Thomas B. Cole

The Risk of Dying in Alcohol-Related Automobile Crashes among Habitual Drunk Drivers

Background Reports suggest that people who drive while intoxicated by alcohol may do so repeatedly. We hypothesized that persons arrested for driving while impaired might be at increased risk for death in an alcohol-related motor vehicle crash. To evaluate this possibility, we studied the deaths of drivers in alcohol-related motor vehicle accidents in North Carolina over a 10-year period. Methods We compared drivers who died in motor vehicle crashes from 1980 through 1989 and who had blood alcohol concentrations of at least 20 mg per deciliter (4.3 mmol per liter), referred to as the case drivers, with those who died in crashes but had blood alcohol concentrations below 20 mg per deciliter, referred to as the control drivers. We identified case drivers and control drivers through the state Medical Examiner System. We then searched North Carolina driver-history files for the five years before each death to identify arrests for driving while impaired. Results We linked a total of 1646 case drivers and 1474 ...

Substance Use Disorders and Clinical Management of Traumatic Brain Injury and Posttraumatic Stress Disorder

UBSTANCE USE DISORDERS, TRAUMATIC BRAIN INJURY (TBI), and posttraumatic stress disorder (PTSD) are commoninmilitaryandcivilianpopulations,andoften occur together. A substantial proportion of militarypersonnelmisusealcohol.AstudyoftheUKarmedforces 1 reported that 67% of men and 49% of women had scores of 8 or higher, defined as hazardous drinking, on the Alcohol UseDisordersIdentificationTest,comparedwith38%ofmen and16%ofwomeninthegeneralpopulation.Inapopulationbased cohort of US soldiers returning from service in Iraq, 2 11.8% reported alcohol misuse on a 2-item alcohol screening test. Recent military service is also associated with TBI, PTSD,anddepression.Ina2008survey, 3 19.5%ofUSarmed servicespersonnelreturningfromserviceinAfghanistanand Iraq reported experiencing a possible TBI, 18.5% met criteria for PTSD or depression, and 7.3% both reported a possible TBI and met criteria for PTSD or depression. By comparison, the lifetime prevalence of PTSD estimated for the general US population is 7.8%, and of those 51.9% of men and27.9%ofwomenhavealifetimeprevalenceofbothPTSD and alcohol abuse or dependence. 4 Substance use disorders, TBI, and PTSD may occur together for several reasons. Alcohol use, for example, may beacauseoraconsequenceofTBI.Studieshaveshownthat depending on the setting studied, 18% to 66% of patients with TBI have a history of alcohol abuse, 5 and one-third to one-half of persons with TBI are intoxicated at the time of their injuries. 6 This is not surprising, considering that alcohol use is a recognized risk factor for motor vehicle injuries, falls, and violence, all of which are important causes of TBI. Hazardous drinking may also persist after TBI. A recentAustralianstudy 5 reportedthathazardousdrinkinginitially decreased after the TBI event and then increased by 2 years postinjury to 25.4% of the cohort. Traumatic brain injury has been reported to be associated with PTSD, 7 and PTSD may be associated with sub

Preventing Intimate Partner Violence: Screening Is Not Enough

PHYSICAL, SEXUAL, AND PSYCHOLOGICAL ABUSE OF WOMen by their intimate partners is common around the world. In response to this widespread public health problem,organizationsofhealthcareprofessionals, including the American Medical Association and the American College of Obstetricians and Gynecologists recommend that alladult femalepatientsbeaskedroutinelyaboutabuse, regardless of their presenting symptoms. However, evidence-based guides to clinical preventive services, such as the US PreventiveServicesTaskForce and theCanadianTaskForceonPreventive Health Care, have concluded that there is insufficient evidence of health benefits to abuse survivors to recommend fororagainstscreeningfor intimatepartnerviolence(IPV),primarily due to methodological weaknesses of available studies. In this issue of JAMA, MacMillan et al address this lack of evidence in the report of a trial that randomized women presenting for care in emergency departments, family practices, and obstetrics/gynecology clinics to be screened for abuse before seeing a clinician or to be seen by a clinician without being screened for abuse. It was then at the discretion of clinicians to discuss abuse (if present) or to make referrals for IPV services. To ensure a minimum standard of care for all women participating in the study, each participant, regardless of screening status, was given a printed card with names and telephone numbers of local agencies and telephone hotlines for women exposed to violence. Screening took place in primary care facilities where clinicians had received standardized training in responding to IPV. After 18 months of follow-up, the difference in recurrence of IPV for screened vs nonscreened women was not statistically significant, and a slight improvement in quality-of-life scores for the screened group was no longer statistically significant after a multiple imputation technique was used to account for loss to follow-up of study participants. Therefore, universal screening, which involves routinely asking all patients about abuse, was not found to be beneficial in this study. Universal screening should be distinguished from assessing abuse as a diagnostic test, which was not addressed in this study. Assessing abuse in women at increased risk may not only detect violence but may also lead to more accurate diagnosis and treatment of co-occurring health problems. MacMillan et al offer 2 possible interpretations for their study’s failure to demonstrate health and quality-of-life benefits of universal screening for exposure to IPV. First, the lack of demonstrated benefits may be attributable to limitations of the study methods and data. These limitations included potential errors in the measurement of violence, enrollment of women during an escalating period of violence that was likely to decrease over time even in the absence of screening (regression to the mean), unmeasured benefits to screened and unscreened women associated with being followed up by study personnel over time (Hawthorne effect), distribution of information about community resources to both screened and unscreened women (the printed card with local agencies’ information), approximately equal use of community resources by both groups, and loss to follow-up, which was 43% in the screened group and 41% in the nonscreened group. However, the authors conducted additional analyses to assess the sensitivity of their findings to these limitations, which confirmed that the most valid conclusion of their investigation was a lack of health benefits of universal screening. The authors’ alternative explanation is that the lack of efficacy of screening for IPV in this study may have been due to the lack of an evidence-based, effective intervention for IPV to accompany the screening. That is, if the clinicians had the opportunity to refer abused women to such an intervention, perhaps they would have been motivated to make more referrals. Similarly, if thestudyparticipantshadperceivedapotentialbenefit froman intervention for IPV,perhapsmorewomenwould havekept their appointmentsandremained in thestudy.Most important, if an interventionhadbeenavailable thatwaseffective in reducing violence and was acceptable to the study participants,measuredviolencesubsequenttoscreeningmighthave abated in thescreenedgroupmore thantheunscreenedgroup. Although interventions for IPV have not yet consistently been demonstrated to be effective in randomized trials, at least 3 approaches hold promise for ameliorating the deleterious effects of IPV and preventing recurrence of violence. First, the most widely used intervention for IPV survivors is referral to community resources, such as counseling, legal services, shelters, and other clinical and social services. In the United States, community-based domestic violence organizations usually serve as the hub for service provision for IPV survivors, offering direct services such as

Hunting firearm injuries, North Carolina

To determine the percentage of unintentional firearm-related injuries associated with hunting and to identify risk factors, we conducted a retrospective, descriptive survey of all hunting firearm injuries identified by two North Carolina surveillance systems. Almost one-third of unintentional shooting deaths are hunting-related, and young hunters appear to be at greatest risk of injury. Safety instruction and wearing highly visible clothing should be encouraged; controlled studies should test the effectiveness of these preventive measures.

A population-based descriptive study of housefire deaths in North Carolina.

We report a population-based study of housefire deaths in North Carolina in 1985 using data obtained from fire investigators and the North Carolina medical examiner system. The crude death rate was 3.2 per 100,000 population; age-specific death rates were highest for ages 75-84 years. Death rates for Whites were one-third as high as death rates for other races. Of those decedents tested for alcohol, 56 percent had blood alcohol levels greater than or equal to 22 mmol/L. Most fatal fires were caused by heating units or cigarettes.

MOTOR VEHICLE-RELATED DROWNING DEATHS ASSOCIATED WITH INLAND FLOODING AFTER HURRICANE FLOYD: A FIELD INVESTIGATION

Drivers and passengers who drown while trapped in their vehicles or exiting from vehicles account for most flood-related deaths in the United States, yet little has been known about crash circumstances or risk factors for flood-related motor vehicle injury. We conducted a case-control study of all occupants of single-vehicle crashes in flood-affected North Carolina counties where drowning deaths occurred on 15, 16, and 17 September 1999 (the days before, during, and after landfall of Hurricane Floyd); a descriptive study of deaths using medical examiner records; and a survey of proxy respondents for persons who drowned. In 66 crashes vehicles hit puddles and went off the road, went off the road in rain, drove into water and stalled, hit trees in the road, or drove into collapsed sections of road; 19 of these vehicles were partially or fully submerged in water. Occupants of submerged vehicles were more likely to have drowned if their vehicles were fully submerged (14 of 19, 73.7%) than if their vehicles were partly submerged (0 of 8, 0%). According to proxy informants, most of the persons who drowned were familiar with the roads traveled during the study period, and all 16 had received severe weather warnings. Motor vehicle occupants in weather-related crashes are more likely to drown if their vehicles are submerged or swept away. Vehicle submersion may often be a consequence of deliberately driving into flooded roadways. However, in flood-affected areas, crashes and injuries may also occur when motorists encounter flooded roadways unexpectedly.

Learning associated with participation in journal‐based continuing medical education

Introduction: Medical journal reading is a standard method of increasing awareness among physicians of evidence‐based approaches to medical care. Theories of physician learning and practice change have suggested that journal reading may be more influential at some stages of behavioral change than at others, but it is not clear how journal reading may influence the learning process that can lead to behavioral change. Methods: A random sample of 170 continuing medical education (CME) participants who had read three journal articles and completed a CME evaluation form received a CME credit certificate with a brief survey appended. The survey asked participants to report their stage of learning on each article topic before and after reading the three articles. Results: Of the 170 CME participants, 138 (81.2%) responded to the survey. Most (106 of 138; 76.8%) reported a progression in stage of learning on the topic of at least one of the three articles read for CME credit. More than one‐fourth of the respondents (37 of 138; 26.8%) made a commitment to change practice related to the topic of one or more articles. CME participants were more likely (relative risk 1.14; 95% confidence interval 1.06–1.22) to report a progression in stage of learning if they had recorded a commitment to change practice related to the same article topic on the CME evaluation form. Discussion: Journal‐based CME activities may be educational at all stages of the learning process, and journal‐based learning episodes may result in commitments to change practice.

Child abuse reporting: rethinking child protection

The general public has been bewildered by the magnitude of sex abuse cases and the widespread failure by pillars of the community to notify appropriate authorities. The crime of sexually abusing children is punishable in all jurisdictions and this article examines the duty to report suspected cases by individuals in positions of trust over young people, such as in the church or university sports. The Federal Child Abuse Prevention and Treatment Act (CAPTA) defines child maltreatment as an act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, and establishes minimum federal standards. Each state has its own definitions of maltreatment and every state identifies persons who are required to report child abuse. As such, state law is highly variable in defining who has a mandatory duty to report, and clergy and other individuals in close supervision of children (e.g., athletic coaches, scout leaders, volunteers in religious programs, and university officials) may necessarily hold such duty.The article outlines why there are strong moral reasons the law should require all adults in close supervision of children to report any individual who they have good reason to believe has abused a child and moreover outlines how to ensure prompt reporting of abuse, while still ensuring that respected individuals are not falsely accused.

Risk factors for suicide among older adults with cancer

Objective: To determine whether the increased risk of suicide for individuals with cancer may be explained by functional limitations, lack of social support, or other factors.Method: In this population-based case-control study, interviews of primary informants for suicides in the state of North Carolina were compared to interviews with participants in the Piedmont Health Study of the Elderly to estimate adjusted odds ratios for suicide and self-reported, physician diagnosed cancer, heart attack, stroke, and hip fracture.Results: Adjusting for all other factors, there was a statistically significant association of suicide and cancer (odds ratio [OR] 2.62, 95% confidence interval [CI] CI 1.84–3.73), but not heart attack, hip fracture, or stroke. The risk of suicide was also elevated for men vs. women (OR 17.15, CI 10.88–27.02), whites vs. blacks (OR 9.70, CI 6.07–15.50), and individuals with stressful life events (OR 2.75, CI 1.97–3.86) or limitations of instrumental (OR 2.93, CI 2.03–4.22) but not physical activities of daily living. Suicide cases were not more likely to be short of breath or poor sleep quality. Suicide was statistically significantly less likely for study participants who were married with spouse living vs. other (OR 0.61, CI 0.43–0.88) or who had one or more indicators of social support (OR 0.27, CI 0.19–0.39).Conclusion: After adjustment for other risk factors, suicide was strongly associated with cancer but not with other disabling, potentially fatal conditions.

Firearms Sales via “Gun Show Loophole” Thwart Efforts to Reduce Gun Violence

LAST SPRING, A GROUP CALLED MAYors Against Illegal Guns, a coalition of US mayors who want more stringent regulation of firearm sales, unveiled a television commercial featuring clips from speeches by the 3 leading presidential candidates. In these clips, Sen Hillary Rodham Clinton (D, NY), Sen Barack Obama (D, Ill), and Sen John McCain (R, Ariz) said they oppose a “gun show loophole” that allows individuals to purchase firearms without a background check. The coalition aired the commercial to draw attention to the problem of illegal guns in US cities, where the toll from gun violence is greatest. In 2005, more than 30 000 persons in the United States died of gunshot wounds; 40% of the deaths were homicides. Nearly 70 000 more persons received care in emergency departments for nonfatal wounds, according to the US Centers for Disease Control and Prevention.