data on frequency and quantity was captured in the BAC ≥400 mg/dL group. The primary analysis was for BAC ≥400 mg/dL.BAC was recorded in 44,502 (96.3%) patients. Those with a BAC ≥400 mg/dL accounted for 1.1% (147) of BAC positive cases. These patients had the lowest proportion of severe trauma and in-hospital death in comparison with the other alcohol groups (p0.001). In adjusted analysis, the risk for severe injury increased with the BAC groups between 1 and 199 mg/dL and was not different or decreased for groups above 200 mg/dL in reference to the BAC negative group (test for trend p=0.001). BAC ≥400 group encountered more injuries caused by blunt trauma in comparison with the other alcohol groups (p0.001), and the group comprised mainly of falls. Admission Glasgow Coma Scale was a poor predictor for traumatic brain injury in the high BAC group. Readmission occurred in 22.4% (33) of patients the BAC ≥400 group. The majority of these patients reported drinking alcohol 4 or more days per week (81, 67.5%) and five or more drinks per day (79, 65.8%), evident of risky alcohol use.Most traumas admitted with BAC ≥400 mg/dL survived and their injuries were less severe than their less intoxicated and sober counterparts. They also had evidence for risky alcohol use and nearly one-quarter returned to the trauma centre with another injury over the study period. Recognition of this highest BAC group presents an opportunity to provide focused care for their risky alcohol use.

Aims To estimate both self-reported and corrected prevalences of substance use in a population-based study of general hospital emergency department (ED) patients and predict undeclared use. Design A state-wide cross-sectional, two-stage probability sample survey that incorporates toxicological screening. Setting Seven Tennessee EDs in acute care, adult, civilian, non-psychiatric hospitals. Participants A total of 1502 Tennessee residents, 18 years of age and older, possessing intact cognition, able to give informed consent and not in police custody. Measurements Prevalence of self-reported current substance use by age, sex and type with correction for underreporting based on toxicological screening. Covariates in the multivariate analysis of undeclared use were sociodemographics, ED visit circumstances, health-care coverage, prior health status and treatment history and tobacco addiction. Findings Declared current use was highest for alcohol (females 26%, males 47%), marijuana (males 11%, females 6%) and benzodiazepines (females 10%, males 7%). After correction for under-reporting, overall use for any of the eight targeted substances rose from 44% to 56% for females and 61% to 69% for males. Largest absolute changes involved opioids, benzodiazepines, marijuana, amphetamines and/or methamphetamine, with little change for alcohol. Patients aged 65 years and older manifested excess undeclared use relative to patients aged 18‐24 years, as did patients not reporting tobacco addiction or receiving substance abuse treatment. Conclusion Adjustment for under-reporting produced minimal change in the estimated prevalence of alcohol use. However, toxicological screening markedly increased estimates of other drug use, especially for the elderly, who may under-report medication use. Screening tests are useful tools for detecting undeclared substance use.

In Finland, the Finnish Association for Swimming Instruction and Life Saving (SUH) and Statistics Finland (SF) both provide nationwide data on unintentional drowning. The SUH database relies on rapid reporting from a newspaper clipping service and additional local police information, whereas the SF database relies on the later release of the death certificate information, which is based on extensive medico-legal investigation. The aim of the study was to explore the main differences between the SUH and SF databases for drowning and to evaluate the capacity of the former to characterize drowning events in Finland from 1998 to 2000. Computerized files of death certificates tabulated by SF were linked with the SUH database by deterministic methods. SF and SUH databases allowed the identification of 704 and 567 unintentional drownings, respectively, giving an unintentional drowning rate of 4.5 and 3.6/100?000 per year. Of the 704 drownings described by SF, 418 (59.4%) were also found in the SUH database. The SUH database markedly underreported drowning fatalities in certain settings, such as bath, ditch and swimming pool drownings; fall- and land-traffic-related drownings; and drownings occurring in South Finland. The narrative text of SUH drownings contributed limited information to characterize the drowning events. It was concluded that the newspaper-based SUH data provide more timely data on individual drownings but are not representative of all drownings. Conversely, the SF vital statistics data are more accurate but may take up to 2 years to become available. Both SUH and SF data provide little detailed information on drowning events. A multidisciplinary national surveillance system for drowning is necessary to provide more accurate and timely drowning data, analyse risk factors and design follow-up studies for developing and monitoring prevention strategies.

This study explored the potential uses of feedback systems in the trucking industry as a means of improving safety. Since truck drivers spend a majority of their working time alone and do not interact with peers, it may be possible to use data gathered by in-vehicle technology to provide feedback to drivers about their driving behavior. The purpose of this study was to examine truck drivers’ attitudes toward using in-vehicle technology to provide feedback for enhancing driving safety and to understand the best ways of providing feedback to truck drivers. Nine focus groups were conducted, with a total of 66 participants, to collect qualitative data on attitudes toward technology and feedback. The focus group results were used to develop a questionnaire. Survey data were then collected from 198 long-haul truck drivers to provide quantitative information. Truck drivers reported that they would like to receive more feedback and that positive feedback was preferred over negative feedback. Feedback from truck drivers’ supervisors or managers was more desired than feedback from technology. However, most drivers were willing to accept feedback by technology if the program was designed properly. The truck drivers expressed no strong preference regarding the best form of feedback by technology on driving performance (i.e., modality, frequency and timing). Therefore it is important for a program which uses technology for providing feedback to be adaptable to different drivers’ preferences.

OBJECTIVE: To determine the activities and circumstances proximal to a welding related occupational eye injury, a hybrid narrative coding approach derived from two well developed classification systems was developed to categorize and describe the activity, initiating process, mechanism of injury, object and/or substance, and the use of protective eyewear from the narrative text data reported for each injury. METHODS: Routinely collected workers' compensation claims over a one year period (2000) were analyzed from a large US insurance provider. An index term search algorithm of occupation, incident, and injury description fields identified 2209 potential welding related eye injury claims. After detailed review of these claims, 1353 welders and 822 non-welders were analyzed. RESULTS: During 2000, eye(s) as the primary injured body part accounted for 5% (n = 26 413) of all compensation claims. Eye injuries accounted for 25% of all claims for welders. Subjects were mainly male (97.1%) and from manufacturing (70.4%), service (11.8%), or construction (8.4%) related industries. Most injuries were foreign body (71.7%) or burn (22.2%) and 17.6% were bilateral. Common activities include welding (31.9%) and/or grinding (22.5%). Being struck by an airborne object occurred in 56.3% of cases. Non-welders showed similar patterns except that burns (43.8%) were more frequent and more often initiated by another worker (13.9%). CONCLUSIONS: Narrative injury text provides valuable data to supplement traditional epidemiologic analyses. Workers performing welding tasks or working nearby welders should be trained to recognize potential hazards and the effective use of proper safety equipment to prevent ocular injury.

Emergency medical services (EMS) personnel treat 22 million patients a year in the United States, yet little is known of their injury risks.To describe the epidemiology of occupational injuries among EMS personnel, calculate injury rates, and compare the findings with those for other occupational groups.This was a retrospective review of injury records kept by two urban agencies. The agencies submitted all 617 case reports for three periods between January 1, 1998, and July 15, 2002. The agency personnel worked an estimated 2,829,906 hours during the study periods. Cases were coded according to U.S. Department of Labor (DOL) criteria.Four hundred eighty-nine cases met the DOL inclusion criteria. The overall injury rate was 34.6 per 100 full-time (FT) workers per year (95% confidence interval [CI] 31.5-37.6). "Sprains, strains, and tears" was the leading category of injury; the back was the body part most often injured. Of the 489 cases, 277 (57%) resulted in lost workdays, resulting in a rate of 19.6 (95% CI 17.3-21.9) per 100 FT workers; in comparison, the relative risks for EMS workers were 1.5 (95% CI 1.35-1.72) compared with firefighters, 5.8 (95% CI 5.12-6.49) compared with health services personnel, and 7.0 (95% CI 6.22-7.87) compared with the national average.The injury rates for EMS workers are higher than rates reported by DOL for any industry in 2000. Funding and additional research are critical to further defining the high risks to EMS workers and developing interventions to mitigate this serious problem.

Objective: To investigate the accuracy of a computerized method for classifying injury narratives into external-cause-of-injury and poisoning (E-code) categories. Methods: This study used injury narratives and corresponding E-codes assigned by experts from the 1997 and 1998 US National Health Interview Survey (NHIS). A Fuzzy Bayesian model was used to assign injury descriptions to 13 E-code categories. Sensitivity, specificity and positive predictive value were measured by comparing the computer generated codes with E-code categories assigned by experts. Results: The computer program correctly classified 4695 (82.7%) of the 5677 injury narratives when multiple words were included as keywords in the model. The use of multiple-word predictors compared with using single words alone improved both the sensitivity and specificity of the computer generated codes. The program is capable of identifying and filtering out cases that would benefit most from manual coding. For example, the program could be used to code the narrative if the maximum probability of a category given the keywords in the narrative was at least 0.9. If the maximum probability was lower than 0.9 (which will be the case for approximately 33% of the narratives) the case would be filtered out for manual review. Conclusions: A computer program based on Fuzzy Bayes logic is capable of accurately categorizing cause-of-injury codes from injury narratives. The capacity to filter out certain cases for manual coding improves the utility of this process.

Endogenous alcohol production can increase the blood alcohol concentration (BAC) of drowning victims following submersion and confound epidemiological studies of the role of alcohol. This study seeks to determine how soon after a drowning death a victim's BAC is influenced by post-mortem alcohol production. The drop in mean lung weight that occurs over time in the water was hypothesized to serve as a proxy for the time course of decomposition, and thus provide an empirical measure to determine how soon after death to first suspect endogenous alcohol. The autopsy lung weights of 562 previously healthy males who drowned were compared across six submersion time groups (0-11.9, 12-23.9, 24-47.9, 48-95.9, 96-167.9 and >or=168 h) and two times of year (winter and non-winter). The hypothesis that a drop in lung weight is sensitive to the time course of decomposition was supported by (1). a statistically significant drop in mean lung weight that occurred 12-23.9 h post-submersion in the non-winter months, but not until 96-167.9 h in the colder winter months; and (2). a significant drop in lung weight was not observed in the group of cases with zero BAC. With a parallel finding that an increase in the proportion of cases with a positive BAC first occurred at the 12-23.9 h submersion group during the warmer non-winter months, we concluded that production of alcohol can occur in bodies recovered from the water as early as 12 h after death. Because excluding drownings with submersion durations greater than 12 h would exclude almost half of our cases from epidemiological studies of alcohol and drowning, additional evidence from the forensic literature was used to develop an adjustment procedure to account for endogenous alcohol production for submersion times of up to 1 week.

This study examines the tendency toward problem behavior as an explanation for the relationship between problem substance use and occupational injury.The authors used a matched case-control study nested in a cohort of 26,413 workers, in which cases (n = 3,994) were workers suffering an occupational injury. Five controls per case (n = 19,970) were selected from the cohort of workers active on the day of the injury and matched on job type. Conditional logistic regression modeled the association of problem substance use with occupational injury, controlling for problem behaviors and worker characteristics. Problem substance use was indicated indirectly if any of the following were alcohol/drug-involved during the comparison period: Employee Assistance Program visit, excused absence or disciplinary action. Discipline records identified minor (absenteeism) and serious (dishonesty, theft, assault, harassment, disrespect) problem behaviors during the comparison period.The odds of injury among workers with an indicator of problem substance use was 1.35 (p = .015) times greater than the odds among workers without an indicator, controlling for job type and demographics as well as adjusting for exposure. This ratio declined to 1.21 (p = .138) when problem behaviors were also controlled for. Minor and serious problem behaviors were significantly associated with occupational injury (odds ratio [OR] = 1.73, p.001, and OR = 2.19, p.001, respectively), controlling for demographics and substance use.The relationship of problem substance use with occupational injury was weak when problem behaviors were controlled for, suggesting that this relationship, observed in previous studies, may be explained by a workers tendency toward problem behaviors. Workplace injury prevention programs should address the expression of problem behaviors as a complement to drug and alcohol deterrent programs.

AIMS: To understand better how often BAC-negative victims suffer fatal and non-fatal alcohol-involved injuries. DESIGN: We analyzed 1988-1993 data from Oklahoma surveillance systems that track all people killed or hospitalized due to burns, submersions and spinal cord injuries (SCIs) and investigate alcohol use by victims and any others who contributed to their injuries. MEASUREMENTS: Percentage of victims BAC-positive and percentage of victims BAC-negative in alcohol-involved incidents. FINDINGS: Of 5107 cases studied, alcohol involvement was known for 4773 (93%), 1882 fire burns (93%), 1560 scald and other burns (97%), 698 submersions (92%) and 967 spinal cord injuries (89%). By type of injuries, BAC-negative victims were 4%, 13%, 6% and 8% of alcohol-involved cases, respectively. CONCLUSION: A sizeable number of BAC-negative victims suffer alcohol-involved injuries. Although alcohol is not the cause of some of these injuries, alcohol policy changes probably could avert others.

Study Objective: We determine whether members of the public understand that alcohol contributes to each of the leading causes of unintentional-injury death in the United States and not just to motor vehicle-related fatalities. Public opinions of selected alcohol control policies were also assessed. Methods: We used a national telephone survey of 943 adults, who were selected by random-digit dialing techniques. Respondents' mean estimates of alcohol's involvement in fatal injuries were compared with published data from a meta-analysis of medical examiner data. Results: The study population accurately estimated the proportion of fatal fall, drowning, and poisoning victims who were legally drunk when they died. Respondents overestimated the proportion of drivers killed in motor vehicle crashes who were intoxicated and underestimated the proportion of fire/burn victims. Fifty-seven percent of participants endorsed the myth that alcohol intoxication is protective against injury in the event of a motor vehicle crash. Participants were divided over whether increasing the legal drinking age to 21 had resulted in fewer injury deaths. Seventy-eight percent of participants did not believe that raising alcohol taxes would reduce fatal injuries. A majority (58%) of respondents supported taking blood alcohol levels on all "seriously injured" patients brought to the hospital. Conclusion: This report suggests that public awareness of alcohol's contribution to the breadth of the injury problem in the United States is high. Conversely, public understanding of whether prevention strategies have proven to be effective is poor. Emergency medicine practitioners can serve as credible sources of more accurate information for patients and the community at large. [Girasek DC, Gielen AC, Smith GS. Alcohol's contribution to fatal injuries: a report on public perceptions. Ann Emerg Med. June 2002;39:622-630.]

▪ Abstract Injuries continue to place a tremendous burden on the public's health and rates vary widely among different groups in the population. Increasing attention has recently been given to the effects of socioeconomic status (SES) as a determinant of health among both individuals and communities. However, relatively few studies have focused on the influence of SES and injuries. Furthermore, those that have, and the other injury studies that have included measures of SES in their analysis, have varying degrees of conceptual and methodological rigor in their use of this measure. Recent advances in data linkage and analytic techniques have, however, provided new and improved methods to assess the relationship between SES and injuries. This review summarizes the relevant literature on SES and injuries, with particular attention to study design, and the measurement and interpretation of SES. We found that increasing SES has a strong inverse association with the risk of both homicide and fatal unintentional injuries, although the results for suicide were mixed. However, the relationship between SES and nonfatal injuries was less consistent than for fatal injuries. We offer potential explanatory mechanisms for the relationship between SES and injuries and make recommendations for future research in this area.

The objective of this study was to evaluate the relationship between alcohol/drug abuse diagnoses, driving convictions (speeding, reckless driving, impaired driving, license violations), and risk-taking dispositions among a series of injured drivers admitted to a trauma center. The driving records of 778 patients were linked to diagnoses of psychoactive substance use disorders (PSUDs), admission blood alcohol concentration (BAC), mode of injury, and results of a risk-taking disposition survey. Twenty-nine percent of patients had one or more convictions in the 3 years before injury. Types of violation were not related to mode of injury. Although there was a positive association between prior impaired-driving convictions, current alcohol dependence, and a BAC + status, a consistent pattern relative to other violations, PSUDs, and BAC status was not apparent. Risk-taking disposition scale scores indicated that patients without PSUDs and without convictions tended toward less risk-taking behavior than patients with PSUDs and with convictions. The complex inter-relationships between PSUDs, risk-taking dispositions, and being convicted of driving dangerously require additional study so that intervention programs and injury prevention initiatives can be targeted effectively.

OBJECTIVE: To describe the epidemiology of drowning in New Zealand for the period 1980-94. METHODS: Drowning-related incidents were identified by linking New Zealand Health Information Service and Water Safety New Zealand databases. RESULTS: 2,606 drowning-related incidents were identified. In three-quarters of the incidents, drowning was listed as the immediate cause of death. The majority of drownings were unintentional (85%), involved males (76%), and 0-4 and 15-24 year age groups had the highest rates. Boating was the leading cause of unintentional drowning (28%) followed by swimming and other water sports (19%), motor vehicle drownings (13%) and falls or slips (12%). CONCLUSIONS AND IMPLICATIONS: Although there has been a significant decline in drownings, New Zealand compares poorly internationally. In particular, our unintentional drowning rate is twice that of Australia. For New Zealand to continue to make substantial progress in addressing its overall drowning rate, we need to continue and strengthen our efforts in priority areas, in particular those due to motor vehicle crashes and boating and among pre-schoolers, adolescents and young adults. Motor vehicle traffic crashes warrant closer attention than has been the case to date.

Objectives—The case-crossover study design was developed to examine triggers for the onset of myocardial infarction. This paper seeks to examine selected methodological issues when applying the casecrossover method to the study of traumatic injuries in the work environment. Methods—Researchers known to be working on occupational case-crossover studies were invited to present at a workshop held at the National Occupational Injury Research Symposium in October 2000. Data from ongoing studies were used to illustrate various methodological issues involved in case-crossover studies of occupational injury. Key findings and issues identified—To utilize the case-crossover design, investigators must clearly define the time during which a worker is at risk of injury, the period of time during which a particular transient exposure could cause an injury and carefully select control time periods that estimate the expected frequency of exposure. Other issues of concern are changing work tasks over time, correlated exposures over time and information bias. Conclusions and future research needs— More case-crossover studies of occupational injury are needed to compare results from multiple studies. The validation of the timing of transient exposures relative to injury onset, whether done in a laboratory or field setting, should be conducted. Nested case-crossover designs in other epidemiological studies (case-control or cohort) can examine both transient and fixed risk factors for occupational injury, and should be attempted. (Injury Prevention 2001;7(Suppl I):i38‐42)

1Non-fatal injuries are an even more pervasive problem. In the United States alone, recent studies estimate that almost 16 000 workers daily are hurt on the job, approximately six million occupational injury cases annually. 2 The field of public health has made significant contributions to worker safety in the United States in the past century. In fact, one review 3 concluded that two of the top 10 leading public health achievements were the decline of workplace injury fatalities from 37 to four fatalities per 100 000 workers between 1933 and 1997, 4 and the reduction in motor vehicle fatalities (many of which are work related) from 18 per 100 million vehicle miles traveled in 1925 to 1.7 in 1997. 5 While the above achievements demonstrate considerable progress, the wide variations in reported occupational injury fatality rates between industrialized countries and even within industries in the same country 12 suggest that much more can be done. This special issue of Injury Prevention, and the recent National Occupational Injury Research Symposium (NOIRS) from which it derives, represent milestones in the public health approach to occupational injury research and to occupational injury control. The articles contained herein and my discussion in this commentary, demonstrate the new focus on the comprehensive, multidisciplinary methods of reducing work injuries that we believe will define the field of occupational public health in the new millennium.

BACKGROUND: Although nonfatal injury prevalence is higher among substance abusers than in the general population, few studies have estimated the injury risk for clinically recognized substance abusers. The extant studies, moreover, analyze rates of visits for injury treatment rather than rates of injury events. This study estimates the excess risk of medically treated and hospitalized nonoccupational injury for people under age 65 with medically identified substance abuse problems and private health care coverage. METHOD: We conducted a retrospective cohort study by using medical claims data from Medstat Systems, Inc., with a longitudinal database of health care claims for 1.5 million people with health care coverage from 70 large corporations. Claims histories for anyone who had an alcohol-related or drug-related primary or secondary diagnosis during 1987 to 1989 were analyzed. A random sample was selected from the remaining people without a substance abuse diagnosis in their medical records. Injury rates were compared among groups. We used logistic regression to estimate odds of medically treated and hospitalized injury, controlling for demographics. RESULTS: Medically identified substance abusers had an elevated risk of injury in a 3-year period; alcohol and drug abusers had the highest risk (58%), followed by drug-only abusers (49%), alcohol-only abusers (46%), and controls (38%). Alcohol and drug abusers were almost four times as likely to be hospitalized for an injury in a 3-year period when compared with controls. Injury risks were elevated substantially more for female then male substance abusers. CONCLUSIONS: This study greatly improves on available information about the risk of injury for drug and multiple-substance abusers. Medically identified substance abusers, especially adult women, have a higher probability of injury, more hospitalized injuries, and more injury episodes per person injured than nonabusers. More aggressive identification and subsequent treatment of female substance abusers appear warranted.

BACKGROUND: To determine whether heavily drinking and alcohol-dependent workers are at higher risk of occupational injury, we analyzed the nationally representative cohort of people enrolled in the National Longitudinal Survey of Youth since 1979. METHODS: This analysis was restricted to the 8569 respondents in the 1989 annual interview (age 24-32) who were employed during the 6 months before the interview. We studied occupational injuries (excluding sprains or strains) reported within 6 months of the interview in 1989 (cross-sectional analysis) and 1990 (prospective analysis). RESULTS: Among current drinkers, significant two-fold increases in the odds of injury for one or more episodes of heavy drinking were reduced to an odds ratio (OR) of 1.2 (95% confidence interval C. = 0.7, 2.1) in the cross-sectional analysis and an OR of 1.6 (CI 1.0, 2.8) in the prospective analysis after adjustment for confounding. No dose-response relationship with the frequency of heavy drinking was found. Alcohol-dependent respondents were not at higher risk of injury in the cross-sectional (OR = 1.1, CI 0.7, 1.8) or prospective (OR = 1.3,CI 0.8, 2.2) analyses after adjustment for confounding. CONCLUSIONS: For young U.S. workers, common occupational injuries (excluding sprains and strains) may not be strongly associated with alcohol dependence. Confounding by other risk factors may explain much of the association between being a heavy drinker and occupational injuries in this population. Language: en

STUDY OBJECTIVE—This study examined both individual and neighbourhood correlates of injury mortality to better understand the contribution of socioeconomic status to cause specific injury mortality. Of particular interest was whether neighbourhood effects remained after adjusting for individual demographic characteristics and socioeconomic status. DESIGN—Census tract data (measuring small area socioeconomic status, racial concentration, residential stability, urbanisation, and family structure) was merged with the National Health Interview Survey (NHIS) and a file that links the respondents to subsequent follow up of vital status and cause of death data. Cox proportional hazards models were specified to determine individual and neighbourhood effects on homicide, suicide, motor vehicle deaths, and other external causes. Variances are adjusted for the clustered sample design of the NHIS. SETTING—United States, 1987-1994, with follow up to the end of 1995. PARTICIPANTS—From a sample of 472 364 persons ages 18-64, there were 1195 injury related deaths over the follow up period. MAIN RESULTS—Individual level effects were generally robust to the inclusion of neighbourhood level variables in the models. Neighbourhood characteristics had independent effects on the outcome even after adjustment for individual variability. For example, there was approximately a twofold increased risk of homicide associated with living in a neighborhood characterised by low socioeconomic status, after adjusting for individual demographic and socioeconomic characteristics. CONCLUSIONS—Social inequalities in injury mortality exist for both persons and places. Policies or interventions aimed at preventing or controlling injuries should take into account not only the socioeconomic characteristics of people but also of the places in which they live. Keywords: socioeconomic status; injury; neighborhood

This issue of the American Journal of Preventive Medicine presents a comprehensive look at the major health problem of the nation’s military population—injuries. Injuries are an important health concern both in the United States and globally.1,2 The 1.5 million members of the services, predominantly young adults, are subject to many of the same hazards that cause injuries to the civilian population in the course of work, travel, and recreation, and are of special pertinence to the study of occupational injuries. The military comprises many occupational specialties that are similar to civilian workforce specialties such as maintenance, transportation, clerical, medical, and others. This issue is particularly timely as the nation seeks to implement the recently developed National Occupational Research Agenda (NORA).3 The NORA Trauma Injury Team Report sought to identify priority areas for investigation, recognize deficiencies in data quality and the methodologies that enable injuries to be prevented, implement efforts and models to permit researchers to address problems, and increase the utility of occupational injury research.4 As the mechanism to identify worker groups with high frequency and risk of injury, surveillance is considered to be the driving force of research and prevention efforts. Without proper attention to surveillance, priority areas based on the magnitude of the problem, risk of injury, and amenability to prevention will go unserved; limited research resources will be directed according to political considerations rather than informed strategy; and the ability to evaluate these efforts will be lost. Population-based administrative databases useful for epidemiologic and outcome studies have typically included national surveys, federal health care programs, large insurance programs or health care delivery systems, statewide hospital discharge databases, and workers’ compensation databases.4,5 However, some of the richest sources of data, those of the Armed Services, have until recently been left untouched. The publication of the Atlas of Injuries in the U.S. Armed Forces by the Department of Defense (DoD) Injury Surveillance and Prevention Work Group6 is an important first step in recognizing the importance of injuries to the Armed Forces. This report and an earlier report to the Armed Forces Epidemiological Board (AFEB)7 clearly identify the value of medical surveillance databases in the military. The creation of a relational database with the ability to link personnel records of the total active duty Army population with various outcome measures (e.g., hospitalization, losttime injury, physical disability, fatality)8 is an example of how more effective use can be made of available data for injury prevention. The number of articles in this supplement that use this database demonstrates the utility of these efforts. The more recent availability of online DoD-wide medical surveillance data for both inpatients and outpatients9 represents another major step forward in the maturation of the field of occupational injury epidemiology and coincides with the presentation of needs for effective research. This commentary describes how many of the research needs pertaining to surveillance systems have already been addressed by existing military administrative databases and suggests that these sources be better used to systematically investigate and devise prevention strategies for important occupational hazards.