Vehicle mismatch: injury patterns and severity

Light truck vehicles (LTV) are becoming more popular on US highways. This creates greater opportunity for collisions with passenger vehicles (PV). The mismatch in weight, stiffness, and height between LTV and PV has been surmised to result in increased fatalities among PV occupants when their vehicles collide with LTV. We reviewed cases of vehicle mismatch collisions in the Seattle Crash Injury Research and Engineering Network (CIREN) database to establish patterns and source of injury. Of the first 200 Seattle CIREN cases reviewed, 32 collisions with 41 occupant cases were found to involve LTV versus PV. The cases were reviewed by type of collision and vehicle of injured occupant: side impact of PV with LTV, front impact of PV with LTV, and front impact of LTV with PV. For each type of crash, injury patterns and mechanisms were identified. For side impact to PV, head and upper thorax injuries were frequently encountered due to LTV bumper frame contact above the PV side door reinforcement. For frontal impact to PV, severe multiple extremity fractures along with some head and chest injuries were caused by intrusion of the instrument panel and steering column due to bumper frame override of the LTV. Underriding of the PV when colliding with the LTV resulted in severe lower extremity fractures of the LTV occupant due to intrusion of the toe pan into the vehicle compartment of the LTV. The injuries and the sources identified in this case series support the need for re-designing both LTV and PV to improve vehicle compatibility. Revising Federal Motor Vehicle Safety Standard 214 to reinforce the entire door, consider adding side airbags, and re-engineering LTV bumpers and/or frame heights and PV front ends are possible ways to reduce these injuries and deaths by making the vehicles more compatible.

Community based program to improve firearm storage practices in rural Alaska

OBJECTIVE

To develop and evaluate a pilot program to reduce unauthorized access to firearms by youth by distributing gun safes and trigger locks to households.

DESIGN

Pilot intervention with pre/post-evaluation design.

SETTING

Two Alaska Native villages in the Bristol Bay Health Corporation region of southwest Alaska.

SUBJECTS

Forty randomly selected households with two or more guns in the home.

INTERVENTION

Initially, a focus group of community members who owned guns was convened to receive input regarding the acceptability of the distribution procedure for the gun storage devices. One gun safe and one trigger lock were distributed to each of the selected households during December 2000. Village public safety officers assisted with the distribution of the safes and provided gun storage education to participants.

MAIN OUTCOME MEASURES

Baseline data were collected regarding household gun storage conditions at the time of device distribution. Three months after distribution, unannounced onsite home visits were conducted to identify if residents were using the gun safes and/or trigger locks.

RESULTS

All selected households had at least two guns and 28 (70%) of the 40 households owned more than two guns. At baseline, 85% of homes were found to have unlocked guns in the home and were most often found in the breezeway, bedroom, storage room, or throughout the residence. During the follow up visits, 32 (86%) of the 37 gun safes were found locked with guns inside. In contrast, only 11 (30%) of the 37 trigger locks were found to be in use.

CONCLUSIONS

This community based program demonstrated that Alaska Native gun owners accepted and used gun safes when they were installed in their homes, leading to substantial improvements in gun storage practices. Trigger locks were much less likely to be used.

Correlation of head injury to vehicle contact points using crash injury research and engineering network data

Head injury is the most common cause of morbidity and mortality in motor vehicle crashes. Efforts to improve vehicle design, which minimize forces exerted to the occupant's head, may lead to a reduction in the frequency and severity of head injury. We therefore set out to identify mechanisms producing severe head injury in motor vehicle crashes (MVC) derived from the crash injury research and engineering network (CIREN) database. CIREN combines crash site analysis, vehicle damage assessment, and occupant kinematics in relation to the occupant's injuries. From the Seattle CIREN database of 101 cases, compiled from 1997 to 1998, we selected those crashes in which the occupant sustained severe head injury (abbreviated injury score, AIS>or=4) for analysis. We examined crash mechanism, energy transfer, point of head contact, vehicle intrusion and resulting injuries. There were 15 cases with severe head injury. These were primarily due to side impacts (n=10) in comparison to front impacts (n=5). The average net change in velocity (delta velocity, DV) was 15 mile/h (range 4-29 mile/h). In cases where the primary point of head contact could be elucidated the B-pillar predominated (4 cases, 33.3%) followed by the striking external object (2 cases, 16.7%), A- (1 case, 8.3%) and C- (1 case, 8.3%) pillars, roof side rail (1 case, 8.3%), windshield header (1 case, 8.3%), windowsill (1 case, 8.3%) and airbag (1 case, 8.3%). In this series the predominant mechanism of head injury was lateral impacts, especially those in which the victims' heads struck the B-pillar. The need for improved head protection from lateral impacts is indicated.

Pediatric motor vehicle related injuries in the Navajo Nation: the impact of the 1988 child occupant restraint laws

BACKGROUND

Navajo motor vehicle mortality is the highest among the 12 Indian Health Service (IHS) administrative areas. In July 1988, the Navajo Nation enacted a primary enforcement safety belt use and a child restraint law.

OBJECTIVE

Assess the impact of the laws on the rate and severity of pediatric (0-19 years) motor vehicle injury resulting in hospitalizations in the Navajo Nation.

METHODS

Hospitalizations associated with motor vehicle related injury discharges were identified by International Classification of Diseases, 9th revision, CM E codes, 810-825 (.0,.1) from the Navajo IHS hospital discharge database. Age specific rates for the period before the law, 1983-88, were compared with those after enactment and enforcement, 1991-95. Severity of injury, measured by the abbreviated injury scale (AIS) score and new injury severity score (NISS), was determined with ICDMAP-90 software. Wilcoxon rank sum and chi(2) tests were used for analysis.

RESULTS

Discharge rates (SE) for motor vehicle injury (per 100 000) decreased significantly in all age groups: 0-4 years (62 (7) to 28 (4)), 5-11 years (55.3 (6) to 26 (4)), and 15-19 years (139 (14) to 68 (7)); p=0.0001. In children 0-4 years, the median AIS score decreased from 1.5 (1,3) (25th, 75th centile) to 1 (1,2), p=0.06, and the median NISS decreased from 3.5 (1,9) to 2 (1,5), p=0.07. The proportion of children with NISS scores >4 decreased significantly for the 0-4 year age group (p=0.03).

CONCLUSIONS

Concurrent with enactment of the Navajo Nation occupant and child restraint laws there was a reduction in the rate of motor vehicle related hospital discharges for children. Severity of injury declined in very young Navajo children. The effect of enactment and enforcement of this Native American child occupant restraint law may serve as an example of an effective injury control effort directed at Native American children.

The cause of infant and toddler subdural hemorrhage: a prospective study

OBJECTIVE

To determine the frequency of child abuse and unintentional injury as a cause of infant and toddler subdural hemorrhage (SDH).

METHODS

A prospective case series of a level I regional trauma center, regional children's hospital, and county medical examiner's office assessed consecutive children who were </=36 months old and had SDH. Children who had previously known hemorrhagic disease, previous neurosurgical procedure, previously recognized perinatal brain injury, meningitis, renal dialysis, and severe dehydration were excluded. Concurrent medical, retinal, skeletal, and social work abuse evaluation were measured. Etiologic assessment using predetermined criteria was conducted.

RESULTS

From March 1995 through December 1998, 66 children were admitted with SDH. Abuse was confirmed in 39 (59%), unintentional injury in 15 (23%), and indeterminate cause in 12 (18%). The mean age of abused children was 8.7 +/- 8.1 months and of children with unintentional injuries was 19.1 +/- 10.0 months. The predominant presenting histories for abusive injury were a minor fall or no mechanism for 33 (84%) of 39 patients. All unintentional injuries resulted from a motor vehicle accident or other documented major trauma. Chronic or mixed acute and chronic SDH were found only in abused children (17 [44%] of 39) and in children whose injuries were indeterminate (8 [67%] of 12), not in children who were unintentionally injured (0 [0%] of 15). Long bone and/or rib fractures were found in 20 (51%) of 39 abused children but in only 1 unintentionally injured child. Retinal bleeding was present in 28 (72%) of 39 of the abused children. Only 1 of the 3 unintentionally injured children who had a retinal examination had bleeding, which was of the type associated with acute increased intracranial pressure.

CONCLUSIONS

Nearly one fifth of infant and toddler SDH resulted from unintentional trauma. Of those without obvious unintentional trauma, 76% were corroborated to have been abused. Abused children were younger, more likely to have chronic SDH, and more likely to have multiple associated injuries. Their injury history usually was minor or absent.

Relationship between trauma center volume and outcomes

CONTEXT

The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown.

OBJECTIVE

To evaluate the association between trauma center volume and outcomes of trauma patients.

DESIGN

Retrospective cohort study.

SETTING

Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystem Consortium Trauma Benchmarking Study.

PATIENTS

Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998.

MAIN OUTCOME MEASURES

Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (</=650 admissions/y) centers.

RESULTS

After multivariate adjustment for patient characteristics and injury severity, the relative odds of death was 0.02 (95% confidence interval [CI], 0.002-0.25) for patients with PAI admitted with shock to high-volume centers compared with low-volume centers. No benefit was evident in patients without shock (P =.50). The adjusted odds of death in patients with multisystem blunt trauma who presented with coma to a high-volume center was 0.49 (95% CI, 0.26-0.93) vs low-volume centers. No benefit was observed in patients without coma (P =.05). Additionally, a shorter LOS was observed in patients with PAI and New Injury Severity Scores of 16 or higher (difference in adjusted mean LOS, 1.6 days [95% CI, -1.5 to 4.7 days]) and in all patients with multisystem blunt trauma admitted to higher-volume centers (difference in adjusted mean LOS, 3.3 days [95% CI, 0.91-5.70 days]).

CONCLUSIONS

Our results indicate that a strong association exists between trauma center volume and outcomes, with significant improvements in mortality and LOS when volume exceeds 650 cases per year. These benefits are only evident in patients at high risk for adverse outcomes.

The role of the pediatrician in the oral health of children: A national survey

OBJECTIVES

To assess pediatricians' knowledge, attitudes, and professional experience regarding oral health, and to determine willingness to incorporate fluoride varnish into their practices.

BACKGROUND

Poor and minority children suffer disproportionately from dental caries and have limited access to dental care. In a recent analysis of national survey data, the General Accounting Office reported that poor children had 5 times more untreated decay than did children from higher income families. Untreated decay can lead to problems with eating, speaking, and attending to learning. Children who are poor suffer 12 times the number of restricted activity days because of dental problems, compared with more affluent children. Despite higher rates of dental decay, poor children had one half the number of dental visits compared with higher income children in 1996. Medicaid's Early Periodic Screening Diagnosis and Treatment (EPSDT) program is intended to provide regular dental screenings and appropriate treatment but has apparently played a limited role in improving access to dental care for poor children. According to a report by the Office of the Inspector General of the Department of Health and Human Services, only 20% of children under 21 years of age, who were enrolled in Medicaid and eligible for EPSDT, actually received preventive dental services. By increasing their involvement in oral health prevention during well-child care visits, pediatricians may be able to play an important role in improving the dental health of their patients who have difficulty obtaining access to professional dental care. However, it is unclear to what degree pediatricians are knowledgeable about preventive oral health and the extent to which they may already be participating in prevention and assessment. Also, little is known about the incidence of dental problems in pediatric practice, and whether pediatricians perceive barriers to their patients' receiving professional dental care. Finally, it is important to know how pediatricians value the promotion of oral health and whether they would be willing to take on additional activities aimed at its improvement. We addressed these questions in a national survey of pediatricians.

DESIGN

We surveyed a national sample of 1600 pediatricians randomly selected from the American Medical Association Master File to assess their knowledge, current practice, and opinion on their role in the promotion of oral health; experience with dental decay among patients and in referring patients for professional dental care; and willingness to apply fluoride varnish.

RESULTS

Of 1386 eligible survey recipients, 862 returned surveys for a response rate of 62%. Respondents reported seeing dental problems regularly. Two thirds of respondents observed caries in their school-aged patients at least once a month. Of the respondents, 55% reported difficulty achieving successful dental referrals for their uninsured patients and 38% reported difficulty referring their Medicaid patients. More than 90% of the respondents agreed that they had an important role in identifying dental problems and counseling families on the prevention of caries. Moreover, respondents were interested in increasing their involvement: 74% expressed a willingness to apply fluoride varnish in their practices. One half of the respondents, however, reported no previous training in dental health issues during medical school or residency, and only 9% correctly answered all 4 knowledge questions.

CONCLUSION

Access to dental care and unmet dental health needs are serious, under addressed problems for poor and minority children in the United States. In promoting preventive oral health, pediatricians benefit all children and particularly the underserved. We know of 2 states, Washington and North Carolina, that have acknowledged, through the provision of reimbursement, that pediatricians have a unique opportunity at well-child care visits to provide caries prevention c

Asthma and bronchiolitis hospitalizations among American Indian children

OBJECTIVE

To compare asthma and bronchiolitis hospitalization rates in American Indian and Alaskan native (AI/AN) children and all children in Washington State.

METHODS

A retrospective data analysis using Washington State hospitalization data for 1987 through 1996. Patients were included if asthma or bronchiolitis was the first-listed diagnosis. American Indian and Alaskan native children were identified by linking state hospitalization data with Indian Health Service enrollment data.

RESULTS

Similar rates of asthma hospitalization were found for AI/AN children older than 1 year compared with all children. In AI/AN children younger than 1 year, hospitalization rates for asthma (528 per 100,000 population; 95% confidence interval [CI], 346-761) and bronchiolitis (2954 per 100,000 population; 95% CI, 2501-3456) were 2 to 3 times higher than the rates in all children (232 per 100,000 population [95% CI, 215-251] and 1190 per 100,000 population [95% CI, 1149-1232], respectively). Hospitalization rates for asthma and bronchiolitis increased 50% between 1987 and 1996 for all children younger than 1 year and almost doubled for AI/AN children younger than 1 year.

CONCLUSIONS

American Indian and Alaskan native children have significantly higher rates of hospitalization for wheezing illnesses during the first year of life compared with children of other age groups and races. Furthermore, the disparities in rates have increased significantly over time. Future public health measures directed at managing asthma and bronchiolitis should target AI/AN infants.

Firearm safety counseling in primary care pediatrics: a randomized, controlled trial

CONTEXT

Physicians have been encouraged to counsel families about risks associated with gun ownership, but the effectiveness of physician counseling regarding gun safety is unknown.

OBJECTIVE

To determine the effectiveness of gun safety counseling during well-child care visits.

DESIGN

Group randomized, controlled trial. Physicians, nurse practitioners, and physician assistants were randomized to either the intervention group or a control group.

SETTING

Group Health Cooperative, a staff-model health maintenance organization. Patients. Consecutive sample of families (n = 1295) seen for a scheduled appointment for well-child care for a child <18 years of age. Of the families originally scheduled for a visit, 80. 3% were seen and completed the outcomes surveys.

INTERVENTION

Each family in the intervention group was given a 60-second message by their practitioner that depended on the presence of guns in the home. Families without guns were informed of the health risks associated with gun ownership and given a standard information pamphlet. Families with guns were given the same information about risks and were told that if they chose to keep a gun, they should store it locked and unloaded. They were given instructions on storage and a folder with material, including the same pamphlet, a letter from the police department, written storage guidelines, and discount coupons for gun storage devices.

MAIN OUTCOME MEASURE

Changes in the following self-reported events: 1) acquisition of a safe storage device; 2) removal of firearms from the home; and 3) acquisition of firearms. Results. There were no important differences between intervention and control groups in the rate of acquisition of new guns (intervention: 1.3% vs control:.9%) after the intervention. Among households with guns at baseline, there were also no differences between groups in the removal of guns (intervention: 6.7% vs control: 5.7%), but there was a fairly large nonsignificant difference in the proportion who purchased trigger locks (intervention: 8.0% vs control: 2.5%).

CONCLUSIONS

A single firearm safety-counseling session during well-child care, combined with economic incentives to purchase safe storage devices, did not lead to changes in household gun ownership and did not lead to statistically significant overall changes in storage patterns.

Effectiveness of automatic shoulder belt systems in motor vehicle crashes

CONTEXT

Approximately 10 million cars with automatic shoulder belt systems are currently in use in the United States. However, reports on the effectiveness of such restraints have yielded conflicting results.

OBJECTIVE

To determine the effectiveness of automatic shoulder belt systems in reducing the risk of injury and death among front-seat passenger vehicle occupants.

DESIGN, SETTING, AND SUBJECTS

Analysis of data collected from the 1993-1996 National Highway Traffic Safety Administration Crashworthiness Data System on front-seat occupants involved in 25,811 tow-away crashes of passenger cars, light trucks, vans, and sport utility vehicles.

MAIN OUTCOME MEASURES

Death and serious injury to specific body areas by use of manual lap and shoulder belts, automatic shoulder belts with manual lap belts, or automatic shoulder belts without lap belts, compared with no restraint use.

RESULTS

Use of automatic shoulder belts without lap belts was associated with a decrease in the risk of death vs no restraint use but was not statistically significant for all crashes (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.42-1.06) or for frontal crashes (OR, 0.71; 95% CI, 0.38-1.35) after adjustment for occupant age, sex, vehicle year, air-bag deployment, estimated change in vehicle speed during the crash, and principal direction of force. This association was significantly weaker than the 86% lower risk observed for use of automatic shoulder belts with lap belts (OR, 0.14; 95% CI, 0.07-0.26 vs no restraint; P<.05). Use of automatic shoulder belts without lap belts was associated with an increased risk of serious chest (OR, 2.66; 95% CI, 1.11-6.35) and abdominal (OR, 2.06; 95% CI, 1.004-4.22) injuries for all crashes.

CONCLUSIONS

These data indicate that improperly used automatic restraint systems may be less effective than properly used systems and are associated with an increased risk of serious chest and abdominal injuries. Given the continued widespread use of these automatic systems, educational programs may be warranted. JAMA. 2000;283:2826-2828

High-risk periods for childhood injury among siblings

OBJECTIVE

To determine whether the risk of unintentional injury requiring emergency department (ED) or inpatient care in children is transiently increased over a 90-day period after injury to a sibling.

DESIGN

Retrospective cohort.

SETTING

King County, Washington. Participants. A total of 41 242 children 0 to 15 years of age continuously enrolled in Medicaid and living in King County during the period October 1, 1992 through September 30, 1993 (27 450 child-years).

OUTCOME MEASURES

The outcome was an unintentional injury treated in the ED or inpatient setting. Incidence rates and hazard ratios were calculated for children whose sibling had been injured in the previous 90 days, compared with children without such exposure. Multivariate analysis was used to adjust for age, gender, race, sibling group size, and noninjury ED use.

RESULTS

. There were 4921 injuries treated only in the ED and 82 hospital admissions. The incidence of ED treated injury was 305 per 1000 child-years among children whose sibling had been injured in the previous 90 days and 174 per 1000 child-years among children without this exposure (relative risk: 1.75; 95% confidence interval: 1.56-1.95). The incidence of injury-related hospitalization was 1.7 per 1000 child-years among children whose sibling had been injured in the previous 90 days, compared with 3.0 per 1000 child-years among children without this exposure (relative risk:.57; 95% confidence interval:.07-2.12). Injury risk peaked in the period 4 to 10 days after a sibling's injury and returned toward, but did not attain, baseline risk over the subsequent 21/2 months. The magnitude of this effect depended on the child's age; the relative risk of injury was higher among older children.

CONCLUSIONS

Injuries treated in the ED or inpatient setting appear to cluster within sibling groups over brief periods of time. Shared social or environmental exposures may contribute to this clustering and may be amenable to targeted, time-limited prevention interventions.

The history of injury control and the epidemiology of child and adolescent injuries

Unintentional injuries claim the lives of more children each year than any other cause of death. A substantial proportion of child hospitalizations and emergency department visits also are attributable to unintentional injuries. The conceptualization of unintentional injuries as a public health problem that is preventable has gained credibility over the past few decades, as effective solutions to reduce the burden of injuries--such as child safety seats, bicycle helmets, and smoke detectors--have been identified. Successful implementation of these strategies requires a clear understanding of the circumstances surrounding injuries and the risk and protective factors that influence the likelihood that a child will be injured. Although adequate data on these factors is available for some causes of injury, such as motor vehicle crashes, it is almost nonexistent for others, such as unintentional firearm injuries. Overall, unintentional injury rates are highest among adolescents ages 15 to 19, males, children from impoverished families, and minorities. Also, some injuries occur more often in rural areas. Although these demographic risk factors cannot be modified, environmental and behavioral risks, such as unsafe roads, alcohol intoxication, unfenced swimming pools, and the absence of a smoke detector in the home, can be modified successfully with appropriate strategies. Motor vehicle occupant, drowning, and pedestrian injuries were the most common unintentional injuries causing death among children ages 0 to 19 in 1996. Together, these mechanisms accounted for more than half of all unintentional injury deaths among children and adolescents, although rates varied considerably by age. Child injury death rates across most age categories and mechanisms of injury have declined during the past 20 years, yet the reasons for these declines are poorly understood. Additional research about risk and protective factors, and efforts to implement successful injury prevention strategies among populations at highest risk for injuries, are necessary to further reduce the toll on children's lives.

A political history of the Indian Health Service

One of the few bright spots to emerge from the history of relations between American Indians and the federal government is the remarkable record of the Indian Health Service (IHS). The IHS has raised the health status of Indians to approximate that of most other Americans, a striking achievement in the light of the poverty and stark living conditions experienced by this population. The gains occurred in spite of chronically low funding and can be attributed to the combination of vision, stubbornness, and political savvy of the agency's physician directors and the support of a handful of tribal leaders and powerful allies in the Congress and the White House. Despite the agency's imperfections and the sizeable health problems that still exist among American Indians and Alaskan Natives, the IHS is an example of one federal program that has worked.

Stapled versus sutured gastrointestinal anastomoses in the trauma patient

BACKGROUND

Construction of gastrointestinal anastomoses by using stapling devices has become a familiar procedure. Most studies have shown no significant differences in complication rates between stapled and sutured anastomoses performed during elective surgery. To date, no study has evaluated the incidence of complications of stapled anastomoses in the trauma patient. The purpose of our study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses after the emergent repair of traumatic bowel injuries.

METHODS

A retrospective analysis of the medical and institutional trauma registry records of patients identified to have undergone a gastrointestinal anastomosis in a regional Level I trauma center over a 4-year period.

RESULTS

A total of 84 patients with 118 gastrointestinal anastomoses were identified. A surgical stapling device was used to create 58 separate anastomoses, whereas a hand-sutured method was used in 60 anastomoses. A complication was defined as an anastomotic leak verified at reoperation. The ratio of blunt versus penetrating injuries, mean abdominal Abbreviated Injury Scale score, and Injury Severity Score were similar in the two groups. Stapling and suturing techniques were evenly distributed between small and large bowel repairs. Mean intensive care unit length of stay was comparable in both cohorts. However, inpatient length of stay was longer in patients with solely a stapled anastomosis compared with sutured anastomoses. Four of the 58 stapled anastomoses and none of the 60 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (relative risk = undefined; 95% confidence interval, 1.14-infinity; p = 0.037). Each anastomotic leak occurred in a separate individual. The only death occurred in the stapled cohort secondary to peritonitis and subsequent sepsis.

CONCLUSION

Anastomotic leaks seem to be associated with stapled bowel repairs compared with sutured anastomoses in the traumatically injured patient.

Self-inflicted and unintentional firearm injuries among children and adolescents: the source of the firearm

CONTEXT

The source and ownership of guns used by children to shoot themselves or others is largely unknown.

OBJECTIVE

To determine the ownership and usual storage location of firearms used in unintentional and self-inflicted intentional firearm deaths and injuries.

DESIGN

Retrospective case series.

SETTING

King County, Washington.

PATIENTS

Youths aged from birth to 19 years who sought medical treatment at a level I trauma center for a self-inflicted or unintentional firearm injury between 1990 and 1995 or who presented to the county medical examiner with a fatal self-inflicted or unintentional firearm injury between 1990 and 1995.

DATA SOURCES

County medical examiner records, regional police investigative reports, medical records from a level I trauma center, and surveys of victims' families.

MAIN OUTCOME MEASURES

Source and ownership of the associated firearm.

RESULTS

Fifty-six fatal injuries and 68 nonfatal firearm injuries that met the criteria were identified. Of these, 59 were intentionally self-inflicted deaths and injuries and 65 were unintentional deaths and injuries. A firearm owned by a household member living with the victim was used in 33 (65%) of 51 suicides and suicide attempts and 11 (23%) of 47 unintentional injuries and deaths. Additionally, a firearm owned by another relative, friend, or parent of a friend of the victim was used in 4 (8%) of the 51 suicides and suicide attempts and 23 (49%) of the 47 unintentional injuries and deaths. Parental ownership accounted for 29 (57%) of the 51 suicides and suicide attempts and 9 (19%) of the 47 unintentional injuries and deaths. More than 75% of the guns used in suicide attempts and unintentional injuries were stored in the residence of the victim, a relative, or a friend.

CONCLUSION

Most guns involved in self-inflicted and unintentional firearm injuries originate either from the victim's home or the home of a friend or relative.

Hospitalization for motor vehicle injuries among American Indians and Alaska Natives in Washington

OBJECTIVE

Little is known about the epidemiology of hospitalization for motor vehicle injury among American Indians and Alaska Natives (AI/ANs) in the Pacific Northwest. Current secondary data sources are inadequate to track this significant health problem. The purpose of this study was to determine the rate of hospitalization for motor vehicle injury in this population through linkage of Indian Health Service (IHS) patient registration data to a statewide hospital discharge database.

METHODS

To create the numerator, IHS patient registration data were linked to Washington State hospital discharge abstracts from 1990 to 1994 for motor vehicle injury (ICD-9 E-codes 810-819). The denominator for this population was derived from the total number of IHS enrollees in 1992. Comparative numerator and denominator data for all residents were derived from the discharge database and Washington State intercensal population estimates, respectively.

RESULTS

AI/ANs experienced a nearly two-fold higher rate of motor vehicle injury hospitalization (N = 588) compared to all residents [Incidence Ratio (I.R.): 1.82; 95% C.I. 1.52-2.19]. The greatest disparity in incidence rates occurred among 25-34 year olds (I.R. 2.18; 95% C.I. 1.53-3.10) and 35-44 year olds (I.R. 2.18; 95% C.I. 1.36-3.47). In-hospital mortality, severity of injury and length of stay were not different between the 2 groups. Median charges for American Indian hospitalizations were $6188 and the IHS was payer in, at most, 24% of hospitalizations.

CONCLUSIONS

AI/ANs are at higher risk of hospitalization for motor vehicle injuries but, compared to all residents of Washington, appear to have similar severity of injuries and outcomes. Motor vehicle injury hospitalization among AI/ANs incurs substantial health care costs.

Hospitalizations for injury among American Indian youth in Washington

OBJECTIVE

To determine the rate and causes of hospitalization for injury among American Indian and Alaska Native (AI/AN) youth in Washington compared with youth of all races.

METHODS

Subjects were aged 0 to 19 years and were admitted to civilian hospitals for care of an injury (International Classification of Diseases N codes 800-995) in Washington between 1990 and 1994. Deaths occurring in the pre-hospital setting and emergency department were not included. Using several fields of identifying information, the Washington state hospital discharge database was linked with the Indian Health Service (IHS) patient registration database to identify AI/AN youth. Denominator data included the total age-specific IHS user population for American Indians and population estimates derived from the US Census. Incidence ratios (IRs) were calculated to compare rates of hospitalization between AI/AN youth and all youth in Washington.

RESULTS

A total of 694 hospitalizations for injury were identified for AI/AN youth and 29,048 were identified for all races. The rate of hospitalization for injuries among AI/AN youth was 507 discharges per 100,000 youth (IR = 1.30; 95% confidence interval [CI] 1.20 to 1.40). The leading mechanism of injury was motor vehicles (IR 1.73, 95% CI 1.49 to 2.01), which was followed by falls (IR 0.95, 95% CI 0.79 to 1.15) and poisonings (IR 1.20, 95% CI 0.80 to 1.78). The disparity was greater for intentional injuries (IR 1.71, 95% CI 1.44 to 2.04). The highest IR for all unintentional injuries was for injuries from fire (IR 2.35, 95% CI 1.42 to 3.87). AI/AN children aged 15 to 19 had the greatest disparity for rates of injury hospitalization (IR 1.4, 95% CI 1.25 to 1.56).

CONCLUSION

AI/AN youth in Washington had a higher rate of hospitalization for injury compared with all youth in the state. Disparities were greatest for injuries related to motor vehicles and assaults. When linked, hospital discharge data can be used for surveillance of AI/AN hospitalizations.

Injury hospitalizations among American Indian youth in Washington

OBJECTIVE

To determine the rate and causes of hospitalizations for injury among American Indian and Alaska Native (AI/AN) youth in the state of Washington, and to compare this with the rate of hospitalizations for injury among youth of all races.

METHODS

Subjects were aged 0-19 years and were admitted to civilian hospitals for care of an injury (International Classification of Diseases N codes 800-995) in Washington between 1990 and 1994. Deaths occurring in the prehospital setting and emergency department are not included. Using several fields of identifying information, the Washington state hospital discharge database was linked with the Indian Health Service (IHS) patient registration database to identify AI/AN youth. Denominator data included the total age specific IHS user population for American Indians and US Census derived population estimates. Incidence ratios (IRs) were calculated to compare rates of hospitalization between AI/AN youth and all youth in Washington.

RESULTS

A total of 694 and 29,048 hospitalizations for injury were identified for AI/AN youth and all races, respectively. The rate of hospitalization for injuries among AI/AN youth was 507 discharges per 100,000 youth (IR = 1.30; 95% confidence interval (CI) 1.20 to 1.40. The leading mechanism of injury was motor vehicles (IR 1.73, CI 1.49 to 2.01), followed by falls (IR 0.95, CI 0.79 to 1.15), and poisoning (IR 1.20, CI 0.80 to 1.78). The disparity was greater for intentional injuries (IR 1.71, CI 1.44 to 2.04). The highest IR for all unintentional injuries was for injuries from fire (IR 2.35, CI 1.42 to 3.87). AI/AN children aged 15-19 had the greatest disparity for rates of injury hospitalization (IR 1.4, CI 1.25 to 1.56).

CONCLUSION

AI/AN youth in Washington had a higher hospitalization rate for injury compared with all youth in the state. Disparities were greatest for injuries related to motor vehicles and assaults. When linked, hospital discharge data can be used for surveillance of AI/AN hospitalizations.

Asthma prevalence among American Indian and Alaska Native children

OBJECTIVES

Although asthma is the most common chronic childhood illness in the United States, little is known about its prevalence among American Indian and Alaska Native (AI/AN) children. The authors used the latest available household survey data to estimate the prevalence of asthma in this population.

METHODS

The authors analyzed data for children ages 1 through 17 years from the 1987 Survey of American Indians and Alaska Natives (SAIAN) and the 1987 National Medical Expenditure Survey (NMES). At least one member of each AI/AN household included in the SAIAN was eligible for services through the Indian Health Service.

RESULTS

The weighted prevalence of parent-reported asthma was 7.06% among 2288 AI/AN children ages 1-17 (95% CI 5.08, 9.04), compared with a US estimate of 8.40% for children ages 1-17 based on the 1987 NMES (95% CI 7.65, 9.15). The AI/AN sample was too small to yield stable estimates for a comparison between AI/AN children and all US children when the data were stratified according to household income and metropolitan vs non-metropolitan residence. The unadjusted asthma prevalence rates were similar for AI/AN children and for children in the NMES sample.

CONCLUSIONS

In 1987, the prevalence of parent-reported asthma was similar for AI/AN children in the SAIAN sample and for children in the NMES sample. More recent data are needed to better understand the current prevalence of asthma among AI/AN children.

Effectiveness of health promotion programs to increase motor vehicle occupant restraint use among young children

OBJECTIVE

To review the effectiveness of nonlegislative community and clinical programs to increase the rate of child motor vehicle occupant restraint use among children under the age of 5 years.

METHOD

This was a systematic review of the world's published literature. The Cochrane Collaboration protocol was used to conduct the literature search. The following databases were searched for literature on this topic: MEDLINE, EMBASE, NTIS, PsychINFO, ERIC, Nursing and Allied Health, Transportation Research and Information Service, and EI Compendex. The bibliographies of relevant publications were used to search for additional references.

SELECTION CRITERIA

Studies were included if they evaluated a clinical or community-based intervention designed to increase the use child restraint devices among motor vehicle passengers under the age of 5 years. Studies of the effects of legislation or law enforcement programs were excluded. All study design types, including randomized controlled trials, controlled trials, and controlled or uncontrolled pre/post evaluations, were included. Studies were excluded if there was either no control group or no baseline data with which to compare outcome data. Studies were also excluded if they did not use observed restraint use as at least one of the outcome measures.

DATA COLLECTION

Each study was reviewed in depth with special attention to the strength of study design. Outcomes were assessed in terms of the absolute difference in observed restraint use within and/or between groups across study intervals.

RESULTS

A total of 18 studies met inclusion criteria for in-depth review. Pooling of results was not possible because of the large differences between studies with regard to study design, settings, target groups, intervention methods, and units of analysis. There were a total of three randomized controlled trials, four controlled trials without random individual or group assignment, three controlled pre-post evaluations, and eight uncontrolled pre/post studies. Among preschool programs, short-term absolute percentage point gains in seat belt use rates ranged from 12% to 52% but only from 8% to 14% one month or more after the intervention. Among community-based media campaigns, long-term child restraint use increased by an absolute margin of 5% to 14%. Of the eleven peri-partum counseling programs, long-term follow-up revealed gains of 6% to 27% with most between 10% to 15%. Many studies had serious design flaws that could overestimate the magnitude of the effect.

CONCLUSIONS

Programs to increase the rate of child restraint use among child occupants of motor vehicles appear to have overall moderate short-term effectiveness. The magnitude of the positive program effects one or more months after the intervention appear to diminish substantially. There is a strong need for high quality randomized controlled trials to determine the long-term effectiveness of child restraint promotion programs.

Handgun purchase trends, Washington state: differences by age of buyer

STUDY OBJECTIVES

To examine trends in legal handgun purchases from federally licensed dealers and specifically to describe recent changes in age and gender of purchaser and caliber of handguns purchased.

METHODS

A cohort study was performed of the adult population of Washington state from 1950 through 1992 using a state dealer record of handgun sales database. The purchase of handguns from licensed dealers was expressed as the number purchased per 100,000 population per year.

RESULTS

The handgun purchase rate increased for the total population between 1950 and 1992, from 169 to 2,076 per 100,000 persons. Between 1983 and 1992, the purchase rate among men aged 21 to 24 years increased 184%; among women of this age group, the rate increased 127%. Among men aged 21 to 24 years, the rate of 9 mm handgun purchases increased 1,682% between 1983 and 1992, the greatest increase for any age-caliber category.

CONCLUSION

The greatest increase in rate of legal handgun purchases in Washington state from 1983 through 1992 was among the youngest purchasers. Sales of 9 mm handguns increased most rapidly, especially among the youngest buyers.

State gun safe storage laws and child mortality due to firearms

CONTEXT

Since 1989, several states have passed laws that make gun owners criminally liable if someone is injured because a child gains unsupervised access to a gun. These laws are controversial, and their effect on firearm-related injuries is unknown.

OBJECTIVE

To determine if state laws that require safe storage of firearms are associated with a reduction in child mortality due to firearms.

DESIGN

An ecological study of firearm mortality from 1979 through 1994.

SETTING

All 50 states and the District of Columbia.

PARTICIPANTS

All children younger than 15 years.

MAIN OUTCOME MEASURES

Unintentional deaths, suicides, and homicides due to firearms.

RESULTS

Laws that make gun owners responsible for storing firearms in a manner that makes them inaccessible to children were in effect for at least 1 year in 12 states from 1990 through 1994. Among children younger than 15 years, unintentional shooting deaths were reduced by 23% (95% confidence interval, 6%-37%) during the years covered by these laws. This estimate was based on within-state comparisons adjusted for national trends in unintentional firearm-related mortality. Gun-related homicide and suicide showed modest declines, but these were not statistically significant.

CONCLUSIONS

State safe storage laws intended to make firearms less accessible to children appear to prevent unintentional shooting deaths among children younger than 15 years.

The association between the purchase of a handgun and homicide or suicide

OBJECTIVES

The purpose of this study was to determine whether purchase of a handgun from a licensed dealer is associated with the risk of homicide or suicide and whether any association varies in relation to time since purchase.

METHODS

A case-control study was done among the members of a large health maintenance organization. Case subjects were the 353 suicide victims and 117 homicide victims among the members from 1980 through 1992. Five control subjects were matched to each case subject on age, sex, and zip code of residence. Handgun purchase information was obtained from the Department of Licensing.

RESULTS

The adjusted relative risk of suicide was 1.9 (95% confidence interval [CI] = 1.4, 2.5) for persons with a history of family handgun purchase from a registered dealer. The adjusted relative risk for homicide, given a history of family handgun purchase, was 2.2 (95% CI = 1.3, 3.7). For both suicide and homicide, the elevated relative risks persisted for more than 5 years after the purchase.

CONCLUSIONS

Legal purchase of a handgun appears to be associated with a long-lasting increased risk of violent death.

Effectiveness of a violence prevention curriculum among children in elementary school. A randomized controlled trial

OBJECTIVE

To determine if a commonly used violence prevention curriculum, Second Step: A Violence Prevention Curriculum, leads to a reduction in aggressive behavior and an increase in prosocial behavior among elementary school students.

DESIGN

Randomized controlled trial.

SETTING

Urban and suburban elementary schools in the state of Washington.

PARTICIPANTS

Six matched pairs of schools with 790 second-grade and third-grade students. The students were 53% male and 79% white.

INTERVENTION

The curriculum uses 30 specific lessons to teach social skills related to anger management, impulse control, and empathy.

MAIN OUTCOME MEASURES

Aggressive and prosocial behavior changes were measured 2 weeks and 6 months after participation in the curriculum by parent and teacher reports (Achenbach Child Behavior Checklist and Teacher Report Form, the School Social Behavior Scale, and the Parent-Child Rating Scale) and by observation of a random subsample of 588 students in the classroom and playground/cafeteria settings.

RESULTS

After adjusting for sex, age, socioeconomic status, race, academic performance, household size, and class size, change scores did not differ significantly between the intervention and control schools for any of the parent-reported or teacher-reported behavior scales. However, the behavior observations did reveal an overall decrease 2 weeks after the curriculum in physical aggression (P=.03) and an increase in neutral/prosocial behavior (P=.04) in the intervention group compared with the control group. Most effects persisted 6 months later.

CONCLUSIONS

The Second Step violence prevention curriculum appears to lead to a moderate observed decrease in physically aggressive behavior and an increase in neutral and prosocial behavior in school.

Motor-vehicle crash-injury risk factors among American Indians

The rates of motor-vehicle crash mortality are highest among American Indians and Alaska Natives, compared to other ethnic groups. The aim of this study was to compare risk factors for motor-vehicle crashes and occupant injuries between rural and urban American-Indian (AI) drivers, and between rural AI and non-AI rural drivers. A statewide traffic-accident database was linked to the Indian Health Service patient-registration database to identify crashes that involved American-Indian drivers. Using a cross-sectional design, crashes occurring in a two-county region during 1989 and 1990 were studied. A total of 9329 motor-vehicle crashes involving 16,234 drivers and 6431 passengers were studied. Two percent of drivers were American Indian. Compared to American-Indian drivers in urban crashes, rural crashes involving American-Indian drivers were more likely to result in injury or death (38% vs 64% p < 0.001). The difference in risk for crashes between urban and rural non-AI drivers was not as high (42% vs 33%). Only 44 percent of rural American-Indian motor-vehicle occupants reported wearing seat belts, compared to 70 percent of urban American-Indian occupants (p < 0.05). Rates of driver alcohol impairment, as assessed by the police, were much higher among AI drivers and highest among rural AI drivers. We conclude that, compared to non-American-Indian drivers, AI drivers are less likely to be restrained and more likely to be alcohol-impaired at the time of the crash. These risks are higher among rural AI drivers than urban AI drivers.

Urban-rural differences in prehospital care of major trauma

OBJECTIVES

To compare differences in response times, scene times, and transport times by advanced life-support-trained paramedics to trauma incidents in urban and rural locations.

METHODS

This report was a prospective cohort study of professional emergency medical services conducted in a five-county area in the state of Washington. Ninety-eight percent of trauma transports are provided by professional paramedics trained in advanced life support. Subjects were included in this study if they qualified as a major trauma victim and were transported or found dead at the scene by one of the region's advanced life support transport agencies between August 1, 1991, and January 31, 1992. The severity of injury was rated using the Prehospital Index. Incident locations were defined as "rural" if they occurred in a US Census division (a geographic area) in which more than 50% of the residents resided in a rural location.

RESULTS

During the 6-month data collection period, advanced life support agencies responded to a total of 459 major trauma victims in the region. A geographic locations was determined for 452 of these subjects. Of these, 42% of subjects were injured in urban areas and the remainder in rural areas. The severity of injuries, as determined both by the triage classification (p = 0.17) and the distribution of Prehospital Index scores (p = 0.92), was similar for urban and rural major trauma patients. Twenty-six (5.7%) subjects died at the scene. About one quarter of both groups had a severe injury, as indicated by Prehospital Index score of more than 3. The mean response time for urban locations was 7.0 minutes (median = 6 minutes) compared with 13.6 minutes (median = 12 minutes) for rural locations (p < 0.0001). The mean scene time in rural areas was slightly longer than in urban areas (21.7 vs. 18.7 minutes, p = 0.015). Mean transport times from the scene to the hospital were also significantly longer for rural incidents (17.2 minutes vs. 8.2 minutes, p < 0.0001). Rural victims were over seven times more likely to die before arrival (relative risk = 7.4, 95% confidence interval 2.4-22.8) if the emergency medical services' response time was more than 30 minutes.

CONCLUSIONS

Response and transport times among professional, advanced life-support-trained paramedics responding to major trauma incidents are longer in rural areas, compared with urban areas.

Hospital services for rural children in Washington State

OBJECTIVE

To examine the current delivery of inpatient hospital services to a statewide population of rural children, define the types of pediatric conditions currently treated in rural hospitals or transferred to urban centers, and explore the role of rural pediatricians and family practitioners in the care of children in rural hospitals.

DESIGN

Retrospective review of statewide hospital discharge data.

SUBJECTS

All patients younger than 18 years of age with nonsurgical diagnoses discharged from both urban and rural civilian hospitals in Washington State during 1989 and 1990.

RESULTS

Of 69690 pediatric hospital discharges during the study period, 16% were rural residents and 10% were from rural hospitals. Rural hospitals cared for 59% of hospitalized rural children. Marked differences were found between urban and rural hospitals in the diagnoses treated; more than two-thirds of all discharges for chemotherapy, psychiatric disorders, and neonates with multiple major problems were from urban hospitals; but the majority of the discharges for gastrointestinal diagnoses, respiratory conditions, or minor problems in the neonatal period were from rural hospitals. Rural hospitals with staff pediatricians had higher annual pediatric discharges, total charges, lengths of stay, and case mix with a higher proportion of neonates with complications, compared to hospitals without pediatricians. However, there was no evidence that these hospitals served as local referral centers for rural pediatric inpatients; the proportion of patients from outside the local hospital catchment areas was similar for rural hospitals with staff pediatricians and for those without. In rural hospitals, pediatricians and family practitioners were listed as the attending physician for 37% and 49% of discharges, respectively. The average rural pediatrician cared for five times as many inpatients as a rural family practitioner. Pediatricians cared for significantly more neonates with birth weights of less than 2500 grams, but otherwise had a similar case mix among inpatient discharges as rural family practitioners.

CONCLUSIONS

Most rural children in Washington who require hospitalization for common problems receive their care in local rural hospitals staffed with pediatricians and family practitioners, although those with illnesses requiring a high level of specialty care are predominantly cared for in urban centers. Rural pediatricians make a substantial contribution to the care of rural children, especially in the area of neonatal care, although their presence in rural hospitals does not in itself create local referral centers. Inpatient volumes are higher for pediatricians, but their case mix is similar to that of rural family practitioners, except in the area of neonatology. These data support the recommendations that family practitioners contemplating rural practice receive training in general inpatient pediatrics (regardless of whether they are going to a site with pediatricians) and that pediatricians in rural practice be trained for a high volume of inpatient cases, including problems of low birth weight infants. Because systems of hospital care for rural children depend on regionalized programs, clinical and educational linkages between urban centers and rural providers should be developed and supported.

Health care utilization as a marker for suicidal behavior on an American Indian Reservation

OBJECTIVE

Overall suicide mortality rates are higher among American Indians than in the general population and are particularly high among Indians residing in the upper Midwest. The identification, during encounters with health care providers, of individuals at high risk of suicide is a potential intervention strategy. The purpose of this study was to examine whether increased health care utilization and symptom patterns were associated with suicide and suicide attempts among American Indian patients in an Indian Health Service facility.

DESIGN

A case-control study design was used.

SETTING/PATIENTS

Cases of completed suicides over a 6-year period and cases of suicide attempts over a 15-month period were identified on a Plains Indian Reservation. The pattern of utilization of health services by these subjects prior to their suicide or attempt was compared with that of control subjects matched for age and gender.

MAIN RESULTS

Only 24% of subjects who died of suicide used the reservation clinic or hospital for services in the 6 months prior to their suicide, compared with 54% of controls (odds ratio [OR] 0.28; 95% confidence interval [CI], 0.09, 0.87). The patterns of symptom complaints and diagnoses for these visits did not differ significantly between case and control subjects. Case subjects who attempted suicide were more likely to be seen during the 6 months prior to their attempt than control subjects (57% vs 40%, OR 1.72; 95% CI 0.75, 3.93). Persons who attempted suicide were more likely to have documentation of psychological and interpersonal problems than were control subjects. Only 14% of subjects completing suicide had a previous history of suicide attempts.

CONCLUSIONS

In this region, American Indians who committed suicide were less likely to use clinical services provided by the Indian Health Service prior to their death. However, there was a relatively strong association between suicide attempts and the prior use of health services, particularly the use of mental health services. In this American Indian population, clinic-based methods for early detection and intervention to prevent imminent suicide would reach fewer than one fourth of suicide victims. Further research is needed to identify the usefulness of community outreach efforts to identify and intervene among individuals at high risk of death by suicide.

Safe storage of handguns. What do the police recommend?

OBJECTIVE

To ascertain the specific suggestions that local police departments in the United States give to parents who ask for advice about methods to safely store handguns.

METHODS

A cross-sectional, semistructured telephone survey was administered to a sample of 102 police departments in the United States in cities with populations of 10,000 or more, selected within blocks of cities of similar population size. An investigator, posing as a parent of 3-year-old and 10-year-old children, called departments seeking specific advice on how to safely store a handgun acquired for protection.

RESULTS

Usable responses were generated for 93 (91%) of the departments sampled. Only 3 departments (3.2%) refused to give advice over the telephone. The most commonly suggested storage methods were trigger locks (55 departments [59%]), portable lockboxes for handguns (48 [52%]), and the separation of guns from ammunition (30 [32%]). Seven percent of departments suggested removing the gun from the household. Over half of those suggesting trigger locks and lockboxes considered these devices safe (35 [64%] for trigger locks and 27 [56%] for lockboxes) and yet rapidly accessible to an adult (36 [65%] for trigger locks and 36 [75%] for lockboxes). Responding police officers most commonly reported using the following storage methods at home: no storage method (31 [38%]), portable lockboxes (23 [28%]), out-of-reach location (11 [13%]), separation of gun and ammunition (10 [12%]), and trigger locks (5 [6%]).

CONCLUSIONS

Trigger locks are frequently recommended but infrequently used by police themselves at home. Portable lockboxes are frequently recommended as well as used by police.

The validity of police assessment of driver intoxication in motor vehicle crashes leading to hospitalization

We evaluated the accuracy of the field sobriety assessment of police officers following a motor vehicle crash. Using linked data from a statewide traffic crash database and the trauma center registry, the results of a field sobriety evaluation for each driver were compared with a blood alcohol concentration (BAC) drawn in the emergency department. BAC values served as the "gold standard" in which drivers with values over 0.1 mg/dl were classified as intoxicated. The subjects were drivers over age 15 years who were admitted or died at Level I trauma center as a results of motor vehicle crash injuries during 1986-1993. A total of 1336 subjects had both a recorded BAC and a police sobriety assessment. Seventy percent of subjects were male and 79% under the age of 35 years. Overall, 40% of all subjects were judged by police to have been impaired, based on the scene sobriety assessment. Among all drivers, the field assessment had a sensitivity of 91%, a specificity of 90% and a predictive value positive of 85%. After excluding the 419 drivers which had breath testing as part of their assessment, the field assessment had a sensitivity of 74% and a specificity of 97%. The sensitivity of the field assessment did not vary appreciably by gender but was lower among older drivers, and higher among severely injured drivers and those involved in weekend and nighttime crashes. Police officers in this sample appear to recognize drunk driving with a high degree of accuracy when investigating crashes in which the driver is transported to a trauma center.

Prevention of traumatic deaths to children in the United States: how far have we come and where do we need to go?

OBJECTIVE

To describe the changes in injury mortality from 1978 to 1991 and determine the number of preventable deaths with currently available intervention strategies.

METHODS

Comparison of injury mortality data for children and adolescents 0 to 19 years in 1978 and 1991. Review of the literature to determine the effectiveness of currently available prevention strategies and application of these to deaths in 1991.

RESULTS

The injury death rate declined by 26% over the 14-year period. Death rates of unintentional injuries decreased by 39%, with declines in all categories of unintentional injuries. Homicides increased by 67% and suicides by 17%; nearly all of this increase was in deaths from firearms. If currently available prevention strategies were fully used, 6640 deaths could have been prevented, a further 31% decrease.

CONCLUSIONS

Although great studies have been made in preventing deaths from trauma, the application of currently available prevention strategies could save a large number of additional lives. However, the increasing problem of intentional injury will partly counterbalance the success in unintentional injury control.

Epidural hemorrhage: is it abuse?

OBJECTIVE

To determine whether children presenting with epidural hemorrhage (EDH) are as likely to have been abused as are children presenting with subdural hemorrhage (SDH).

DESIGN

Retrospective chart review.

SETTING

Level I regional trauma center and a regional children's hospital.

PATIENTS

All children at both institutions 3 years old or younger with a diagnosis of EDH or SDH identified by a search of the computerized trauma registry and hospital medical records from 1985 through 1991.

MEASUREMENT AND RESULTS

Complete records were found for 93 of 94 eligible subjects. The diagnosis of accidental or inflicted injury was ascertained from the patient's hospital medical record or the records of Child Protective Services. Of all subjects (n = 93), 52% (48/93) were male and the median age was 15 months. Abuse was diagnosed in 47% (28/59) of children with SDH and 6% (2/34) of those with EDH. Other significant injuries were found in 47% of children with SDH and 18% of children with EDH. There was no statistically significant difference between the two groups with respect to the likelihood of identifying a skull fracture, the need for surgical evacuation of the hemorrhage, or mortality.

CONCLUSIONS

Our data are consistent with current biomechanical concepts of intracranial injury. EDHs results from brief linear contact forces that commonly occur in unintentional falls. SDHs are caused by global high-energy rotational acceleration/deceleration forces that are commonly generated in episodes of abuse. Compared with SDH, EDH rarely results from abuse.

Trauma among American Indians in an urban county

OBJECTIVE

To describe severe injury among American Indians in a large metropolitan county given that most previous studies of the high Indian injury morbidity and mortality rates have been conducted primarily in rural areas.

METHODS

A retrospective analysis of a hospital trauma registry was conducted for the years 1986-92 at the Harborview Medical Center, the only Level I trauma center in King County, Washington, metropolitan county with the seventh largest number of urban American Indians in the United States.

RESULTS

Of 14,851 King County residents included in the registry, 593 (4%) were classified as American Indian. With King County whites as the reference, the age-standardized incidence ratio for inclusion of American Indians in the registry was 4.4 (95% confidence interval 4.1, 4.8). The standardized incidence ratios and proportional incidence ratios showed significant differences in mechanism and whether it was intentional or unintentional among Indians compared with whites. Hospitalizations for stab wounds, bites, and other blunt trauma were all significantly more frequent among Indians. Trauma admissions among Indians were disproportionately associated with assaults. A high proportion (72.3%) of American Indians tested had blood alcohol levels exceeding 0.1%.

CONCLUSION

Urban American Indians experience high rates of trauma, differing from those among whites. Efforts to reduce injury in urban areas should include collaboration with representative urban American Indian organizations.

Physician experience with pediatric inpatient care in Washington State

OBJECTIVE

To determine the frequency with which pediatricians and family physicians in Washington State serve as attending physicians for pediatric inpatients.

DESIGN

Retrospective review of statewide hospital discharge data.

SUBJECTS

Attending physicians for all patients younger than 18 years of age with nonsurgical diagnoses discharged from civilian hospitals in Washington State during 1989 and 1990.

RESULTS

Using medical rosters, the self-identified specialty of the attending physician was determined for 93% (n = 181,581) of discharges. Pediatricians and family physicians were listed as attending for 61% and 28%, respectively, of all eligible patients. Statewide, 97% (n = 555) of all pediatricians and 86% (n = 939) of all family physicians served as attending physicians for at least one inpatient, including healthy newborns, during the 2-year study period. The median annual number of discharges per physician was 78 for pediatricians and 14.5 for family physicians. Excluding healthy newborns, the median annual number of discharges was 25 for pediatricians and 3 for family physicians. Five percent of the physician attending group provided inpatient care for 50% of all children hospitalized with diagnoses other than healthy newborn; 50% of attending physicians cared for 95% of the patients. In rural hospitals, where family physicians served as attending physicians for 44% of pediatric inpatients, children were 3.3 times more likely to receive their care from family physicians than those hospitalized in urban centers.

CONCLUSIONS

Most pediatricians and family physicians serve as inpatient attending physicians for hospitalized children only infrequently. These findings question whether the emphasis on inpatient care in many pediatric and family medicine training programs remains an appropriate goal.

Firearm injury prevention counseling by pediatricians and family physicians. Practices and beliefs

OBJECTIVES

To ascertain and compare beliefs, attitudes, and counseling practices of primary care physicians of children and adolescents regarding firearm injury prevention counseling.

DESIGN

Cross-sectional survey.

SETTING

State of Washington.

SUBJECTS

All active members of the state chapters of the American Academy of Pediatrics and American Academy of Family Physicians. A total of 979 pediatricians and family physicians (53%) responded to the survey after two mailings.

MAIN OUTCOME MEASURES

Attitudes, beliefs, and current practices with regard to firearm safety counseling among families of child and adolescent patients.

RESULTS

Only 25% of pediatricians and 12% of family physicians currently counsel more than 5% of their patients. Pediatricians were more likely than family physicians (70% vs 46%, P < .001, chi 2 test) to believe that physicians have a responsibility to counsel families about firearm safety. Pediatricians recommended removing guns from the home more frequently than family physicians (32% vs 19%, P < .001, chi 2 test), but most physicians of both specialties perceived that parents are rarely receptive to this advice. However, 97% of physicians from both specialties agreed that firearms should be stored locked separately from ammunition, and a substantial majority believed that parents would be receptive to this advice. Compared with physicians who owned guns (32%), non-owners were 15 times more likely (odds ratio, 15; 95% confidence interval, 10 to 23) to agree that families with children should not keep firearms in the home.

CONCLUSIONS

Few primary care physicians who see children and adolescents currently counsel families about firearm safety, although many agree that they have such a responsibility. At least half of these physicians would potentially benefit from an intervention to improve their knowledge of and counseling skills on this topic.

Prevalence of corporal punishment among students in Washington State schools

OBJECTIVES

To determine the prevalence of corporal punishment in Washington State and the factors associated with its use in Washington elementary and secondary schools.

DESIGN

Cross-sectional mail survey performed during the summer of 1992.

SETTING

All elementary and secondary schools in the state of Washington.

RESULTS

One thousand eighteen schools (47%) responded to the survey, of which 80% were publicly funded and 63% were located in urban areas. The study sample closely resembled the profile of all schools in the state. Almost 11% of participating schools permitted corporal punishment at the time of the survey and 3.2% reported its actual use during the 1991-1992 school year, resulting in an estimated prevalence of 7.2 incidents per 1000 students per year. Sixteen percent of corporal punishment actions occurred in schools not permitting its use. Ninety percent of public schools relied on district policy regarding corporal punishment. School characteristics associated with the use of corporal punishment included rural location (crude odds ratio, 2.2; 95% confidence interval, 1.5 to 3.4), enrollment of less than 500 students (crude odds ratio, 1.7; 95% confidence interval, 1.1 to 2.7), and kindergarten to eighth-grade or kindergarten to 12th-grade enrollment (crude odds ratio, 2.5; 95% confidence interval, 1.6 to 3.9).

CONCLUSIONS

The lack of a statewide ban on school corporal punishment at the time of this survey was associated with the continued use of corporal punishment against children in districts that continued to permit it. School policies against corporal punishment were associated with much lower prevalence. Continued efforts are needed to enact and enforce laws in the remaining states that have not yet banned corporal punishment.

From roadside to bedside: the regionalization of trauma care in a remote rural county

OBJECTIVE

To determine the current role of rural hospitals and prehospital agencies in the care of motor vehicle crash victims in a remote, rural county prior to the statewide regionalization of trauma care. Specifically, we determined the proportion of crashes that required a response by emergency medical services (EMSs), the timeliness of the response, the proportion of patients treated in local hospitals, and the factors that predicted referral to trauma centers.

DESIGN

Population-based retrospective cohort study linking emergency medical services, emergency department, and hospital discharge data to police motor vehicle crash reports and coroner data.

SETTING

Okanogan County, Washington.

SUBJECTS

All motor vehicle occupants, pedestrians or pedalcyclists who were involved in a motor vehicle collision with a response by emergency medical system personnel or the county coroner.

INTERVENTION

None.

MAIN OUTCOME MEASURES

EMS response times, emergency department and hospital discharge disposition, Injury Severity Scores, hospital length of stay, procedures, deaths.

RESULTS

Twelve percent of 669 crashes reported to the police led to the dispatch of EMS. Crashes with EMS involvement were more likely to include occupants without restraints, who were ejected from the vehicle or who had alcohol as a contributing circumstance. The median interval between crash and EMS dispatch was 5 minutes (95th percentile: 40 minutes), the median scene time was 15 minutes (95th percentile: 35 minutes), and the median interval between dispatch and emergency department arrival was 48 minutes (95th percentile: 95 minutes). Among the 210 patients treated by EMSs, 67 (32%) were admitted to local hospitals, and 19 (9%) were referred to a distant trauma center. Of these, 17 were referred directly from the emergency department, one from the scene, and one after local admission. Compared with patients who were admitted locally, referred patients had a significantly higher mean Injury Severity Score (14.4 vs. 5.1), hospital length of stay (9.1 vs. 1.8 days), and rate of operative procedures (37% vs. 9%). Of the 13 crash-related deaths during the year, nine were declared dead at the scene before EMS arrival, three were asystolic at the time of EMS arrival at the scene, and one died at a referral hospital.

CONCLUSIONS

The linkage of data from police, prehospital agencies, and hospitals can reveal important information about the sequence of health care for trauma patients. The rural hospitals in this county currently play a major role in the stabilization and treatment of motor vehicle crash victims.

Health status of urban American Indians and Alaska Natives. A population-based study

OBJECTIVE

To use vital statistics and communicable disease reports to characterize the health status of an urban American Indian and Alaska Native (AI/AN) population and compare it with urban whites and African Americans and with AI/ANs living on or near rural reservations.

DESIGN

Descriptive analysis of routinely reported data.

SETTING

One metropolitan county and seven rural counties with reservation land in Washington State.

SUBJECTS

All reported births, deaths, and cases of selected communicable diseases occurring in the eight counties from 1981 through 1990.

MAIN OUTCOME MEASURES

Low birth weight, infant mortality, and prevalence of risk factors for poor birth outcomes; age-specific and cause-specific mortality; rates of reported hepatitis A and hepatitis B, tuberculosis, and sexually transmitted diseases.

RESULTS

Urban AI/ANs had a much higher rate of low birth weight compared with urban whites and rural AI/ANs and had a higher rate of infant mortality than urban whites. During the 10 years, urban AI/AN infant mortality rates increased from 9.6 per 1000 live births to 18.6 per 1000 live births compared with no trend among the other populations. Compared with rural AI/AN mothers, urban AI/AN mothers were 50% more likely to receive late or no prenatal care during pregnancy. Relative to urban whites, urban AI/AN risk factors for poor birth outcomes (delayed prenatal care, adolescent age, and use of tobacco and alcohol) were more common and closely resembled the prevalence among the African-American population except for a higher rate of alcohol use among AI/ANs. Compared with urban whites, urban AI/AN mortality rates were higher in every age group except the elderly. Differences between urban whites and AI/ANs were largest for injury- and alcohol-related deaths. All-cause mortality was lower among urban AI/ANs compared with rural AI/ANs and urban African Americans, although injury- and alcohol-related deaths were higher for AI/ANs. All communicable diseases studied were significantly (P < .05) more common among urban AI/ANs compared with whites. Tuberculosis rates were highest in the urban AI/AN group, but rates of sexually transmitted diseases were intermediate between urban whites and African Americans.

CONCLUSIONS

In this urban area, great disparities exist between the health of AI/ANs and whites across almost every health dimension we measured. No consistent pattern was found in the comparison of health indicators between urban and rural AI/ANs, though rural AI/ANs had lower rates of low birth weight and higher rates of timely prenatal care use. The poor health status of urban AI/AN people requires greater attention from federal, state, and local health authorities.

The meaning of death to adolescents in an American Indian community

BACKGROUND

A high rate of premature death exists among young Native Americans in North America. To understand the qualitative effect of this phenomenon, we undertook this study to explore the meaning of death to adolescents in a Salish American Indian community.

METHODS

Standard methods of ethnography were employed: community entry, open-ended in-depth interviews using key informant sampling, audiotape and field note transcription, review of field notes for key themes, and community feedback. Interviews were conducted with seven elders and 21 adolescents in a Pacific Northwestern American Indian community selected by key informants. Probe questions and narrative accounts primarily focused on personal experience with premature death among family and peers.

RESULTS

The primary themes in the study were the subjects' personal exposure to death, alcohol and drugs. Spirit Sickness (a culturally defined illness experience), and healing.

CONCLUSIONS

There are persistent beliefs in Spirit Sickness among adolescents and young adults in the Salish Indian community. Personal exposure to death is a precipitant of this potentially fatal illness experience. Clinicians working with Salish Native Americans should recognize potential beliefs in this illness experience among the youths.

Prior injury and motor vehicle crash as risk factors for youth suicide

We conducted a case-control study to determine whether adolescents and young adults who have been in a motor vehicle crash or hospitalized for unintentional and intentional injury are at greater risk for suicide. Cases were 700 Washington State residents age 16-35 with a driver's license who died of suicide during 1987-1989. Controls were 3,494 licensed drivers matched by age, sex, and zip code. Using two different databases, we were able to determine the past incidence of in-state injury hospitalizations and motor vehicle crashes for all subjects. Overall, the incidence of suicide was tenfold higher among those with a past hospitalization for injury. Many of these admissions were for suicide attempts [odds ratio (OR) = 56, 95% confidence interval (CI) = 27-120], but the risk of suicide was also higher among those hospitalized for unintentional injuries (OR = 5.0, 95% CI = 2.2-11.5) and assaults (OR = 4.5, 95% CI = 1.1-18). The relative risk for suicide was 2.7 (95% CI = 2.0-3.5) for those with prior injury as a driver in a motor vehicle crash and 2.9 (95% CI = 2.2-3.8) for those with involvement in a single vehicle crash. Many unintentional injury hospitalizations and a proportion of motor vehicle crashes in younger adults may represent unrecognized suicide attempts.

Risk and prevention of youth suicide

The rate of fatal suicide attempts among males rose dramatically between 1950 and 1980 and has continued to rise significantly during the 1980s among 15- to 19-year-old youth. Nonfatal suicide attempts, although far more frequent among females, appear to share similar risk factors with completed suicide. The most important preconditional risk factors for both fatal and nonfatal suicide attempts are a history of a previous attempt, major affective and conduct disorders, chronic substance abuse, and a history of personal losses, including experience of suicide attempts by peers and family members. Risk factors for the acute precipitation of an attempt include the acute disruption of an interpersonal relationship, alcohol intoxication, and access to firearms. Preventive efforts can be enhanced by pediatricians both in the office and the community. Clinical case finding of individuals thought to be at high risk will continue to identify some potential victims. Families with household firearms should be counseled regarding the risk of firearm injury and death, particularly in a home with an individual with other risk factors. Community campaigns to improve the mental health of youth and to reduce firearm ownership may hold future promise for the reduction of the unacceptable morbidity and mortality associated with adolescent suicide attempts.

Injury control in childhood

The behavior and environment of individuals are key determinants of both unintentional and intentional injuries in childhood and adolescence. These two determinants often interact so that certain behaviors lead to different injury outcomes depending on the environmental context of the injury. For example, depression is more likely to lead to suicide in the presence of alcohol intoxication. Alcohol intoxication is much more likely to lead to the choice of a firearm in a suicide attempt. Children with poor pedestrian crossing skills are far more likely to be hit in a busy urban intersection than in a safer location. The science of injury control has attempted to learn more about both the behavioral, environmental, and agent characteristics that lead to injury. Each of these dimensions offers opportunities for injury prevention or amelioration of the outcome. Despite increasing knowledge about how certain behaviors are associated with specific types of injuries, there has been only limited success achieved by attempts to modify behavior, particularly by persuasion or education. More success has been derived by legislative mandates. The most success, particularly in the prevention of unintentional injury, has been achieved by modification of the environments and the agents that are most often associated with injury. Because intentional injuries involve extremely complex and aberrant behavior, there is a persistent concern that attempts to modify the environment (e.g., handgun control) will be overridden by those with a high level of intent, i.e., they will seek another method. Although this may be true for carefully premeditated acts, suicide attempts and assaults by youth are usually precipitated by an acute stressor that depends on the availability of a weapon at that immediate time. While we develop more sophisticated psychosocial epidemiologic models that accurately predict violent behavior, we must continue to analyze aspects of intentional injuries that offer an opportunity to reduce the injury severity after the injury has occurred. Pediatricians and other health providers of children have played three important historical roles in the field of injury control. As clinicians, we have a unique opportunity to discuss these concerns with our patients and use our influence to attempt to modify individual behavior and inform about risks. As investigators, pediatricians have been important advocates of research initiatives to use the same epidemiologic methods used to study infectious diseases and cancer and apply them to the study of injury. Finally, pediatricians have played a critical public policy role in the evolution of injury control. Pediatricians have been at the helm behind most legislative initiatives to reduce injury among all people.(ABSTRACT TRUNCATED AT 400 WORDS)

Risk factors for suicide attempts among Navajo adolescents

BACKGROUND

Rates of adolescent suicide in the United States are highest among Native Americans but little is known about risk factors for suicide attempts in this population.

METHODS

To identify risk factors for self-reported suicide attempts by Navajo adolescents, we analyzed the 1988 Indian Health Service Adolescent Health Survey that was administered to 7,254 students in grades 6 through 12 on the Navajo reservation. The responses of students reporting a past suicide attempt were compared to others.

RESULTS

Nearly 15 percent (N = 971) reported a previous suicide attempt; over half of those admitted to more than one attempt. Controlling for age, a logistic regression model revealed the following associations with suicide attempts: a history of mental health problems (OR = 3.2); alienation from family and community (OR = 3.2); having a friend who attempted suicide (OR = 2.8); weekly consumption of hard liquor (OR = 2.7); a family history of a suicide or attempt (OR = 2.3); poor self-perception of health (OR = 2.2); a history of physical abuse (OR = 1.9); female gender (OR = 1.7); and sexual abuse (OR = 1.5).

CONCLUSIONS

Efforts to prevent adolescent suicide attempts in this population should target individuals with those risk factors of the highest risk and prevalence of exposure.