The criteria for causation of alcohol in violent injuries based on emergency room data from six countries

Where to next? An exploration of 'night-out' location progression and propensity to experience violence in night -time entertainment precincts

BACKGROUND

Alcohol related violence in night-time entertainment precincts (NEPs) is a significant public health concern. Studies suggest characteristics including venue density, bar hopping and permissive social norms facilitate violence in NEPs. Yet, we have a limited understanding of how individual drinking occasions progress within NEPs and how location sequence is associated with the propensity to experience violence in these spaces.

METHODS

In this study we apply sequence analysis and logistic regression to examine the association between location sequences and experiences of violence among a sample of NEP patrons (N=387).

RESULTS

We find that individuals who stay out longer and visit a greater number of unique location types are more likely to experience a violent event. We also find that attending a 'non-venue' pre-event such as a private party, gathering, sporting or celebratory event, is associated with elevated risk experiencing violence during a night out.

CONCLUSION

The findings offer important insights into the dynamic context in which risky drinking occasions may emerge and suggest that the context and location in which pre-drinking occurs should be considered in future research.

Temporal changes in trauma according to alcohol sale restrictions during the South African national COVID-19 lockdown

Introduction

The South African government enforced various alcohol sale restrictions during the COVID-19 lockdown in order to reduce hospital admissions related to alcohol-associated injuries. A cross-sectional study was performed to describe the temporal changes in trauma according to alcohol sale restrictions during the South African national COVID-19 lockdown.

Methods

Data from all trauma-related patients presenting to the emergency centre of Mitchells Plain Hospital from 01/03/2020 till 29/9/2020 and corresponding periods during 2019 were exported from an existing database. The relationship between variables was determined with the χ²-test, Fisher's exact test, independent samples median test or t-test. A sub-analysis compared similar 2020 lockdown levels when a second alcohol ban were instituted while most business were allowed to operate (level 3b – alcohol banned versus level 3 – alcohol restricted).

Results

Total number of trauma presentations were 539 (14.6%) less in 2020 (n = 3160) than in 2019 (n = 3699); the mean number decreased by 2.5 per day (95% CI −2.9 to −2.1). Lockdown levels with an alcohol ban had on average 4.8 less patients per day than corresponding periods in 2019 (p < 0.001). No significant difference was observed in lockdown levels with alcohol sale restrictions (mean difference per day −0.4, p = 0.195). Trauma presentations increased significantly (mean difference per day 7.0 (95% CI 6.5 to 7.5)) from 2020 lockdown levels with alcohol sales ban (mean per day 11.4) to 2020 lockdown levels with alcohol sale restrictions (mean per day 18.4). Significantly less patients (mean −3.2 (95% CI −3.9 to −2.5)) presented during 2020 lockdown level 3b (alcohol sales banned, mean 13.9) compared to level 3 (alcohol sales restricted, mean 17.1).

Conclusion

Temporal changes in trauma were observed according to alcohol sale restrictions during South Africa's COVID-19 lockdown periods. Significantly less trauma cases presented during periods with an alcohol ban compared to periods where alcohol sales were only restricted.

Alcohol Consumption and Violent Deaths in the City of Sao Paulo in 2015

Background: Excessive alcohol consumption is a serious public health issue, because drunkenness affects critical judgment and self-control, making people more vulnerable to violence and accidents, with thus a potential association between alcohol consumption and violent deaths. Objective: To assess the association between alcohol consumption and violent deaths in the city of Sao Paulo, Brazil, in 2015, and its relationship with gender, age, cause of death and blood alcohol concentration (BAC) of victims. Methods: A cross-sectional retrospective study was conducted by collection of data from 2,882 victims of violent deaths subjected to examination of BAC from the archives of the Institute of Legal Medicine of the State of Sao Paulo, Brazil. Results: Alcohol was detected in blood samples of 27.06% of the victims and mean BAC levels were 1.92 ± 1.24 g/L. The mean age of the victims was 33.49 ± 15.19 years. The majority of the victims were male (84.14%) and the prevalence of positive BAC was higher amongst men (28.74%) than women (18.16%). Homicide was the most prevalent cause of death in the sample (36.57%), but there were a higher proportion of traffic accidents victims with positive BAC (32.01%), as well as higher BAC levels in these victims (46.77% in the range of 1.6-2.5 g/L). Conclusions: The results obtained in this study support a potential association between alcohol consumption and violent deaths in the city of Sao Paulo, mainly in traffic accidents victims.

Sexual Aggression in Brazilian Nightclubs: Associations with Patron's Characteristics, Drug Use, and Environmental Factors

Bars and nightclubs are main locations for sexual assault outcomes such as rape, attempted rape, stalking, and other forms of sexual harassment. Alcohol use is strongly associated with violence in nightlife settings. The present study aimed to identify individual and environmental factors, such as different types of nightclubs, music styles, and physical environment associated with nightclub patron's report of being victims of sexual aggression inside nightclubs in São Paulo, Brazil. Two levels of data were collected: observational data inside nightclubs and individual-level survey data of 2422 patrons at the entrance and 1822 patrons (1111 men; 711 women) at the exit of 31 nightclubs. Among patrons, 11.5% (95% CI 7.9-16.2%) reported being a victim of sexual aggression inside the venues in the night of the survey. Groping and forced kissing were the most prevalent forms of sexual aggression (9.8%; [7.2-13.1%]), which was more strongly associated with environmental factors such as crowding (OR = 2.9 [1.6-5.2%]), entrance consumption fee (OR = 4.2 [2.5-7.0%]), and music style than with individual-level factors. In funk (OR = 3.3 [1.6-6.9%]), electronic (OR = 3.2 [1.8-5.8%]), and pop dance (OR = 7.9 [2.2-29.1%]) nightclubs, patrons had higher chances of being a victim of sexual aggression compared to those ones at the eclectic nightclubs. Presence of reserved areas for sex increased the chances of reporting sexual aggression (OR = 1.8 [1.2-2.8%]). No significant gender differences for sexual aggression were detected. Results suggest a requirement of security improvement where environmental characteristics are potential predictors of victimization.

Risk Factors for Violent Injuries and Their Severity Among Men in The Gambia

A matched case-control study was conducted to identify risk factors for injury from physical violence and its severity in Gambian men. Study participants were recruited from eight emergency rooms and outpatient departments in two health administrative regions. Cases were male patients aged ⩾15 years who had been violently injured. A control patient for each case, matched for the hospital or health center, date of injury, gender, and age, was selected from those injured due to nonviolence causes. In total, 447 case-control pairs were recruited. Results of the conditional logistic regression analysis showed that case patients who worked as businessmen (odds ratio [OR], 1.93; 95% confidence interval [CI] [1.16, 3.20]), had monthly household income of ⩾US$311 (OR, 2.12; 95% CI [1.06, 4.24]), had two or more male siblings (OR, 2.20; 95% CI [1.15, 4.21]), had consumed alcohol in the past week (OR, 3.32; 95% CI [1.25, 8.84]), and had been physically abused (OR, 5.10; 95% CI [2.71, 9.62]) or verbally abused (OR, 1.63; 95% CI [1.04, 2.56]) in the past 12 months were significantly associated with the occurrence of injury from physical violence. Severe injuries during the violence were significantly associated with events that took place in public spaces, with certain injury mechanisms (being stabbed/cut/pierced, struck by an object, assaulted by fist punching/leg kicking/head-butting, and scalded/stoned), having injuries to the upper extremities, and smoked cigarettes in the past week. Specific public health programs aimed at preventing physical violence and severe injuries against men should be developed in The Gambia based on modifications of the identified risk factors.

Factores asociados con la hospitalización por lesiones en pacientes atendidos en los servicios de urgencias

Objetivo Identificar los factores asociados con la hospitalización por lesiones en pacientes atendidos en el servicio de urgencias de dos hospitales.Métodos Estudio transversal, en lesionados mayores de 15 años que solicitaron atención en el servicio de urgencias de dos hospitales de Xalapa, Veracruz, México. Se realizó un análisis bivariado y un análisis de regresión logística para estimar los riesgos mediante Odds Ratio (OR) e identificar los factores asociados con la probabilidad de hospitalización.Resultados De los 505 lesionados, 10,7% requirieron ser hospitalizados. El riesgo de hospitalización se asoció con el sexo masculino (OR=2,7, IC95% 1,2-6,1), la edad de 46 años o más (OR=2,3, IC95% 1,2-4,5), el consumo de alcohol antes de la lesión (OR=2,3, IC95% 1,2-4,6), la violencia (OR=2,3, IC95% 1,1-4,9). En cuanto al tipo de lesión, mostraron mayor riesgo las fracturas (OR=7,4, IC95% 3,0-17,8).Conclusión Los resultados de esta investigación mostraron que algunos factores presentan mayor riesgo de hospitalización por lesiones. Dicha información puede utilizarse para proponer estrategias y desarrollar intervenciones que puedan incidir en la prevención de factores de riesgo que den como resultado lesiones graves que ameriten hospitalización.

Late night environments: Bar "morphing" increases risky alcohol sales in on-premise outlets

Niche theory proposes that in areas of high alcohol availability, alcohol sales outlets will compete for patrons by diversifying their operating characteristics to provide a diversity of drinking contexts. We aimed to characterize features of outlet operations which contribute to increased risk for alcohol problems across communities. We conducted ethnographic observations in 97 on-premise outlets across 6 California cities and interviewed staff and patrons in a subsample of these. We observed outlet managers deliberately altering the environments in 17.5% of establishments. These modifications aimed to increase bar/nightclub effects, enabling venues to "morph" (i.e., alter operating conditions from restaurant to bar, or from bar to club) and display environmental characteristics associated with over-service and alcohol-related problems (e.g., more young male patrons, crowding, and dancing). Late night morphing was observed in some outlets in most cities and included outlets operating with restaurant licenses. Staff and patrons identified morphing as a strategy to increase alcohol sales in late night hours. Competition for late night customers may encourage business practices that increase the number of alcohol sales establishments operating under risky circumstances. Community alcohol policies and practices should attend to the potential expansion of risky alcohol sales niches in night time economies.

Demographic and Substance Use Factors Associated with Non-Violent Alcohol-Related Injuries among Patrons of Australian Night-Time Entertainment Districts

This study examined the relationship between patron demographics, substance use, and experience of recent alcohol-related accidents and injuries that were not due to interpersonal violence in night-time entertainment districts. Cross-sectional interviews (n = 4016) were conducted around licensed venues in entertainment districts of five Australian cities. Demographic factors associated with non-violent alcohol-related injuries were examined, including gender, age, and occupation. The association between substance use on the night of interview; blood alcohol concentration (BAC), pre-drinking, energy drink consumption, and illicit drug use; and experience of injury was also explored. Thirteen percent of participants reported an alcohol-related injury within the past three months. Respondents aged younger than 25 years were significantly more likely to report an alcohol-related injury. Further, a significant occupation effect was found indicating the rate of alcohol-related injury was lower in managers/professionals compared to non-office workers. The likelihood of prior alcohol-related injury significantly increased with BAC, and self-reported pre-drinking, energy drink, or illicit drug consumption on the night of interview. These findings provide an indication of the demographic and substance use-related associations with alcohol-related injuries and, therefore, potential avenues of population-level policy intervention. Policy responses to alcohol-related harm must also account for an assessment and costing of non-violent injuries.

Changes in Classes of Injury-Related Risks and Consequences of Risk-Level Drinking: a Latent Transition Analysis

Risk-level drinking, drinking and driving, and alcohol-related violence are risk factors that result in injuries. The current study sought to identify which subgroups of patients experience the most behavioral change following a brief intervention. A secondary analysis of data from a brief alcohol intervention study was conducted. The sample (N = 664) includes at-risk drinkers who experienced an injury and were admitted for care to a Level 1 trauma center. Injury-related items from the Short Inventory of Problems+6 were used to perform a latent transition analysis to describe class transitions participants experienced following discharge. Four classes emerged for the year before and after the current injury. Most individuals transitioned from higher-risk classes into those with lower risk. Some participants maintained risky profiles, and others increased risks and consequences. Drinking and driving remained a persistent problem among the study participants. Although a large portion of intervention recipients improved risks and consequences of alcohol use following discharge, more intensive intervention services may be needed for a subset of patients who showed little or no improvement.

Diagnosis-based emergency department alcohol harm surveillance: What can it tell us about acute alcohol harms at the population level?

INTRODUCTION AND AIMS

Acute harm from heavy drinking episodes is an increasing focus of public health policy, but capturing timely data on acute harms in the population is challenging. This study aimed to evaluate the precision of readily available administrative emergency department (ED) data in public health surveillance of acute alcohol harms.

DESIGN AND METHODS

We selected a random sample of 1000 ED presentations assigned an ED diagnosis code for alcohol harms (the 'alcohol syndrome') in the New South Wales, Australia, automatic syndromic surveillance system. The sample was selected from 68 public hospitals during 2014. Nursing triage free-text fields were independently reviewed to confirm alcohol consumption and classify each presentation into either an 'acute' or 'chronic' harm. Positive predictive value (PPV) for acute harm was calculated, and predictors of acute harm presentations were estimated using logistic regression.

RESULTS

The PPV of the alcohol syndrome for acute alcohol harm was 53.5%. Independent predictors of acute harm were ambulance arrival [adjusted odds ratio (aOR) = 3.4, 95% confidence interval (CI) 2.4-4.7], younger age (12-24 vs. 25-39 years: aOR = 3.4, 95% CI 2.2-5.3), not being admitted (aOR 2.2, 95% CI 1.5-3.2) and arriving between 10 pm and 5.59 am (aOR 2.1, 95% CI 1.5-2.8). PPV among 12 to 24-year-olds was 82%.

DISCUSSION AND CONCLUSIONS

The alcohol syndrome provides moderate precision as an indicator of acute alcohol harms presenting to the ED. Precision for monitoring acute harm in the population is improved by filtering the syndrome by the strongest independent predictors of acute alcohol harm presentations. [Whitlam G, Dinh M, Rodgers C, Muscatello DJ, McGuire R, Ryan T, Thackway S. Diagnosis-based emergency department alcohol harm surveillance: What can it tell us about acute alcohol harms at the population level? Drug Alcohol Rev 2016;35:693-701].

Epidemiology of alcohol consumption and related problems in Latin American countries: Contributions of psychology

Alcohol consumption is the leading risk factor for morbi-mortality in many Latin American Countries. However, epidemiologic studies are relatively scarce. Among factors such as limited research capacity, disciplinary traditions and an emphasis on psychopathology within the field of psychology, have been postulated to account for this. The aim of this article is to review epidemiologic research on alcohol in Spanish Speaking Latin American Countries, and to measure the contribution of psychology to the field. A systematic search was performed in English and Spanish using regional and international data bases. We identified 269 articles. Most focused on consumption patterns in youth, with samples from a single school and using a variety of measures. With the exception of multinational efforts like Emergency Room Collaborative Alcohol Analysis Project or those supported by World Health Organization/Pan American Health Organization, studies reviewed reflected little cross country collaboration. Mexico accounted for most of the productivity, while many countries had very few or no articles. Most research was performed by health science researchers with a small contribution from psychology, but which increased significantly over time. The results of this review provide a broad identification of patterns regarding epidemiologic research on alcohol, and demonstrate the need for national scientific policies to promote research on public health topics.

Effects of brief intervention on subgroups of injured patients who drink at risk levels

Alcohol-related injuries are a major source of admission for trauma care. Screening and brief intervention (SBI) for injured patients can result in decreased drinking and risk behaviors. It is not clear SBI is equally beneficial for all injured patients. A secondary data analysis of 553 patients admitted to two Level-1 trauma centers was conducted. Latent class analysis was used to identify patient subgroups based on injury-related risks and consequences of alcohol use. Intervention effects on drinking were examined among subgroups. Five subgroups were identified. Drinking improved in patients reporting multiple risks and injuries/accidents and drinking and driving. Patients that reported drinking and driving and taking foolish risks or fighting while drinking and taking foolish risks did not show improvements. Trauma centers may benefit from targeting interventions based on injury-related risks and consequences of alcohol use. Further research is needed to test bedside approaches for tailored interventions.

Neighborhood Context and Binge Drinking by Race and Ethnicity in New York City

BACKGROUND

Neighborhood context is associated with binge drinking and has significant health, societal, and economic costs. Both binge drinking and neighborhood context vary by race and ethnicity. We examined the relations between neighborhood characteristics--neighborhood norms that are accepting of drunkenness, collective efficacy, and physical disorder--and binge drinking, with a focus on examining race and ethnic-specific relationships.

METHODS

Respondent data were collected through 2005 random digit-dial-telephone survey for a representative sample of New York City residents; neighborhood data were based on the 2005 New York City Housing and Vacancy Survey. Participants were 1,415 past-year drinkers; Whites (n = 877), Blacks (n = 292), and Hispanics (n = 246). Generalized estimating equations were used to estimate population average models.

RESULTS

For the overall sample, neighborhood norms that were more accepting of drunkenness were associated with greater binge drinking (odds ratio [OR] = 1.22; 95% confidence interval [CI] = 1.09, 1.37); collective efficacy and physical disorder were not significant. However, when examining this by race/ethnicity, greater collective efficacy (OR = 0.75; 95% CI = 0.62, 0.91) and greater physical disorder (OR = 0.76; 95% CI = 0.62, 0.93) were associated with less binge drinking for Whites only. Neighborhood norms that were more accepting of drunkenness were associated with binge drinking among Whites (OR = 1.20; 95% CI = 1.05, 1.38) and, while not significant (perhaps due to power), the associations were similar for Hispanics (OR = 1.18; 95% CI = 0.83, 1.68) and slightly lower for Blacks (OR = 1.11; 95% CI = 0.67, 1.84).

CONCLUSIONS

Overall, results suggest that neighborhood characteristics and binge drinking are shaped, in part, by factors that vary across race/ethnicity. Thus, disaggregating data by race/ethnicity is important in understanding binge drinking behaviors.

A Review of Existing Studies Reporting the Negative Effects of Alcohol Access and Positive Effects of Alcohol Control Policies on Interpersonal Violence

Alcohol consumption often leads to elevated rates of violence yet alcohol access policies continue to relax across the globe. Our review establishes the extent alcohol policy can moderate violent crime through alcohol availability restrictions. Results were informed from comprehensive selection of peer-reviewed journals from 1950 to October 2015. Our search identified 87 relevant studies on alcohol access and violence conducted across 12 countries. Seventeen studies included quasi-control design, and 23 conducted intervention analysis. Seventy-one (82%) reported a significant relationship between alcohol access and violent offenses. Alcohol outlet studies reported the greatest percentage of significant results (93%), with trading hours (63%), and alcohol price following (58%). Results from baseline studies indicated the effectiveness of increasing the price of commonly consumed alcohol, restricting the hours of alcohol trading, and limiting the number of alcohol outlets per region to prevent violent offenses. Unclear are the effects of tax reductions, restriction of on-premises re-entry, and different outlet types on violent crime. Further, the generalization of statistics over broad areas and the low number of control/intervention studies poses some concern for confounding or correlated effects on study results, and amount of information for local-level prevention of interpersonal violence. Future studies should focus on gathering longitudinal data, validating models, limiting crime data to peak drinking days and times, and wherever possible collecting the joint distribution between violent crime, intoxication, and place. A greater uptake of local-level analysis will benefit studies comparing the influence of multiple alcohol establishment types by relating the location of a crime to establishment proximity. Despite, some uncertainties particular studies showed that even modest policy changes, such as 1% increases in alcohol price, 1 h changes to closing times, and limiting establishment densities to <25 outlets per postal code substantively reduce violent crime.

Alcohol misuse, firearm violence perpetration, and public policy in the United States

OBJECTIVE

Firearm violence is a significant public health problem in the United States, and alcohol is frequently involved. This article reviews existing research on the relationships between alcohol misuse; ownership, access to, and use of firearms; and the commission of firearm violence, and discusses the policy implications of these findings.

METHOD

Narrative review augmented by new tabulations of publicly-available data.

RESULTS

Acute and chronic alcohol misuse is positively associated with firearm ownership, risk behaviors involving firearms, and risk for perpetrating both interpersonal and self-directed firearm violence. In an average month, an estimated 8.9 to 11.7 million firearm owners binge drink. For men, deaths from alcohol-related firearm violence equal those from alcohol-related motor vehicle crashes. Enforceable policies restricting access to firearms for persons who misuse alcohol are uncommon. Policies that restrict access on the basis of other risk factors have been shown to reduce risk for subsequent violence.

CONCLUSION

The evidence suggests that restricting access to firearms for persons with a documented history of alcohol misuse would be an effective violence prevention measure. Restrictions should rely on unambiguous definitions of alcohol misuse to facilitate enforcement and should be rigorously evaluated.

A Review of the Statistical and Quantitative Methods Used to Study Alcohol-Attributable Crime

Modelling the relationship between alcohol consumption and crime generates new knowledge for crime prevention strategies. Advances in data, particularly data with spatial and temporal attributes, have led to a growing suite of applied methods for modelling. In support of alcohol and crime researchers we synthesized and critiqued existing methods of spatially and quantitatively modelling the effects of alcohol exposure on crime to aid method selection, and identify new opportunities for analysis strategies. We searched the alcohol-crime literature from 1950 to January 2014. Analyses that statistically evaluated or mapped the association between alcohol and crime were included. For modelling purposes, crime data were most often derived from generalized police reports, aggregated to large spatial units such as census tracts or postal codes, and standardized by residential population data. Sixty-eight of the 90 selected studies included geospatial data of which 48 used cross-sectional datasets. Regression was the prominent modelling choice (n = 78) though dependent on data many variations existed. There are opportunities to improve information for alcohol-attributable crime prevention by using alternative population data to standardize crime rates, sourcing crime information from non-traditional platforms (social media), increasing the number of panel studies, and conducting analysis at the local level (neighbourhood, block, or point). Due to the spatio-temporal advances in crime data, we expect a continued uptake of flexible Bayesian hierarchical modelling, a greater inclusion of spatial-temporal point pattern analysis, and shift toward prospective (forecast) modelling over small areas (e.g., blocks).

An overview of injuries to adolescents and young adults related to substance use: data from Canadian emergency departments

Objective:

Alcohol is a significant risk factor for injury, and is one of the leading causes of death, disability and premature mortality among young Canadians. This paper provides an overview of alcohol-related injury among adolescents and young adults presenting to Canadian emergency departments (EDs).

Methods:

We reviewed records from the Canadian Hospitals Injury Reporting and Prevention Program database during the 4-year period between 2000 and 2003. We included individuals younger than 25 years who presented to EDs in 11 pediatric and general hospitals with injuries for which alcohol, either alone or in conjunction with drugs, was recorded as a contributing factor. We examined key socio-demographic and injury-related factors associated with alcohol and drug-related injuries, including intent and disposition.

Results:

Alcohol was identified as a factor in 2389 injuries during this 4-year period; 408 (17%) of these cases also involved drug use. Approximately 55% of these patients were male and the majority was between 15 and 19 years of age. Unintentional injuries were the most common presentation, self-harm injuries were more common among female patients and violence-related injuries were more common among male patients. Most patients received treatment for their injuries. However, as age increased, outcome differences were observed between sexes.

Conclusion:

Alcohol-related injuries are increasing among Canadian youth. These findings highlight the importance of obtaining thorough drug and alcohol histories and measurement, when appropriate, for adolescents and young adults presenting to EDs with injuries.

Latent Classes Among Recipients of a Brief Alcohol Intervention: A Replication Analysis

The purpose of this study was to identify differential improvement in alcohol use among injured patients following brief intervention. Latent class analysis was conducted to identify patient profiles based on alcohol-related risk from two clinical trials (Texas: N = 737; Maryland: N = 250) conducted in Level-1 trauma centers. Drinking was analyzed to detect improvements at 6 and 12 months. The four classes that emerged from Maryland participants were similar to four of the five classes from Texas. Increases in both studies for days abstinent were reported by classes characterized by multiple risks and minimal risks. Decreases in volume consumed for both studies were also reported by classes characterized by multiple risks and minimal risks. By classifying patients according to alcohol-related risk, providers may be able to build on positive prognoses for drinking improvements or adapt interventions to better serve those likely to improve less.

Risk factors associated with different types of intimate partner violence (IPV): an emergency department study

BACKGROUND

Domestic intimate partner violence (IPV) is a serious health care concern, which may be mitigated by early detection, screening, and intervention.

OBJECTIVES

We examine posited predictors in IPV and non-IPV groups, and in four different IPV profiles. Possible factors include 1) alcohol use, 2) drug use, 3) depression, 4) impulsivity, 5) age, and 6) any childhood experience in observing parental violence. We also introduce a new "Five Steps in Screening for IPV" quick reference tool, which may assist emergency physicians in detection and treatment.

METHODS

This was a cross-sectional study using survey data from 412 inner-city emergency department patients. Associations were explored using a chi-squared test of independence, independent-samples t-tests, and a one-way analysis of variance.

RESULTS

Nearly 16% had experienced IPV. As a group, they were younger, and more depressed and impulsive than the non-IPV group. They were more likely to engage in binge drinking, use drugs, and had more childhood exposure to violence. In the IPV group, 31% were perpetrators, 20% victims, and 49% both victims and perpetrators. The latter group was younger, more impulsive and depressed, used drugs, and was more likely to have observed parental violence as a child.

CONCLUSION

Correlates in groups affected by IPV indicate the same general risk factors, which seem to more acutely affect those who are both perpetrators and victims. Alcohol and drug use, depressive symptoms, and childhood exposure to violence may be factors and signs for which emergency physicians should screen in the context of IPV.

Brief motivational intervention for adolescents treated in emergency departments for acute alcohol intoxication - a randomized-controlled trial

Background

Alcohol misuse among youth is a major public health concern and numbers of adolescents admitted to the emergency department for acute alcoholic intoxication in Germany are recently growing. The emergency setting offers an opportunity to reach at-risk alcohol consuming adolescents and provide brief interventions in a potential “teachable moment”. However, studies on brief interventions targeting adolescents in emergency care are scarce and little is known about their effectiveness when delivered immediately following hospitalization for acute alcohol intoxication. In this protocol we present the HaLT-Hamburg trial evaluating a brief motivational intervention for adolescents treated in the emergency department after an episode of acute alcoholic intoxication.

Methods

The trial design is a parallel two-arm cluster randomized-controlled trial with follow-up assessment after 3 and 6 months. N = 312 participants aged 17 years and younger will be recruited Fridays to Sundays in 6 pediatric clinics over a period of 30 months. Intervention condition is a manual-based brief motivational intervention with a telephone booster after 6 weeks and a manual-guided intervention for caregivers which will be compared to treatment as usual. Primary outcomes are reduction in binge drinking episodes, quantity of alcohol use on a typical drinking day and alcohol-related problems. Secondary outcome is further treatment seeking. Linear mixed models adjusted for baseline differences will be conducted according to intention-to-treat (ITT) and completers (per-protocol) principles to examine intervention effects. We also examine quantitative and qualitative process data on feasibility, intervention delivery, implementation and receipt from intervention providers, receivers and regular emergency department staff.

Discussion

The study has a number of strengths. First, a rigorous evaluation of HaLT-Hamburg is timely because variations of the HaLT project are widely used in Germany. Second, prior research has not targeted adolescents in the presumed teachable moment following acute alcohol intoxication. Third, we included a comprehensive process evaluation to raise external validity. Fourth, the study involved important stakeholders from the start to set up organizational structures for implementation and maintaining project impact.

Trial registration

Current Controlled Trials ISRCTN31234060 (April 30^th 2012).

Injury-related consequences of alcohol misuse among injured patients who received screening and brief intervention for alcohol: a latent class analysis

BACKGROUND

Screening and brief alcohol intervention has demonstrated efficacy in improving drinking and other risk behaviors for some patient populations. However, it is not clear that brief interventions are helpful to all injured patients who drink at risk levels. This paper identifies latent classes of intervention recipients based on injury-related consequences and risks of alcohol misuse and then determines which profiles experienced the greatest improvements in drinking.

METHODS

A secondary analysis was conducted using data from injured patients (N = 737) who reported heavy drinking and received a brief alcohol intervention in a Level I trauma center. Latent class analysis was used to determine patient profiles, and 7 indicators commonly associated with alcohol-related injury from the Short Inventory of Problems+6 were used to determine the latent class measurement model. Covariates were regressed onto the model to assess factors related to class membership, and drinking outcomes were analyzed to examine improvements in drinking.

RESULTS

Five classes emerged from the data. The classes that reported the greatest improvements in drinking following discharge were those characterized by multiple alcohol-related risks and those characterized by a history of alcohol-related accidents and injuries. Attributing the current injury to drinking was a significant predictor of class membership among those classes that reported higher levels of improvement.

CONCLUSIONS

This study provides tentative evidence that subclasses exist among heavy drinking injured patients who received a brief intervention in a Level I trauma center, and some subclasses experience greater drinking improvements than others. Further research is required to substantiate the findings of this secondary analysis.

Alcohol and drug use as predictors of intentional injuries in two emergency departments in British Columbia

BACKGROUND

While a substantial literature exists demonstrating a strong association of alcohol and intentional injury, less is known about the association of intentional injury with recreational drug use, either alone, or in combination with alcohol.

OBJECTIVES

The risk of intentional injury due to alcohol and other drug use prior to injury is analyzed in a sample of emergency department (ED) patients.

METHODS

Logistic regression was used to examine the predictive value of alcohol and drug use on intentional versus non-intentional injury in a probability sample of ED patients in Vancouver, BC (n = 436).

RESULTS

Those reporting only alcohol use were close to four times more likely (OR = 3.73) to report an intentional injury, and those reporting alcohol combined with other drug(s) almost 18 times more likely (OR = 17.75) than those reporting no substance use. Those reporting both alcohol and drug use reported drinking significantly more alcohol (15.7 drinks) than those reporting alcohol use alone (5 drinks).

CONCLUSIONS

These data suggest that alcohol in combination with other drugs may be more strongly associated with intentional injury than alcohol alone.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The strong association of alcohol combined with other drug use on injury may be due to the increased amount of alcohol consumed by those using both substances, and is an area requiring more research with larger samples of intentional injury patients.

Alcohol and violence in the emergency room: a review and perspectives from psychological and social sciences

Our objective is to present a focused review of the scientific literature on the effect of alcohol consumption on violence related-injuries assessed in the emergency room (ER) and to show how psychological and behavioral sciences could lead to a better understanding of the factors contributing to alcohol-related injuries in the ER. We retrieved published literature through a detailed search in Academic Search Premier, MEDLINE with Full Text PsycARTICLES, Psychology and Behavioral Sciences Collection, PsycINFO, PUBMed and SocINDEX with Full Text for articles related to emergency rooms, medical problems and sociocognitive models addressing alcohol intoxication articles. The first search was conducted in June 2011 and updated until August 2013. Literature shows that compared to uninjured patients; injured ones have a higher probability of: (i) having an elevated blood-alcohol concentration upon arrival at the ER; (ii) reporting having drunk alcohol during the six hours preceding the event; and (iii) suffering from drinking-related consequences that adversely affect their social life. The main neurocognitive and sociocognitive models on alcohol and aggression are also discussed in order to understand the aetiology of violence-related injuries in emergency rooms. Suggestions are made for future research and prevention.

Validating the ability of a single-item assessing drunkenness to detect hazardous drinking

BACKGROUND

To simplify the screening process to identify problem drinking, researchers have developed single-item, quantity-based instruments. Quantity-based items, however, suffer from several limitations.

OBJECTIVE

Determine whether a non-quantity-based single item assessing drunkenness would be able to identify those who exhibited signs of hazardous alcohol use, as determined by Alcohol Use Disorders Identification Test (AUDIT)-C scores.

METHODS

Between September and November of 2011, the alcohol-related behaviors of 1062 self-identified current drinkers were assessed with self-report measures (i.e. AUDIT-C and one item assessing frequency of drunkenness) in addition to corresponding biologic samples (i.e. breath alcohol concentration (BrAC) samples). We assessed the concurrent validity of the single item to identify hazardous alcohol use established via gender-based AUDIT-C thresholds. Convergent validity of the single-item was assessed by determining its relationship to BrAC levels.

RESULTS

The single item accounted for 0.791 of the area under the received operating characteristics curve for hazardous alcohol use (p < 0.001). When employing a cut-off of 1, the single-item question was 95.9% sensitive in identifying hazardous alcohol use.

CONCLUSION

The results reported herein highlight the validity (both concurrent and convergent) and potential utility of a non-quantity-based single-item alcohol screen for assessing drunkenness. Additional research is warranted to confirm the utility of this one-item drunkenness measure to capture risk of injury and hazardous drinking.

One more beer? Serving alcohol to pseudo-intoxicated guests in bars

BACKGROUND

Consuming large quantities of alcohol might result in negative consequences for both individual drinkers (alcohol dependency and addiction) and society (violence, traffic crashes). In order to decrease the prevalence of alcohol abuse, many countries have adopted regulations prohibiting the catering industry to serve alcohol to intoxicated guests. This article investigated compliance with these regulations in the Netherlands.

METHODS

A study was conducted in which pseudo-intoxicated actors tried to order alcoholic drinks in 58 bars. A 2 × 2 design was used, based on (i) the number of actors involved (1 vs. 2) and (ii) the level of intoxication (moderately vs. very drunk). In contrast to earlier studies, research accomplices checked afterward whether the bartenders noticed that the actors appeared intoxicated.

RESULTS

In 86% of the cases, the actors were able to buy alcohol, without comments or questions. In 10%, the actors were refused entrance by a bouncer. Only in 4%, the bartender refused to serve. In 81% of the cases, the bartenders remembered the actors: In 93% of those cases, they noticed that the actor appeared intoxicated. Only the "very drunk" script involving 2 actors led to refusals.

CONCLUSIONS

The results show that compliance with the regulations regarding overserving to intoxicated guests is problematic in the Netherlands. Misinterpretations of the situation could be ruled out: Most bartenders noticed that the actors appeared intoxicated but served nonetheless.

Community organization moderates the effect of alcohol outlet density on violence

There is growing evidence from multiple disciplines that alcohol outlet density is associated with community levels of assault. Based on the theoretical and empirical literatures on social organization and crime, we tested the hypothesis that the association between alcohol outlet density and neighbourhood violence rates is moderated by social organization. Using geocoded police data on assaults, geocoded data on the location of alcohol outlets, and controlling for several structural factors thought to be associated with violence rates, we tested this hypothesis employing negative binomial regression with our sample of 298 block groups in Cincinnati. Our results revealed direct effects of alcohol outlet density and social organization on assault density, and these effects held for different outlet types (i.e., off-premise, bars, restaurants) and levels of harm (i.e., simple and aggravated assaults). More importantly, we found that the strength of the outlet-assault association was significantly weaker in more socially organized communities. Subsequent analyses by level of organization revealed no effects of alcohol outlet density on aggravated assaults in organized block groups, but significant effects in disorganized block groups. We found no association between social (dis)organization and outlet density. These results clarify the community-level relationship between alcohol outlets and violence and have important implications for municipal-level alcohol policies.

Attribution of alcohol to violence-related injury: self and other's drinking in the event

OBJECTIVE

Alcohol can result in harm (including injury) not only to the drinker but also to others; however, little research exists on the additional proportion of violence-related injuries that can be attributed to the perpetrator.

METHOD

Data are reported from emergency department studies in 14 countries on the prevalence of patients' self-report of drinking within the 6 hours before the violence-related injury event, patients' belief that the event would not have happened if they had not been drinking at the time, and patients' perception that the perpetrator had been drinking. Alcohol-attributable fraction was calculated based on the patients' perception that their own drinking was causally related to the event and on their perception that the perpetrator had been drinking.

RESULTS

Across all countries, 62.9% of the violence-related injuries involved alcohol use on the part of the victim, the perpetrator, or both. Rates of others definitely drinking, as perceived by the victim, ranged from 14% to 73% across countries and was positively associated with patients' own drinking in the event and with attributing a causal association between their drinking and the event. Estimates of alcohol-attributable fraction were 38.8% when the victim and perpetrator were considered together compared with 23.9% when only the patient was considered and varied by country-level drinking pattern.

CONCLUSIONS

These findings suggest adjustments that could be made to global burden of disease estimates because of violence-related injury morbidity to better reflect alcohol-attributable fraction when drinking by others and country-level drinking patterns are taken into account.

Are the stages of change relevant for the development and implementation of a web-based tailored alcohol intervention? A cross-sectional study

Background

Computer-tailored programs are a promising tool to stimulate health behavior change, such as reducing alcohol intake. Yet more research is needed to assess whether groups differing in their motivational level to change may need different types of feedback. Furthermore, it is unknown whether motivational level may also determine reactions to computer-tailored interventions. Our aim is to identify the potential relevance of the application of the stages of change concept in the development and implementation of alcohol interventions.

Methods

A web-based instrument was used to disseminate a questionnaire and to provide tailored feedback messages among adults in the Netherlands (N = 170; 96 females). Motivational level was assessed by the stage of change construct. The survey furthermore assessed alcohol consumption, attitude, social influence, self-efficacy, and program evaluation (i.e., survey items, tailored advice, layout and functionality of the program). The Least Significant Difference method was used to compare people in different stages of change with regard to psychosocial determinants of drinking behavior and program evaluation.

Results

Of the respondents, 34.1% (n = 58) reported no intention to change to healthier drinking habits in the foreseeable future (precontemplation), 22.9% (n = 39) intended to improve their drinking behavior in the near future (contemplation/preparation) and 42.9% (n = 73) reported to currently adhere to the Dutch alcohol consumption guidelines (action/maintenance). When comparing the three groups, people in the action or maintenance stage reported the lowest number of pros of drinking alcohol, having most healthy drinking role models and the highest levels of self-efficacy regarding healthy drinking in difficult situations, whereas precontemplators reported to receive the least social support regarding healthy drinking. In general, the intervention was positively evaluated, but it seemed to be most appreciated by contemplators and preparers.

Conclusions

Stage-matched interventions may be useful to encourage people to reduce their alcohol intake. Different factors seem to be important for people in different motivational stages. Longitudinal studies are needed to determine whether these factors also predict stage transition. The intervention could be optimized by tailoring the feedback messages more precisely to the needs of people in different motivational stages, for example by applying the different processes of change.

The association between the incidence of emergency department attendances for alcohol problems and assault incidents attended by police in New South Wales, Australia, 2003-2008: a time-series analysis

AIM

To assess the short-term temporal relationship between emergency department (ED) attendances for acute alcohol problems and assaults reported to police.

DESIGN

Cross-sectional time-series analysis.

SETTING

Population of New South Wales (NSW), Australia between 2003 and 2008.

PARTICIPANTS

All patients who attended any of 56 large NSW public hospital EDs and had a recorded diagnosis of acute alcohol problems, and all persons involved in assault incidents reported to the NSW Police Force.

MEASUREMENTS

Weekly count time-series were formed for ED attendances, assault incidents and persons of interest in assault incidents. Cross-correlation analysis was used to determine any time lag in the relationship between the alcohol and the assault series. Poisson regression was used to assess the magnitude of the relationship. Splines of week controlled for seasonality.

FINDINGS

There was no time lag found between the ED and police series. A weekly increase of 100 attendances in people aged 15 years and above to EDs for alcohol problems was associated with an 11% [95% confidence interval (CI): 7-15%] increase in the number of incident assaults attended by police. The relationship was similar and statistically significant for domestic and non-domestic assaults and urban areas. The association was stronger between ED attendances and persons of interest aged 15-24 years (27%, 95% CI: 15-41%), 15-24-year-old males (39%, 95% CI: 16-66%) and 15-24-year-old females (66%, 95% CI: 20-129%).

CONCLUSIONS

There is a clear, short-term temporal association between independent population-level markers of excessive alcohol use and violence.

Behavioural indicators of motives for barroom aggression: implications for preventing bar violence

INTRODUCTION AND AIMS

To develop new strategies for preventing violence in high-risk licensed premises, we identify behavioural indicators of apparent motives for aggression in these settings and outline the implications of different motivations for prevention.

DESIGN AND METHODS

The four types of motives for aggressive or coercive acts defined by the theory of coercive actions framed the research: gaining compliance, expressing grievances/restoring justice, attaining a favourable social identity and pursuing fun/excitement. Incidents of aggression from the Safer Bars evaluation research were analysed to identify behavioural indicators of each motivation.

RESULTS

Compliance-motivated aggression typically takes the form of unwanted social overtures, third party intervention to stop conflicts or staff rule enforcement. Prevention strategies include keeping the aggressor's focus on compliance to avoid provoking grievance and identity motives that are likely to escalate aggression. Grievance motives are typically elicited by perceived wrongdoing and therefore prevention should focus on eliminating sources of grievances and adopting policies/practices to resolve grievances peacefully. Social identity motives are endemic to many drinking establishments especially among male patrons and staff. Prevention involves reducing identity cues in the environment, hiring staff who do not have identity concerns, and training staff to avoid provoking identity concerns. Aggression motivated by fun/excitement often involves low-level aggression where escalation can be prevented by avoiding grievances and attacks on identity.

DISCUSSION AND CONCLUSIONS

Knowledge of behavioural indicators of motives can be used to enhance staff hiring and training practices, reduce environmental triggers for aggression, and develop policies to reduce motivation for aggression.

Type of alcohol drink and exposure to violence: an emergency department study

We compared the prevalence of exposure to violence across different types of alcohol consumed and the association between the type of alcohol consumed and exposure to violence. A cross-sectional analysis of data collected from a sample of 295 Emergency Department (ED) patients identified as having an alcohol problem. Outcome measure include exposure to violence, and the main study predictor was "type of alcoholic drink" including: malt liquor beer (MLB), regular beer, wine cooler, wine, fortified wine or hard liquor. Using logistic regression analysis, ED patients who drank MLB in combination with other types of alcohol increased their odds of being both threatened and physically attacked by 8.5 compared to ED patients who drank other types of alcohol. Being female increased the odds of being both threatened and physically attacked by 2.5 and using illicit drugs increased the odds by 3.8. Analysis of covariance and estimated marginal means revealed that ED patients who only drank MLB had a higher exposure to violence compared to non-MLB drinkers, and that female illicit drug users who drank MLB in combination with other types of alcohol had the highest exposure to violence. MLB was identified as a predictor of the amount of exposure to violence and in particular, that the use of malt liquor beer in combination with other types of alcohol increased the risk of being both threatened and physically attacked. Implications for ED and community interventions are suggested.

Improving shop floor compliance with age restrictions for alcohol sales: effectiveness of a feedback letter intervention

PURPOSE

In this study, we investigated the effects and handling of an intervention to increase compliance with age limits regarding alcohol sales. The intervention tested in this field experiment was a feedback letter sent to alcohol outlets about their individual compliance results based on a mystery shopping study.

METHOD

We measured compliance in 146 alcohol outlets (cafeterias, supermarkets, bars, liquor stores and youth centres) in one region in the Netherlands with 15-year-old mystery shoppers. About half (n=72) of the outlets received the intervention letter (the experimental group). After this intervention, we measured compliance again (n=138). Then we sent the same letter to the control group and interviewed all the outlets regarding their handling of the intervention (n=106).

RESULTS

After the experimental group received the letter, compliance increased significantly (from 18.1% to 32.4%). In the control group, compliance did not change. Of the outlets interviewed, 81% stated that they had received the letter, and the action most commonly taken was to bring the letter to the attention of their staff.

CONCLUSIONS

Positive feedback letters are more often copied and shared integrally with personnel, compared with negative letters. Compliance with respect to underage alcohol sales can be improved, although compliance levels remain low in the Netherlands.

'Hotspots' for aggression in licensed drinking venues

INTRODUCTION AND AIMS

In order to better understand the social context of barroom aggression, the aim was to identify common locations ('hotspots') for aggression in bars and examine the association of hotspots with aggression severity and environmental characteristics.

DESIGN AND METHODS

Aggression hotspots were identified using narrative descriptions and data recorded on premises' floor plans for 1057 incidents of aggression collected in the Safer Bars evaluation. Hierarchical Linear Modelling was used to identify bar-level and night-level characteristics associated with each hotspot.

RESULTS

The most common location for aggression was the dance floor (20.0% of incidents) or near the dance floor (11.5%), followed by near the serving bar (15.7%), at tables (13.1%), aisles, hallways and other areas of movement (6.2%), entrance (4.5%) and the pool playing area (4.1%). Hotspots were predicted mainly by bar-level characteristics, with dance floor aggression associated with crowded bars, a high proportion of female and young patrons, lots of sexual activity, a large number of patrons and staff, security staff present, better monitoring and coordination by staff, and people hanging around at closing. Incidents at tables and pool tables tended to occur in bars with the opposite characteristics. Nightly variations in patron intoxication and rowdiness were associated with aggression at tables while variations in crowding and sexual activity were associated with aggression in areas of movement. Incidents outside tended to be more severe.

DISCUSSION AND CONCLUSIONS

Each aggression location and their associated environments have somewhat different implications for staff training, premises design, policy and prevention.

The Association of Drinking Pattern with Aggression Involving Alcohol and with Verbal versus Physical Aggression

In a general population survey of 1,019 Ontario adults, the present study examined the relationships of (a) drinking pattern (i.e., drinking frequency, heavy episodic drinking (HED), and hazardous drinking with alcohol involvement in aggression (i.e., no aggression, aggression without alcohol, and aggression involving alcohol); (b) drinking pattern with level of aggression (i.e., no aggression, verbal, and physical aggression); and (c) alcohol involvement with level of aggression (i.e., physical versus verbal). All three drinking-pattern measures were associated with aggression involving alcohol but not with aggression not involving alcohol. HED and hazardous drinking were associated with physical aggression (compared with no aggression). Alcohol involvement in aggression was associated with physical aggression (vs. verbal). The findings suggest that, while a pattern of heavy or hazardous drinking is associated with increased risk of aggression, this increased risk only applies to alcohol-related aggression and drinking at the time may contribute to severity of aggression.

Assaults in the elderly--a population-based study with victim and perpetrator characteristics

The aim of the present epidemiological study was to investigate characteristics of assaults in the elderly aged 65 years and above from the perspective of the victim and perpetrator. This population-based study included 23,142 assaults (according to §§ 224/226 StGB of German criminal law) that were recorded in Bavaria, Germany, from 1999 to 2005. The population-based ratio of serious crimes of battery for the elderly in comparison with the reference population was markedly lower (0.10; 95% CI: 0.09-0.11) in suspects aged more than 65 years and 0.08 (95% CI: 0.07-0.09) for the injured above 65 years. Elderly perpetrators differed significantly concerning the manner of the assault (p < 0.001). They committed less crimes in urban areas (56.1% vs. 68.8%) and were victimized significantly more in rural areas (p < 0.001; 41.2% vs. 30.2%). Violence in the elderly differs from that of the younger population. Further research is warranted to establish prevention measures.

Adolescent alcohol intoxication in the Dutch hospital departments of pediatrics: a 2-year comparison study

PURPOSE

To monitor the prevalence of, and the circumstances leading to, adolescent alcohol intoxication admissions in Dutch hospital departments of pediatrics.

METHODS

Data were collected in 2007 and 2008, using the Dutch Pediatric Surveillance System, in which pediatricians received questionnaires on varying issues, including adolescent alcohol intoxication admissions.

RESULTS

The adolescents treated in 2008, as in 2007, were average youth across proportion of gender, educational level, school performances, family structure, siblings, familiarity with medical or aid agencies, alcohol use, and other (illicit) drug use. In 2008, 13% more adolescents were treated. These adolescents showed a trend of having a younger average age, higher blood alcohol concentrations, and longer durations of mental impairment. About 45% of the adolescents who were treated for alcohol intoxication had purchased alcohol from a commercial place, despite that 51 times the specific adolescent had not reached the legal age of 16 years old. About one-third of the youngsters consumed alcohol at home or at a friend's home.

CONCLUSIONS

The number of adolescents suffering from alcohol intoxication increased in 2008 compared with 2007. Parental (lack of) involvement and responsibilities of commercial sales personnel are discussed.

Mechanisms of trauma at a rural hospital in Uganda

INTRODUCTION

Trauma is an increasing cause of mortality worldwide with road traffic accidents (RTAs) causing 1.3 million deaths annually with 90% of this mortality occurring in low and middle income countries. The rise in trauma deaths has been neglected with infectious diseases taking precedence. More research needs to be conducted in resource poor countries to establish the main causes of trauma and find better solutions to the rising trend in mortality. Much of the trauma research in resource poor countries has focused on urban areas. This study aims to find the leading causes of trauma at a rural Ugandan hospital.

METHODS

A retrospective case note review was performed on all adult patients admitted to Kuluva Hospital with trauma related injuries in 2007. Kuluva Hospital is a rural 250 bed hospital in North-West Uganda.

RESULTS

490 trauma patients were admitted in 2007 accounting for 9.4% of admissions. 70.2% (n=344) were males and 29.8% (n=146) were females. The mean age of patients was 31.3 years and the mean length of stay was 7.4 days. In 2007 9 patients died following trauma, 6 from RTAs, 2 from burns and one after an assault. RTAs were the leading cause of trauma with 64.2% of admissions (n=315), followed by assaults with 16.5% (n=81) of admissions. Soft tissue injuries with 28.4% (n=149) and lacerations with 27.3% (n=143) were the most common diagnoses after trauma with fractures making up 18.7% of injuries (n=99).

CONCLUSION

RTAs were an important cause of morbidity and mortality in a rural Ugandan hospital as they also are in urban areas. Low cost initiatives to reduce speed, prevent alcohol impaired driving, improve public education and wider access to high quality trauma care are vital to reducing the mortality and morbidity caused by RTAs in Africa.

ALCOHOL AND VIOLENCE-RELATED INJURIES AMONG EMERGENCY ROOM PATIENTS IN AN INTERNATIONAL PERSPECTIVE

While alcohol has been found to be more closely associated with violence-related injury than with injury from other causes, little data is available which documents heterogeneity in this association across countries or cultures, taking into consideration usual drinking patterns and other socio-cultural variables. Data are reported from 15 countries comprising the Emergency Room Collaborative Alcohol Analysis Project and the WHO Collaborative Study on Alcohol and Injury. Case-crossover analysis was used to analyze the risk of injury (among current drinkers) from drinking six hours prior to the event, based on frequency of usual drinking, for violence-related injuries and separately for non-violence related injuries. Relative risk (RR) for a violence-related injury was significantly greater than for injuries from other causes across all countries (pooled RR=22.22 vs. 4.33), but the magnitude of risk varied considerably (ranging from 4.68 in Spain to 942 in Canada). Pooled effect size was found to be heterogeneous across countries, and was explained, in part, by the level of detrimental drinking pattern in a country. Risk for a violence-related injury was not significantly different by age (<30 and 30+), reporting 5 or more drinks on at least one occasion during the last year, or reporting symptoms of alcohol dependence. A number of methodological concerns suggest that risk of a violence-related injury compared to injuries from other causes may be inflated, and such variables as context of drinking should be taken into consideration in establishing relative risk and alcohol attributable fraction of violence-related injury across countries and cultures.

Nightlife violence: a gender-specific view on risk factors for violence in nightlife settings: a cross-sectional study in nine European countries

Within nightlife settings, youth violence places large burdens on both nightlife users and wider society. Internationally, research has identified risk factors for nightlife violence. However, few empirical studies have assessed differences in risk factors between genders. Here, a pan-European cross-sectional survey of 1,341 nightlife users aged 16 to 35 assessed a variety of risk-taking traits, including violence, sexual, alcohol, and drug-related current and historic behaviors. Results show that the likelihood of having been involved in a physical fight in nightlife increases with younger age, drunkenness, and increasing preference for tolerant venues for both genders. The odds of involvement in a fight for females who were drunk five or more times in the past 4 weeks were almost five times higher than those who were never drunk (odds ratio for males 1.99). Use of cocaine more than doubled the risk of involvement in violence among males. However, no association was found for females. For heterosexual men, the odds for violence almost doubled compared with bisexual or homosexual men, whereas for women heterosexuality was a protective factor. The effects of structural risk factors (e.g., bar and club characteristics) for nightlife violence differed by gender. To develop effective violence prevention measures in nightlife, considerations need to be made regarding the demographic composition of patrons in addition to wider structural elements within the nighttime environment.

The validity of injury surveillance system measures of assault: a lesson from the study of violence in Alaska

This article considers the validity of estimates of intentional violence using a statewide injury recording system: the Alaska Trauma Registry (ATR). One benefit of using data from an injury surveillance system is that its records are generated without police involvement, thereby reducing the likelihood of undercounting. However, there is reason to suspect that measures of violence derived from injury surveillance systems do not accurately measure underlying levels of assault in a population and are instead partly a reflection of influential patient characteristics. The ATR was used to compare assault injury cases of Alaska Natives with those of non-Natives to determine if patient characteristics varied between racial groups and to determine if those characteristics served to bias comparisons of injury rates. Results indicate that differences in assault injury rates are partly attributable to a greater proportion of Alaska Native patients being hospitalized for injuries of only minor or moderate severity.

Study designs and evaluation models for emergency department public health research

Abstract Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. This article is the product of a breakout session from the 2009 Academic Emergency Medicine consensus conference entitled "Public Health in the ED: Screening, Surveillance, and Intervention" and serves to describe in detail aspects of performing emergency department (ED)-based public health research, while serving as a resource for current and future researchers. In doing so, the authors describe methodologic features of study design, participant selection and retention, and measurements and analyses pertinent to public health research. In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation.

The role of causal criteria in causal inferences: Bradford Hill's "aspects of association"

As noted by Wesley Salmon and many others, causal concepts are ubiquitous in every branch of theoretical science, in the practical disciplines and in everyday life. In the theoretical and practical sciences especially, people often base claims about causal relations on applications of statistical methods to data. However, the source and type of data place important constraints on the choice of statistical methods as well as on the warrant attributed to the causal claims based on the use of such methods. For example, much of the data used by people interested in making causal claims come from non-experimental, observational studies in which random allocations to treatment and control groups are not present. Thus, one of the most important problems in the social and health sciences concerns making justified causal inferences using non-experimental, observational data. In this paper, I examine one method of justifying such inferences that is especially widespread in epidemiology and the health sciences generally - the use of causal criteria. I argue that while the use of causal criteria is not appropriate for either deductive or inductive inferences, they do have an important role to play in inferences to the best explanation. As such, causal criteria, exemplified by what Bradford Hill referred to as "aspects of [statistical] associations", have an indispensible part to play in the goal of making justified causal claims.