Injury prevention. First of two parts.
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Accident Prevention↗
Biomedical subjects
P Cummings
Publications and source records attributed to P Cummings.
Estimating the risk of breast cancer in relation to the interval since last term pregnancy.
We review the analytical methods of studies that asked whether a term pregnancy transiently increases a woman's risk of breast cancer. These analyses must separate the possible influence of a recent pregnancy from that of two other correlated variables, attained age and age at last pregnancy. Most analyses have compared women of the same parity. To determine, however, whether the risk of breast cancer is different than it would have been had the last pregnancy never occurred, it is necessary to compare the risk of breast cancer over time among women of parity N+1 with women of parity N, which has been done in a few studies. To generate relative risk estimates that are independent of arbitrary coding decisions, we show that the analytical models must be more complex than those in published studies. We used these models to compare women of parity N and N+1 for breast cancer occurrence, using data from the U.S. Cancer and Steroid Hormone Study. For the first 6 years after delivery, first term pregnancy was associated with lower or unchanged risk of breast cancer, second pregnancy with higher risk, third pregnancy with lower risk, and fourth pregnancy with both lower and higher risk depending on age at delivery. Given the inconsistent findings between adjoining levels of parity and the wide confidence intervals around the estimates, we could not find clear evidence for or against the theory that term pregnancy is transiently associated with an increased risk of breast cancer.
Adult↗
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.
Adolescent↗
Randomized clinical trial of an absorbable stent for vasectomy reversal.
PURPOSE: More successful methods of vasectomy reversal would benefit those undergoing this treatment and might also increase the popularity of vasectomy. We conducted a randomized, prospective clinical trial of vasectomy reversal methods, comparing a new absorbable stent with 2-layer reattachment. MATERIALS AND METHODS: We studied 116 men seeking vasectomy reversal between November 1990 and March 1994. Data were analyzed primarily by intention to treat. RESULTS: Patients in the stent (64 cases) and no stent (52) randomized groups were similar in age distribution, age of spouses, years since vasectomy, proportion who had undergone prior vasectomy reversal and proportion who had previously achieved pregnancy. Operation time was more than 19 minutes shorter in the stent randomized group (p = 0.006). Fewer patients in the stent than the no stent group had patent vasovasostomies (81.0 versus 89.6%, respectively, p = 0.2) postoperatively. Fewer stent randomized patients had motile sperm (76.2 versus 81.3%, respectively, p = 0.5) and normal total motile sperm counts (49.2 versus 52.1%, respectively, p = 0.8) than did those without a stent. Conception occurred in 22 and 51% of all couples in the stent and no stent groups. The relative risk of conception among those in the stent group was 0.42 (95% confidence interval 0.24 to 0.71, p = 0.002). A Mantel-Cox log-rank test comparing pregnancies in each group according to the number of postoperative months revealed that the no stent group achieved more earlier pregnancies (p = 0.003). CONCLUSIONS: The 2-layer microscopic vasovasostomy results in greater pregnancy rates than vasovasostomy using the absorbable stent.
Absorption↗
Injuries due to firearms in three cities.
BACKGROUND: To describe the incidence and outcome of injuries due to firearms, we conducted a population-based study of fatal and nonfatal gunshot wounds in three cities: Memphis, Tennessee; Seattle; and Galveston, Texas. METHODS: Records of the police, medical examiners, ambulance crews, and hospital emergency departments and hospital admissions were monitored to identify all injuries caused by firearms that were severe enough to prompt emergency medical treatment. These records were linked to generate a complete picture of each event. Census data were used to calculate rates of injury for various population groups. RESULTS: A total of 1915 cases of injury due to firearms were identified between November 16, 1992, and May 15, 1994. The crude rate of firearm injury per 100,000 person-years was 222.6 in Memphis, 143.6 in Galveston, and 54.1 in Seattle. Approximately 88 percent of the injuries were incurred during confirmed or probable assaults; 7 percent were sustained in the course of suicide or attempted suicide; unintentional injuries accounted for 4 percent of the cases. Handguns were used in 88 percent of the cases in which the type of weapon was recorded. Five percent of the 1677 victims who were brought to a hospital emergency department could not be resuscitated; 53 percent were hospitalized, and 42 percent were treated and released. Ninety-seven percent of the deaths occurred within 24 hours of the injury. Emergency department and inpatient charges exceeded $16.5 million. CONCLUSIONS: Injuries due to firearms, most involving handguns, are a major cause of morbidity and mortality in U.S. urban areas. The incidence varies greatly from city to city.
Adolescent↗
Prehospital endotracheal intubation of children by paramedics.
STUDY OBJECTIVE: To describe the experience of an emergency medical services system with the use of liberal indications for prehospital pediatric endotracheal intubation. METHODS: We performed a retrospective review of prehospital and hospital patient records in an urban and suburban prehospital care system. The study included all children aged 15 years or younger who were intubated in the prehospital setting by King County paramedics from January 1, 1984, to December 31, 1990. RESULTS: During the 7-year study period, 654 children were intubated, of which 355 (54%) were study patients. The median age of the patients was 3 years; 60% had an injury diagnosis. On arrival of the paramedics, 60% of the patients were in sinus rhythm, 62% had a systolic blood pressure of 70 mm Hg or greater, and 56% had a respiratory rate of 10 breaths per minute or greater. The Glasgow Coma Scale score was 8 or lower in 83% of the patients. Succinylcholine was used to facilitate intubation in 47% of patients. On arrival at the emergency department, 79% of the patients were in sinus rhythm; 75% had an adequate blood pressure (70 mm Hg or greater); 86% had a PaO2 value of 100 mm Hg or greater; and 74% had a PaCO2 value of 45 mm Hg or lower. Complications of intubation, more than half of which were classified as minor, were noted in 22.6% of patients. We were unable to determine the number of failed intubation attempts. Most of the patients (58%) survived to hospital discharge. Among cardiac arrest victims, only 12% survived. CONCLUSION: In a setting where paramedics practice with close medical direction, applying liberal indications for pediatric intubation and permitting the use of succinylcholine allowed paramedics to intubate children of different ages and diagnoses.
Adolescent↗
Physicians' children are treated differently in the emergency department.
The objective was to determine whether children with a physician parent receive treatment different from that of children of nonphysician parents when they present to the emergency department (ED). The design was a retrospective cohort study. The setting was a university-affiliated children's hospital ED. All children with a physician parent seen in the ED during a 16-month period were identified. Children with a nonphysician parent were matched to children with a physician parent by date and time of visit. Length of stay in ED, performance of laboratory or radiological testing, evaluation by a consultant, and training level of the least experienced physician to evaluate the patient in the ED were measured. The authors identified 92 children with a physician parent and 181 children with nonphysician parents. Children of physician parents were similar to controls with regard to age, sex, nursing acuity level, length of stay, and whether a laboratory or radiographic procedure was performed. Children with a physician parent saw significantly fewer nonconsultant physicians while in the ED (P = .005). Compared with controls, the most junior member of the medical team seen by children of a physician parent was less likely to be a medical student (relative risk [RR] = 0.22) or a resident (RR = 0.71) and more likely to be an ED staff physician (RR = 1.52) or consultant (RR = 1.84). This trend was statistically significant (P = .002). The children of physician parents are more likely to see only an ED staff physician and/or consultant and less likely to see trainees than other children presenting to the pediatric ED.
Adolescent↗
Failure to detect Chlamydia pneumoniae in coronary atheromas of patients undergoing atherectomy.
To further investigate a proposed relationship between Chlamydia pneumoniae and coronary heart disease, coronary atheromas were collected from patients undergoing percutaneous atherectomy. Fifty-eight atheroma specimens were examined by culture and polymerase chain reaction (PCR) and 22 by electron microscopy. All were negative for C. pneumoniae, except a single specimen that was PCR-positive. These results differ from studies in other populations, in which this organism was identified by nonculture methods within coronary atheromas obtained at autopsy. Anti-C. pneumoniae antibody titers from 65 of the patients were compared with those of 28 asymptomatic controls. IgG titers were higher in controls than in patients. There is no evidence that C. pneumoniae exists within atheromas in this study population, nor does seroprevalence correlate with the presence of coronary disease in these patients.
Adult↗
Physician parents and utilization of a pediatric emergency department.
OBJECTIVE: Health care costs might be reduced if patients could be taught to avoid using an emergency department (ED) for nonurgent illness. This study sought to determine whether children with a physician parent, a group whose parents possess special expertise in judging the severity of acute illness, utilize a pediatric ED differently from children with non-physician parents. DESIGN: Retrospective cohort study. SETTING: A children's hospital ED. PARTICIPANTS: The study population consisted of all children who visited the ED over an 11-month period who had a physician parent. These children were compared to 1000 controls randomly selected from children who visited the ED over the same time period. Two other groups were selected for comparison to controls: children with a nurse parent and children with an attorney parent. MAIN OUTCOME MEASURES: Urgent versus nonurgent final diagnosis. RESULTS: There were no clinically important or statistically significant differences with regard to age, sex, time of presentation, disposition from the ED, or nursing acuity level when the 72 children with a physician parent, the 136 children with a nurse parent, or the 135 children with an attorney parent were compared to the control children. Compared to the control group, children of physician parents were less likely to have a nonurgent final diagnosis: 33 versus 53%; relative risk (RR) 0.62 (95% confidence interval [CI] 0.44-0.87). Children with a nurse parent and children with an attorney parent were no more likely to present with a nonurgent diagnosis compared to control children: 49 versus 53%, RR 0.92 (95% CI 0.76-1.10) for children with a nurse parent and 45 versus 53%, RR 0.85 (95% CI 0.70-1.03) for children with an attorney parent. CONCLUSIONS: Children with a physician parent were less likely to use a pediatric ED for nonurgent problems compared to other children. However, children with a nurse parent, a group whose parents have more medical education than we can expect the general public to ever attain, had a pattern of pediatric ED utilization that was similar to the control children. These data suggest that improved parental education alone may not decrease ED use for conditions that could be managed in a less costly setting.
Adolescent↗
Injuries and their relation to potential hazards in child day care.
OBJECTIVES: To prospectively determine the incidence rate of injuries that required medical attention among children in day care and to identify possible hazards related to these injuries. SETTING: King County, Washington. METHODS: Prospective cohort study of children in a sample of licensed day care facilities. RESULTS: From 1 July 1992 to 30 June 1993, 53 medically attended injuries were reported by 133 day care sites; incidence rate 1.9 per 100,000 hours of day care attendance. The rate of injury in 91 small family day care homes was essentially the same as that in 42 larger day care centers; relative rate 1.0 (95% confidence interval 0.6 to 1.9). Injuries that required sutures accounted for 39% of the cases, while 17% required a cast, splint, or sling. No child was hospitalized. Sixty nine sites were inspected and all had potentially correctable physical hazards, with a median of 15 hazards per site (range 7 to 26). These potential hazards had little relationship to the risk of injury and a case-by-case review identified only two injuries that might have been prevented by a more energy absorbent playground surface. CONCLUSIONS: The incidence of medically attended injuries found in this study is consistent with other studies from the United States. Most injuries were minor and had little relation to physical hazards at day care locations.
Accident Prevention↗
Infant injury death in Washington State, 1981 through 1990.
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Accidents↗
Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies.
A meta-analysis was conducted to determine whether prophylactic systemic antibiotics prevent infection in patients with nonbite wounds that are managed in the emergency department (ED). A literature search was performed to identify published, randomized trials of prophylactic antibiotics for nonbite wounds. Blinded review of trial methods was used to select trials that randomly assigned patients to antibiotic or control groups and analyzed results by intention to treat. Of 9 randomized trials, 7 (with 1,734 study subjects) were accepted for analysis. The odds ratio for infection in treated patients compared with controls was used as the measure of effect, and a summary odds ratio was calculated. Patients treated with antibiotics had a slightly greater incidence of infection compared with untreated controls: odds ratio 1.16 (95% confidence interval [CI] 0.77 to 1.78). Even among patients treated with a penicillinase-resistant antibiotic (5 trials with 1,204 patients), there was no benefit from treatment; odds ratio 1.00 (95% CI 0.59 to 1.71). In conclusion, there is no evidence in published trials that prophylactic antibiotics offer protection against infection of nonbite wounds in patients treated in EDs.
Anti-Bacterial Agents↗
Outbreak of Escherichia coli O157:H7 hemorrhagic colitis and hemolytic uremic syndrome: effect on use of a pediatric emergency department.
STUDY OBJECTIVE: To evaluate the effect of an outbreak of Escherichia coli O157:H7 colitis, and media coverage of the outbreak, on use of an emergency department. DESIGN: Review of pediatric ED use and charges for gastrointestinal illness during the epidemic and during a control period. SETTING: Pediatric ED in Seattle, Washington. PARTICIPANTS: All children seen in the ED with a gastrointestinal illness during the epidemic period (January and February 1993) and during a control period (January and February 1992). RESULTS: During the epidemic, 31 patients with E coli O157:H7 infection had 45 visits to the ED. The number of visits for gastrointestinal illness not caused by E coli O157:H7 was 103% higher in the epidemic period than in the control period (653 in 1992, 1,327 in 1993). The number of visits was closely associated with the number of newspaper stories about E coli O157:H7 illness (correlation coefficient, .88; P = .002). The increased number of evaluations for gastrointestinal illness not caused by E coli O157:H7 infection during the epidemic period was associated with an additional $101,193 in charges per month compared with the control period. There were no important differences in the evaluation of gastrointestinal illness between 1992 and 1993 except for an increase in the proportion of patients with stool cultures (13.1% versus 26.4%, P < .001). CONCLUSION: For every visit by a patient with E coli O157:H7 infection, there were 15 additional visits (above the baseline from the control period) by patients with other gastrointestinal illness. The true cost of this epidemic included not only the evaluation of patients with disease but also the evaluation of those who presented because they were worried they had the disease. The intensity of media coverage of a disaster may correlate with the number of visits to the ED, and understanding of this fact may help in disaster planning.
Adolescent↗
Predicting outcome in pediatric submersion victims.
STUDY OBJECTIVE: To predict outcome in children after near-drowning. DESIGN: Retrospective cohort study. Vegetative state and death were classified as unfavorable outcomes, whereas all other outcomes were classified as favorable. Demographic, episode-related, clinical, laboratory, and treatment variables available at the time of admission were evaluated for their usefulness in predicting outcome. SETTING: Pediatric referral hospital. PARTICIPANTS: Children admitted after submersion injury in non-icy waters. RESULTS: The study cohort comprised 194 children (median age, 2.6 years; range, 5 months to 18 years); 131 were neurologically normal at the time of discharge, 10 had some degree of neurologic impairment, 15 were in a vegetative state at the time of discharge, and 38 died. We used a combination of partitioning and logistic regression to combine variables in a prediction rule that was always correct when unfavorable outcome was predicted. The final rule predicted favorable outcome for all children who were not comatose. Among comatose children, unfavorable outcome was predicted by a combination of absent pupillary light reflex, increased initial blood glucose concentration, and male sex. This rule had a specificity of 100%--children with favorable outcomes were always predicted to do well--and a sensitivity of 65%. Therefore the rule was overly optimistic for 35% of patients with unfavorable outcomes. CONCLUSION: Pediatric submersion victims can be assigned to high or low likelihoods of unfavorable outcome with the use of four variables: comatose state, lack of pupillary light reflex, sex, and initial blood glucose concentration. This prediction rule may be useful if it can be validated in another cohort.
Adolescent↗
Association of alcohol with fatal snowmobile accidents.
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Accidents, Traffic↗
Methodological challenges in injury epidemiology and injury prevention research.
In the past decade there has been increasing attention to the public health importance of injuries. Public health agencies seeking to reduce injuries need methods for counting injuries, calculating injury rates, identifying the causes of injuries, and measuring outcomes of interventions. All of these areas present problems for injury epidemiologists and injury prevention programs. This paper provides a framework for classifying these problems into five categories: (a) numerator problems; (b) denominator problems; (c) causation; (d) exposure measurement problems; and (e) multiplicity. For most problems, we identify proven or potential solutions, using examples from the literature of injury epidemiology.
Causality↗
Risk of breast cancer in relation to the interval since last full term pregnancy.
OBJECTIVE: To examine whether the risk of breast cancer is increased by a recent term pregnancy. DESIGN: Population based case-control study. SETTING: Eight areas in the United States. SUBJECTS: Cases were 2279 multiparous women residents of the eight areas aged 25-49 who were diagnosed as having breast cancer during 1980-2. Controls were 2357 multiparous women selected from the same areas by random digit dialing. MAIN OUTCOME MEASURE: Relative risk of developing breast cancer according to the time interval since last full term pregnancy. RESULTS: The distribution of intervals since the last term pregnancy was similar in cases and controls. Adjusted for age, parity, and age at first term pregnancy, the odds ratios observed for categories of years since the last full term pregnancy were: 0-2 years, odds ratio 1.16 (95% confidence interval 0.84 to 1.59); 3-6 years, odds ratio 1.21 (0.95 to 1.54); 7-9 years, odds ratio 1.04 (0.84 to 1.38); > or = 10 years, odds ratio 1.00 (reference). CONCLUSIONS: Among multiparous women aged 25-49 years there was no association between the risk of breast cancer and the time interval since the last full term pregnancy.
Adult↗
The association between cholesterol and death from injury.
PURPOSE: To review the association between low serum cholesterol and death from injury. DATA SOURCES: Relevant English-language papers identified through MEDLINE and Current Contents searches and bibliographies of identified articles. STUDY SELECTION: More than 150 articles were reviewed to identify data, meta-analyses, or important reviews of the association between low cholesterol and injuries. DATA EXTRACTION: Estimates of the association between cholesterol and death from injury were extracted from published reports. DATA SYNTHESIS: Animal studies and descriptive studies have provided little information about serum cholesterol and injuries. The Conference on Low Blood Cholesterol pooled results from 14 cohort studies in men and found a relative risk of 1.4 for death from injury in men whose cholesterol levels were lower than 4.14 mmol/L (160 mg/dL) compared with men whose cholesterol levels were 4.14 to 5.15 mmol/L (P = 0.003). Most cohort studies support this finding. The strongest evidence that cholesterol and death from injury are related comes from a meta-analysis of six randomized cardiac primary prevention trials of cholesterol reduction; the relative risk for death from injury for treated men compared with controls was 1.42 (95% Cl, 0.94 to 2.15). CONCLUSIONS: In cohort studies, the strength of the association between low serum cholesterol levels and subsequent death from injury is weak and may be caused by confounding factors such as socioeconomic status. The modestly elevated risk ratio found in a meta-analysis of trials of cholesterol reduction in men is of borderline statistical significance. This association may be related to efforts to lower cholesterol rather than to low absolute levels of serum cholesterol. Until more data are available, the hypothesized relation between low cholesterol and injuries remains unsettled.
Animals↗