Lethal means restriction for suicide prevention: beliefs and behaviors of emergency department providers

BACKGROUND

We sought to examine the beliefs and behaviors of emergency department (ED) providers related to preventing suicide by reducing suicidal patients' access to lethal methods (means restriction) and identify characteristics associated with asking patients about firearm access.

METHODS

Physicians and nurses at eight EDs completed a confidential, voluntary survey.

RESULTS

The response rate was 79% (n = 631); 57% of respondents were females and 49% were nurses. Less than half believed, "most" or "all" suicides are preventable. More nurses (67%) than physicians (44%) thought "most" or "all" firearm suicide decedents would have died by another method had a firearm been unavailable (P < .001). The proportion of providers who reported they "almost always" ask suicidal patients about firearm access varied across five patient scenarios: suicidal with firearm suicide plan (64%), suicidal with no suicide plan (22%), suicidal with nonfirearm plan (21%), suicidal in past month but not today (16%), and overdosed but no longer suicidal (9%). In multivariable logistic regression, physicians were more likely than nurses to "almost always" or "often" ask about a firearm across all five scenarios, as were older providers and those who believed their own provider type was responsible for assessing firearm access.

CONCLUSIONS

Many ED providers are skeptical about the preventability of suicide and the effectiveness of means restriction, and most do not assess suicidal patients' firearm access except when a patient has a firearm suicide plan. These findings suggest the need for targeted staff education concerning means restriction for suicide prevention.

Firearms and suicide in the United States: is risk independent of underlying suicidal behavior?

On an average day in the United States, more than 100 Americans die by suicide; half of these suicides involve the use of firearms. In this ecological study, we used linear regression techniques and recently available state-level measures of suicide attempt rates to assess whether, and if so, to what extent, the well-established relationship between household firearm ownership rates and suicide mortality persists after accounting for rates of underlying suicidal behavior. After controlling for state-level suicide attempt rates (2008-2009), higher rates of firearm ownership (assessed in 2004) were strongly associated with higher rates of overall suicide and firearm suicide, but not with nonfirearm suicide (2008-2009). Furthermore, suicide attempt rates were not significantly related to gun ownership levels. These findings suggest that firearm ownership rates, independent of underlying rates of suicidal behavior, largely determine variations in suicide mortality across the 50 states. Our results support the hypothesis that firearms in the home impose suicide risk above and beyond the baseline risk and help explain why, year after year, several thousand more Americans die by suicide in states with higher than average household firearm ownership compared with states with lower than average firearm ownership.

Literature review of passenger lymphocyte syndrome following renal transplantation and two case reports

Passenger lymphocyte syndrome (PLS) is an immune-mediated hemolysis. It occurs following ABO blood group mismatched solid organ and/or bone marrow transplantation between donor and recipient. We report two cases of PLS occurring after renal transplantation. Both recipients received live related kidney transplants; one from his mother and the other from his brother. The direction of blood group transfer, from donor to recipient, was O Rh D+ to A Rh D+ in both cases. Approximately 12 days after transplantation, both recipients showed a rapid fall in their hemoglobin levels with no identifiable bleeding source. DAT positive hemolysis was confirmed and anti-A antibodies were detected in recipient sera, confirming a diagnosis of PLS. Both cases required blood transfusion support to maintain their hemoglobin and both had good renal outcomes. We have identified 99 PLS cases following renal transplant in the English literature. Previous ABO sensitization, donor blood group O to recipient blood group A or B transfer, and ciclosporin treatment have been identified as risk factors for PLS. Clinical outcomes in general are good; nonetheless, cases of graft failure and deaths have been reported. Early diagnosis and appropriate treatment are important in at risk individuals.

Method choice in nonfatal self-harm as a predictor of subsequent episodes of self-harm and suicide: implications for clinical practice

OBJECTIVES

We examined time-varying and time-invariant characteristics of nonfatal intentional self-harm episodes in relation to subsequent episodes of self-harm and suicide.

METHODS

We conducted a follow-up cohort study through 2007 of 3600 patients discharged from hospitals in New Jersey with a primary diagnosis of intentional self-harm in 2003. We determined repetition of self-harm from hospital records and suicide from state registers.

RESULTS

Use of methods other than drug overdose and cutting in self-harm events, greater medical severity of nonfatal episodes, and a history of multiple self-harm episodes increased the risk of suicide. However, most suicides occurred without these risk factors. Most suicides took place without intervening episodes of self-harm, and most persons used a low-lethality method (drug overdose or cutting) in their index episode, but switched to a more lethal method in their fatal episode.

CONCLUSIONS

Our findings suggest that preventing suicide among persons with a history of self-harm must account for the possibility that they will adopt methods with higher case-fatality ratios than they previously tried.

Bespoke latex allergen testing improves assessment of respiratory symptoms in textile-braiding workers

BACKGROUND

Latex allergy is poorly understood in latex-exposed textile workers.

METHODS

A cross-sectional study was carried out to better characterize respiratory symptoms, using personal breathing zone latex allergen measurement and specific IgE to latex allergens.

RESULTS

Forty-four of the 86 (51% participation rate) participated. Ten of 39 workers who gave a blood sample (25.6%) were found to have IgE to at least one workplace allergen (5/39 positive to either latex braiding coated with silica or talc, 4/39 were positive to the dyed cotton extract, and 1/39 to latex braiding coated with silica or talc and dyed cotton extract), whilst only 2 of these 10 had specific IgE to the commercial latex extract.

CONCLUSIONS

The presence of symptoms with evidence of sensitization was strongly dictated by current latex exposure. Bespoke workplace allergen IgE testing identified cases of WR respiratory symptoms with sensitization that otherwise would not have been identified.

Sensitization and symptoms associated with soybean exposure in processing plants in South Africa

BACKGROUND

Following the results of a previous study that highlighted the potential for significant levels of dust exposure in South African soybean processing plants, a clinical investigation was undertaken to study the respiratory health of workers in this industry.

METHODS

Workers from three soybean-processing plants were studied with a respiratory questionnaire and estimation of atopy and specific soybean IgE.

RESULTS

A total of 144 of the 181 (79.6% participation rate) plant employees completed the questionnaire and 136 (75.1%) gave blood samples for analysis of specific IgE. There was a significant association between work-related chest tightness (OR 4.0 [95% CI 1.3-12.6]), work-related nasal symptoms (OR 4.3 [95% CI 1.3-14.6]) and cough or chest tightness after handling soybean (OR 3.6 [95% CI 1.1-11.6]) and soybean sensitization. There was a significant association between current exposure to dust during soybean off-loading and "flu-like" illness (OR 2.7 [95% CI 1.0-7.2]), and cough or chest tightness after such work (OR 7.4 [95% CI 2.4-23.6]). The strongest predictor of work related nasal symptoms was sensitization to soybean, the latter strongly predicted by the presence of atopy (OR 34.7 [95% CI 6.6-182.5]).

CONCLUSIONS

Exposure and sensitization to soybean were associated with the presence of work related symptoms, including flu-like symptoms, cough, chest tightness, and nasal symptoms. The aetiology of these symptoms and more particularly the best intervention strategies require more detailed investigation.

Veterans and suicide: a reexamination of the National Death Index-linked National Health Interview Survey

OBJECTIVES

We assessed the risk of suicide among veterans compared with nonveterans.

METHODS

Cox proportional hazards models estimated the relative risk of suicide, by self-reported veteran status, among 500,822 adult male participants in the National Death Index (NDI)-linked National Health Interview Survey (NHIS), a nationally representative cohort study.

RESULTS

A total of 482 male veterans died by suicide during 1,837,886 person-years of follow-up (76% by firearm); 835 male nonveterans died by suicide during 4,438,515 person-years of follow-up (62% by firearm). Crude suicide rates for veterans and nonveterans were, respectively, 26.2 and 18.8 per 100,000 person-years. The risk of suicide was not significantly higher among veterans, compared with nonveterans, after adjustment for differences in age, race, and survey year (hazard ratio = 1.11; 95% confidence interval = 0.96, 1.29).

CONCLUSIONS

Consistent with most studies of suicide risk among veterans of conflicts before Operation Iraqi Freedom/Operation Enduring Freedom, but in contrast to a previous study using the NDI-linked NHIS data, we found that male veterans responding to the NHIS were modestly, but not significantly, at higher risk for suicide compared with male nonveterans.

Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide

Suicide mortality varies widely across age, sex, race, and geography, far more than does mortality from the leading causes of natural death. Unlike the tight correlation between cancer mortality and the incidence of cancer, suicide mortality is only modestly correlated with the incidence of suicidal acts and other established risk factors for suicidal behavior, such as major psychiatric disorders. An implication of this modest correlation is that the proportion of all suicidal acts that prove fatal (the case fatality ratio) must account for a substantial portion of the (nonrandom) variation observed in suicide mortality. In the United States, the case fatality ratio is strongly related to the availability of household firearms. Findings from ecologic and individual-level studies conducted over the past two decades illustrate the importance of accounting for the availability of highly lethal suicide methods in efforts to understand (and ultimately reduce) disparities in suicide mortality across populations.

History of military service and the risk of suicidal ideation: findings from the 2008 national survey on drug use and health

Studies of completed suicide by history of military service have produced inconsistent findings; no representative population-based study has compared the risk of nonfatal suicidal behavior among veterans with risk among nonveterans. The objective of this study was to examine whether male veterans of the U.S. military are at heightened risk of suicidal ideation, compared with males who never served in the U.S. military. A total of 17,641 adult men completed the 2008 National Survey on Drug Use and Health (NSDUH). Subjects provided information about history of ever having served in the U.S. armed forces, past suicidal ideation, alcohol and drug abuse and dependence, measures of psychological distress, and sociodemographic data. Overall, men who had ever served in the armed forces were no more likely than men who had never served to report having seriously considered suicide over the prior 12 months. Military status was not differentially associated with other known suicide risk factors assessed by NSDUH, including psychiatric disorders. Our findings suggest that evidence-based suicide prevention strategies applicable to the general population should be employed to reduce suicide risk among the veteran population as well.

Suicidal behavior and firearm access: results from the second injury control and risk survey

The association between home firearms and the likelihood and nature of suicidal thoughts and plans was examined using the Second Injury Control and Risk Survey, a 2001-2003 representative telephone survey of U.S. households. Of 9,483 respondents, 7.4% reported past-year suicidal thoughts, 21.3% with a plan. Similar proportions of those with and without a home firearm reported suicidal thoughts, plans, and attempts. Among respondents with suicidal plans, the odds of reporting a plan involving a firearm were over seven times greater among those with firearms at home, compared with those without firearms at home. The results suggest people with home firearms may not be more likely to be suicidal, but when suicidal they may be more likely to plan suicide by firearm.

Too many or too few unintentional firearm deaths in official U.S. mortality data?

We examined the accuracy of data on unintentional firearm fatalities in the United States. We began with data from the National Violent Death Reporting System (NVDRS) and examined every firearm death reported as an accident by any NVDRS data source--the NVDRS abstracter, the State Vital Statistics Registry (i.e., the ICD-10 Underlying Cause of Death code and manner of death from the death certificate), the medical examiner or coroner report, and the police Supplementary Homicide Report. After carefully reading the information from all sources, we then classified each case as either unintentional or intentional using NVDRS definitions. Comparing our classification with that of the NVDRS abstracter, we conclude that NVDRS data accurately report unintentional firearm deaths (sensitivity 98%; positive predictive value [PPV] 99%). We then compared our classification with that of the State Vital Statistics Registry based on the ICD-10 Underlying Cause of Death code and found great inaccuracy (sensitivity 62%; PPV 58%). Thirty-eight percent of true cases were missed and 42% of reported cases were false positives. As has been previously reported in the literature, over half of unintentional shootings that were inflicted by another person were classified as homicides, not accidents. This is a particular problem for the data on young victims. What was unexpected, however, was the opposite problem: we found many unambiguous suicides and homicides that were reported as accidents. We believe this is due to the ICD-10 coding practice of assigning injury deaths to the "accident" category when manner of death is "pending" or left blank. Finally, at the state-level, we compared our overall results for each state and year with the official National Vital Statistics System count (reported on CDC's WONDER website). We found evidence of even greater over-reporting of unintentional firearm deaths there. In answer to the question, "Are there too many or too few unintentional firearm deaths in official mortality data?" the best answer is, "Both." Many true accidents are missed, while many suicides and homicides are mistakenly reported as accidents. By contrast, the NVDRS applies a case definition for unintentional firearm deaths with consistency and accuracy.

Who are the owners of firearms used in adolescent suicides?

In this brief report, the source of firearms used in adolescent suicides was examined using data from the National Violent Injury Statistics System, the pilot to the CDC's National Violent Death Reporting System, a uniform reporting system for violent and firearm-related deaths. Data represent the 63 firearm suicides among youth (<18 yrs) that occurred in 2001 or 2002 in one of four states (CT, ME, UT, WI) or two metropolitan counties (San Francisco, CA; Allegheny County, PA). Four-fifths of the suicides took place in the decedents' homes, and--when the firearm owner was known--most of the firearms were owned by parents. Findings replicate results from previous research and highlight the importance of limiting youth access to firearms.

Unintentional firearm deaths: a comparison of other-inflicted and self-inflicted shootings

This study compares other-inflicted and self-inflicted unintentional firearm fatalities. Data come from the National Violent Death Reporting System, a new surveillance system from the Centers for Disease Control and Prevention. Data are currently available from 16 states and parts of California for various years 2003-2006. Of the 363 unintentional firearm fatalities, about half (49%) were other-inflicted, ranging from 78% of child (aged 0-14) deaths to 19% of older adult (aged 55+) deaths. In other-inflicted shooting deaths, the shooters were overwhelmingly young (81% under age 25). The shooters in the other-inflicted deaths were primarily friends (43%) or family (47%); brothers were the most common family shooter. To learn how to prevent unintentional injuries, it is critical to have information not only on the victim, but also on the person who inflicted the injury.

Suicide among US veterans: A prospective study of 500,000 middle-aged and elderly men

Expert opinion is divided about whether US military veterans, the vast majority of whom are middle-aged or older, are at increased risk of suicide. To assess the risk of suicide associated with veteran status, the authors conducted a prospective cohort study of 499,356 male participants in the Cancer Prevention Study II. Participants reported their veteran status and other characteristics in 1982 and were followed for mortality through 2004. The relative risk of mortality from suicide according to veteran status at baseline was estimated by using Cox proportional hazards models. During follow-up, 1,248 veterans and 614 nonveterans died by suicide. In age-adjusted analyses, the risk of suicide did not differ by veteran status. Additional adjustment for several sociodemographic, behavioral, and clinical factors had little effect on hazard ratios. The authors concluded that the risk of death from suicide among middle-aged and older US males is independent of veteran status and suggest that policies to prevent veteran suicide should focus on factors that may heighten suicide risk rather than on veteran status per se.

Characteristics of infant homicides: findings from a U.S. multisite reporting system

OBJECTIVE

The purpose of this study was to describe homicides of infants (children <2 years of age) in the U.S.

METHODS

Cases were derived from the National Violent Injury Statistics System; 71 incidents involving 72 infant homicides were in the data set. Type 1 involved beating/shaking injuries inflicted by a caretaker; type 2 involved all other homicides (including neonaticide, intimate partner problem-related homicide, crime-related death, and other types).

RESULTS

Seventy-five percent of the incidents were type 1 incidents, perpetrated mainly by men (83%; typically the infant's father or the boyfriend of the infant's mother). In 85% of the type 1 incidents, the infant was transported to the hospital, usually at the initiative of the perpetrator or another household member. In almost one half of the type 1 incidents, a false story was offered initially to explain the injuries. In contrast, the type 2 incidents (16 cases) were perpetrated mainly by women (11 of 16 cases) and involved methods such as poisoning, drowning, sharp instruments, or withdrawal of food and water; most infants were not taken to the hospital. Although 93% of incidents were perpetrated by caretakers, the large differences between the 2 incident types suggest different avenues for prevention.

CONCLUSIONS

The circumstances involved in the type 1 homicides (beatings by caretakers) suggested that those attacks occurred impulsively, death was unintended, and emergency care was summoned, often with a false story. Previous abuse was suspected in more than one half of those incidents.

Multiscale analysis reveals restricted gene flow and a linear gradient in heterozygosity for an island population of feral horses

We studied the genetic (microsatellite) diversity of a feral population of horses ( Equus caballus L., 1758) on Sable Island, Nova Scotia, Canada (1983–2003), at two spatial scales: (1) for the island as a whole and (2) at the level of four equally sized subdivisions along the length of Sable Island, which is a long (42 km) and narrow (1.5 km) vegetated sand bar. At the island scale (n = 264 horses), observed heterozygosity over 10 loci was 0.647 ± 0.035 (mean ± 1 SE), while expected heterozygosity was 0.696 ± 0.029; we observed significant heterozygote deficiency with all loci considered (P < 0.0001). At the subdivision scale, observed heterozygosity ranged from 0.589 to 0.694 in a gradient from west to east. We observed a corresponding gradient in effective number of alleles and allelic richness. Pairwise values of FST were significant for most subdivision pairs, ranging as high as 0.067 from west to east. Western areas showed highest levels of inbreeding (FIS = 0.113) with outbreeding indicated in the east (FIS = –0.008). Our results suggest that for a large mammal that lives in polygynous social groups, like the feral horse, gene flow along linear habitats (corridors) may be restricted (relative to the dispersal capabilities of the species), even over short distances.

Systematic review of endoscopic treatments for gastro-oesophageal reflux disease

BACKGROUND

The aim of this review was to assess the safety and efficacy of endoscopic procedures for gastro-oesophageal reflux disease.

METHODS

Literature databases including Medline, Embase and PubMed were searched up to May 2006 without language restriction. Randomized controlled trials and non-randomized comparative studies with at least ten patients in each study arm, and case series studies of at least ten patients, were included.

RESULTS

A total of 33 studies examining seven endoscopic procedures (Stretta procedure, Bard EndoCinch, Wilson-Cook Endoscopic Suturing Device, NDO Plicator, Enteryx, Gatekeeper Reflux Repair System and Plexiglas) were included in the review. Of the three procedures that were tested against sham controls (Stretta procedure, Bard EndoCinch and Enteryx), patient outcomes in the treatment group were either as good as, or significantly better than, those of control patients in terms of heartburn symptoms, quality of life and medication usage. However, for the two procedures that were tested against laparoscopic fundoplication (Stretta) procedure and Bard EndoCinch), outcomes for patients in the endoscopic group were either as good as, or inferior to, those for the laparoscopic group.

CONCLUSION

At present there is insufficient evidence to determine the safety and efficacy of endoscopic procedures for gastro-oesophageal reflux disease, particularly in the long term.