Andrew L. Dannenberg

Homicide and other injuries as causes of maternal death in New York City, 1987 through 1991

OBJECTIVESnWe attempted to document the role of homicide and other injuries as causes of maternal death and to compare the risk of fatal injury among pregnant women with that in the general population.nnnSTUDY DESIGNnWe reviewed New York City medical examiner records of 2331 women aged 15 to 44 years who died of injury in 1987 through 1991. Pregnancies were identified from autopsy information.nnnRESULTSnA total of 115 (39%) of 293 deaths in currently or recently pregnant women were attributable to injury. These 115 deaths included homicide (63%), suicide (13%), motor vehicle crashes (12%), and drug overdoses (7%). Minority women were overrepresented among the injury deaths (black 53%, Hispanic 24%, white 19%). Recent substance use was documented in 48% of the injury deaths. Pregnancy was documented on only 35% of the 115 death certificates. The risk of fatal injury is similar for currently pregnant women and for women in the general population, except for an increased risk of homicide among pregnant black women.nnnCONCLUSIONSnHomicide and other injuries are major contributors to maternal mortality and should be (but rarely are) included routinely in maternal mortality surveillance systems. Prenatal and postpartum clinic visits represent an ideal time to implement interventions to prevent injuries among pregnant women.

BICYCLE HELMET LAWS AND EDUCATIONAL CAMPAIGNS: AN EVALUATION OF STRATEGIES TO INCREASE CHILDREN'S HELMET USE

OBJECTIVESnThe passage of a mandatory bicycle helmet law for children in Howard County, Maryland, provided an opportunity to compare legislation and education as strategies to increase helmet use.nnnMETHODSnIn 1991, a survey was mailed to fourth-, seventh-, and ninth-grade students attending a stratified sample of public schools in Howard County and in two similar suburban/rural counties without helmet laws.nnnRESULTSnOf 7217 students surveyed, 3494 responded (48.4%). Self-reported helmet use in Howard County rose from 11% to 37% after the law and accompanying educational campaign went into effect. Helmet use changed from 8% to 13% in Montgomery County, where educational efforts were undertaken, and from 7% to 11% in Baltimore County, where helmet promotion activities were minimal. Predictors of helmet use included having friends who wore helmets, believing helmet laws are good, being in fourth grade, living in Howard County, and using seatbelts regularly.nnnCONCLUSIONSnLegislation combined with education appears to increase bicycle helmet use substantially more than does education alone. The Howard County law may be considered a successful model of a strategy to increase childrens helmet use.

Infant Mechanical Suffocation Deaths in the United States, 1980–1997

Purpose. To document specific patterns and products associated with mechanical suffocation among infants younger than 13 months of age for the period 1980 to 1997. Methodology. A total 2178 case summaries from the US Consumer Product Safety Commissions Death Certificate File were reviewed. A computerized database was created for information about the infants, products, and patterns of suffocation. The relationships among products, patterns, and age groups were analyzed by χ2. Thirty-eight investigations conducted on a subset of cases involving cribs were reviewed for details on crib age, structural integrity, and compliance with the federal crib regulation. Mortality rates were calculated based on the US population younger than 1 year old. Results. The most frequent causes of suffocation were 1)u2009wedging between a bed or mattress and a wall and 2)u2009oronasal obstruction by plastic bag. Patterns of suffocation were significantly related to age group, but not to sex. Pattern-specific mortality rates comparing three time frames for the the 16-year period from 1980 to 1995 showed continued increases for overlain and oronasal obstruction; an increase followed by a plateau for wedging, a decrease for hanging, and no substantial change for entrapment with suspension. Conclusions. Suffocation hazards presented by beds, bedding, pillows, and plastic bags continue to be underrecognized by parents and caregivers. Bed-sharing and use of adult beds for infants should be discouraged. Only complying cribs should be used and maintained properly to ensure structural integrity. Suffocation deaths involving plastics should be investigated to determine the specific material characteristics and use patterns to design more effective interventions than selective labeling.

Secular blood pressure trends in normotensive persons: The Framingham Study

Trends in hypertension prevalence are difficult to assess because of a massive increase in the prevalence of antihypertensive treatment. Over the past three decades mean blood pressure levels among the 5209 members of the Framingham Study cohort have declined, and elevated blood pressure is only one third as prevalent. However, if those receiving treatment who have normalized blood pressures are defined as hypertensive, in addition to those with elevated blood pressure, the prevalence of hypertension has increased. No consistent secular trend in the incidence of hypertension was noted over three decades, but high blood pressure eventually developed in two thirds of the study cohort. To determine whether untreated blood pressure levels are changing over time, trends in mean blood pressure were examined in normotensive subjects over three decades. Only a 1 mm Hg decline in mean systolic and diastolic pressure over each 10-year interval was noted (p < 0.001). Thus blood pressure in the normotensive segment of the population has been quite stable. Because the incidence of hypertension is very high and future hypertension arises from the upper end of the normal blood pressure distribution, there is an urgent need for primary prevention. Preventive measures such as exercise, avoidance of salt and alcohol, and especially weight control deserve a high priority.

Predictors of Injury Among 1638 Riders in a Recreational Long-Distance Bicycle Tour: Cycle Across Maryland

To assess the incidence of and risk factors for injuries in a group of bicyclists with a well-defined exposure to bicycling, we conducted a prospective study of 1638 recreational bicyclists who rode in the 6-day 339-mile Cycle Across Maryland tour in 1994. The mean age of participants was 39 years (range, 7 to 79), and two- thirds were male. All riders wore helmets. During the tour there were 85 acute traumatic injuries (15.4 per 100,000 person-miles), 76 overuse injuries (13.7 per 100,000 person-miles), and 37 other medical problems (6.7 per 100,000 person-miles). Acute traumatic inju ries were associated with a history of racing versus none (relative risk = 2.2, 95% confidence limits = 1.3, 3.7) and with inexperience, no previous Cycle Across Maryland tours versus one or more (relative risk = 1.7, 95% confidence limits = 1.04, 2.8), but not with sex, training, or prior injuries. Inexperience and lack of pre ride conditioning were risk factors for overuse injuries. The most common overuse injuries and medical prob lems were knee pain, hand or wrist numbness, foot blisters, insect stings and bites, and heat and dehydra tion. Study results provide exposure-based incidence rates of bicyclist injuries and suggest overuse injuries may be reduced by increased preride conditioning.

Intentional and unintentional injuries in women. An overview.

Injuries are the leading cause of death for females 1 to 34 years old, and a major source of preventable morbidity and mortality in middle-aged and elderly women. In the United States, 43,000 women die from injuries and approximately 1 million women are hospitalized for injuries annually. The leading causes of injury death in women are motor vehicle-related injuries (34%), suicide (14%), falls (14%), and homicide (12%). Injuries of particular concern include fatal and nonfatal falls in elderly women, homicides among young black women, suicides among young white women, work-related homicides among female convenience store workers, and fatal and nonfatal injuries in pregnant and nonpregnant women associated with domestic violence. Strategies to prevent most types of injuries are either known or being investigated. Increased efforts to develop, implement, and evaluate such interventions would help to reduce the toll of injuries on womens health.

Head injuries incurred by children and young adults during informal recreation.

To examine injuries related to playground equipment, childrens vehicles, roller skates, and skateboards, 1991 data on emergency room patients younger than 25 years in the Consumer Product Safety Commissions 91 surveillance hospitals were used. Head injury was the primary diagnosis for an estimated 58,480 patients, exceeding the total number of head injuries to bicyclists younger than 25 years. The head injury rate decreased with age. The large number and high rate of head injuries in children involved in a variety of recreational activities suggests the value of multipurpose helmets.

Teaching safety: evaluation of a children's village in Maryland.

OBJECTIVES: The purpose of this study was to evaluate Childrens Village, a life safety education facility for children. SETTING: The study took place in Washington County, Maryland, a rural county. METHODS: Eight elementary schools with 20 second grade classrooms (410 students aged 7 and 8) were selected to participate. Using a quasiexperimental design, tests were administered to two cohorts of children before (pretest) and after (post-test) they attended the Childrens Village during 1993-4. Parent and teacher surveys were also completed after the program. RESULTS: Among children who attended in December 1993-January 1994, there was a significant improvement in average test scores between the pretest (58% correct) and post-test (78%). Among children who attended in April 1994, there also was a significant improvement in test scores between pretest (74%) and post-test (85%). Among parents, 70% reported that their child learned a great deal at Childrens Village and 33% reported having made changes in their home as a result. The parent survey also revealed that 25% of children and 35% of adults did not always wear their seat belts, and 74% of children did not always wear bicycle helmets. Teachers responses to the program were generally positive. CONCLUSIONS: Childrens Village brought together an extensive network of community leaders, parents, and teachers dedicated to safety education of children. The curriculum had a positive impact on childrens knowledge and, to a lesser extent, on parents safety practices. Program impact could be enhanced by more emphasis on automobile restraints and helmets (behaviors that parents reported were not consistently practiced) and by expanding the village services to parents as well as children. Others considering creating similar programs need to identify community leaders willing to commit the time, effort, and resources required to develop and sustain such programs.

A proposal for the mandatory inclusion of helmets with new children's bicycles.

To reduce bicycle-related head injuries in children, we propose new regulations be established that mandate the inclusion of approved helmets with the sale of all new childrens bicycles. Currently, purchasing a helmet is a separate economic decision that acts as a barrier to helmet ownership and use. The inclusion of a helmet with the bicycle would markedly increase helmet ownership. The increased demand would reduce the manufacturing cost per helmet, so the cost of the bicycle with the helmet would be lower than the current retail price of the two separately. This proposal could potentially be implemented by federal or state legislation, a Consumer Product Safety Commission regulation, or voluntary adoption of a practice or standard by bicycle manufacturers. Increased helmet ownership is necessary but not sufficient to raise helmet use rates. The increased ownership generated by this proposal, complemented by enhanced educational, promotional, and legal interventions, is probably the most practical and cost-effective public health strategy available to increase helmet usage and prevent bicycle-related head injuries in children.