Trends in the incidence of physician-diagnosed posttraumatic stress disorder among active-duty U.S. military personnel between 1999 and 2008.

BACKGROUND: The impact of combat operations in Iraq and Afghanistan on the incidence of post-traumatic stress disorder (PTSD) in military service members has been poorly quantified. The purpose of this study was to examine trends in the incidence rate of physician-diagnosed PTSD in active-duty military personnel between 1999 and 2008. METHODS: We conducted a retrospective cohort study utilizing data extracted from the Defense Medical Surveillance System to identify incident cases of PTSD within the study population. The incidence rate of physician-diagnosed PTSD was the primary outcome of interest. Multivariable Poisson regression was used to analyze the data. RESULTS: The overall incidence rate of PTSD among all active-duty US military personnel was 3.84 (95% CI: 3.81, 3.87) cases per 1000 person-years. The adjusted average annual percentage increase in the incidence rate of PTSD prior to the initiation of Operation Iraqi Freedom (OIF) was a modest 5.02% (95% CI: 1.85, 8.29%). Following the initiation of OIF, the average annual percentage increase in the rate of PTSD was 43.03% (95% CI: 40.55, 45.56%). Compared to the baseline period between 1999 and 2002, the incidence rate of PTSD in 2008 was nearly 7 times higher (RR = 6.85, 95% CI: 6.49, 7.24). Significant increases in the incidence rate of PTSD were observed following the initiation of OIF regardless of sex, age, race, marital status, military rank, or branch of military service. Notably, the rate of PTSD among females was 6-7 times higher prior to OIF, but there was no difference by gender by 2008. CONCLUSIONS: Overall, these data quantify the significant increase in the incidence rate of PTSD following the initiation of combat operations in Iraq and Afghanistan within the active-duty military population during the study period.

Helicopter crashes into water: warning time, final position, and other factors affecting survival.

INTRODUCTION: According to 40 yr of data, the fatality rate for a helicopter crash into water is approximately 25%. Does warning time and the final position of the helicopter in the water influence the survival rate? METHODS: The National Transportation Safety Board (NTSB) database was queried to identify helicopter crashes into water between 1981 and 2011 in the Gulf of Mexico and Hawaii. Fatality rate, amount of warning time prior to the crash, and final position of the helicopter were identified. RESULTS: There were 133 helicopters that crashed into water with 456 crew and passengers. Of these, 119 occupants (26%) did not survive; of those who did survive, 38% were injured. Twelve died after making a successful escape from the helicopter. Crashes with < 15 s warning had a fatality rate of 22%, compared to 12% for 16-60 s warning and 5% for > 1 min. However, more than half of fatalities (57%) came from crashes for which the warning time could not be determined. DISCUSSION: Lack of warning time and how to survive in the water after the crash should be a topic for study in all marine survival/aircraft ditching courses. Investigators should be trained to provide estimates of warning time when investigating helicopter crashes into water.

How do public health practitioners in China perceive injury prevention? A survey.

To report public health practitioners' perceptions of injury prevention in Changsha, China. We undertook a cross-sectional study at Changsha, Hunan, China. An anonymous self-reported survey was conducted to ascertain the proportion of respondents who answered negatively to questions about the value of injury prevention. Over 20% of respondents answered 'unpreventable' or 'don't know' to whether injuries from natural environmental disaster, homicide/assault, poisoning, animal bite, cut/pierce, suffocation and electric current were preventable. More than 40% of respondents answered 'no' or 'don't know' to whether the prevention of injuries from homicide/assault, cut/pierce, fall, suicide/self-harm, drowning, road traffic crash and fire/burn belonged to the job of public health. Only 48% of respondents supported building a division/office within the Centers for Disease Control and Preventions at all levels. Many public health practitioners in Changsha had misperception about injury prevention. Education and training are needed to correct their misperception.

The stories behind the statistics.

Too often, we fail to illustrate our research findings with descriptions of the circumstances of injury. These details make the subject come alive and provide insight into likely preventive measures. Often the descriptions can be gleaned from accompanying text, relevant newspaper articles, or from visits to the scene of injury. Restricting our findings to cold statistics and numerical data does a disservice to our readers and reduces the likelihood that the research results will have maximum effect.

Hot-air balloon tours: crash epidemiology in the United States, 2000-2011.

INTRODUCTION: Hot-air balloon tours are FAR Part 91-governed balloon rides conducted for compensation or hire. Part 91, General Aviation, in general involves the least strict federal regulations and accounts for the majority of aviation crashes and fatalities. METHODS: National Transportation Safety Board reports of hot-air balloon tour crashes in the United States from 2000 through 2011 were read and analyzed. RESULTS: During the 12-yr period, 78 hot-air balloon tours crashed, involving 518 occupants. There were 91 serious injuries and 5 fatalities; 83% of crashes resulted in one or more serious or fatal outcomes. Of the serious injuries characterized, 56% were lower extremity fractures. Most crashes (81%) occurred during landing; 65% involved hard landings. Fixed object collisions contributed to 50% of serious injuries and all 5 fatalities. During landing sequences, gondola dragging, tipping, bouncing, and occupant ejection were associated with poor outcomes. Of the crashes resulting in serious or fatal outcomes, 20% of balloons were significantly damaged or destroyed. DISCUSSION: The incidence of morbidity and mortality is high among hot-air balloon tour crashes, and the proportion of balloon crashes attributed to paid rides appears to have increased over time. In addition to examining the role of restraint systems, personal protective equipment, and power line emergency procedures in ballooning, injury prevention efforts should target factors such hard landings, object strikes, gondola instability, and occupant ejections, which are associated with balloon injuries and deaths. Crash outcomes may also improve with vehicle engineering that enables balloons themselves to absorb impact forces.

US commercial air tour crashes, 2000-2011: burden, fatal risk factors, and FIA Score validation.

INTRODUCTION: This study provides new public health data concerning the US commercial air tour industry. Risk factors for fatality in air tour crashes were analyzed to determine the value of the FIA Score in predicting fatal outcomes. METHODS: Using the Federal Aviation Administration's (FAA) General Aviation and Air Taxi Survey and National Transportation Safety Board data, the incidence of commercial air tour crashes from 2000 through 2010 was calculated. Fatality risk factors for crashes occurring from 2000 through 2011 were analyzed using regression methods. The FIA Score, Li and Baker's fatality risk index, was validated using receiver operating characteristic (ROC) curves. RESULTS: The industry-wide commercial air tour crash rate was 2.7 per 100,000 flight hours. The incidence rates of Part 91 and 135 commercial air tour crashes were 3.4 and 2.3 per 100,000 flight hours, respectively (relative risk [RR] 1.5, 95% confidence interval [CI] 1.1-2.1, P=0.015). Of the 152 air tour crashes that occurred from 2000 through 2011, 30 (20%) involved at least one fatality and, on average, 3.5 people died per fatal crash. Fatalities were associated with three major risk factors: fire (adjusted odds ratio [AOR] 5.1, 95% CI 1.5-16.7, P=0.008), instrument meteorological conditions (AOR 5.4, 95% CI 1.1-26.4, P=0.038), and off-airport location (AOR 7.2, 95% CI 1.6-33.2, P=0.011). The area under the FIA Score's ROC curve was 0.79 (95% CI 0.71-0.88). DISCUSSION: Commercial air tour crash rates were high relative to similar commercial aviation operations. Disparities between Part 91 and 135 air tour crash rates reflect regulatory disparities that require FAA action. The FIA Score appeared to be a valid measurement of fatal risk in air tour crashes. The FIA should prioritize interventions that address the three major risk factors identified by this study.

Narrative text analysis to identify technologies to prevent motor vehicle crashes: examples from military vehicles.

INTRODUCTION: The purpose of this research is to describe the leading circumstances of military vehicle crashes to guide prioritization and implementation of crash avoidance and/or warning technologies. METHODS: A descriptive study using narrative text analysis on 3,944 military vehicle crash narratives. Crash data on drivers, from 2001 to 2006, were assembled from the U.S. Army Combat Readiness/Safety Center. Reviewers collected information on the circumstances of crashes and determined if vehicle technology could have prevented the crash. RESULTS: Nearly 98% of the crashes were nonfatal; 63% occurred in the U.S. and 24% in Iraq. Among crash events where the direction of the impact was recorded, 32% were to the front of the vehicle and 16% involved a vehicle being rear-ended. Rollovers were mentioned in 20% of the narratives. Technology was determined to have the potential to prevent 26% of the crashes, with the forward collision warning system, rear end collision avoidance, emergency brake assistance, and rollover stability control system likely to have the greatest impacts. CONCLUSIONS: Some technologies available for civilian vehicles may prevent certain military crash circumstances. IMPACT ON INDUSTRY: The results of this research are significant in light of ongoing global military operations that rely on military vehicles. Improving the preventive technology featured on military vehicles may be an effective strategy to reduce the occurrence of military crashes.

Increase in suicide by hanging/suffocation in the U.S., 2000-2010.

BACKGROUND: Recently, suicide exceeded motor vehicle crashes as the leading cause of injury death in the U.S. However, details of this change in suicide methods and the relationship to individual demographics, such as age and societal influences, have not been reported. PURPOSE: To determine the characteristics of the changes in suicide rates between 2000 and 2010. METHODS: Data came from CDC's Web-Based Injury Statistics Query and Reporting System (WISQARS™). Line charts were plotted to reveal changes in suicide rates by firearm, poisoning, and hanging/suffocation (ICD-10 codes: X72-X74, X60-X69, and X70). The measure of change used is the percentage change in suicide rate between 2000 and 2010. RESULTS: The overall suicide rate increased from 10.4 to 12.1 per 100,000 population between 2000 and 2010, a 16% increase. The majority of the increase was attributable to suicide by hanging/suffocation (52%) and by poisoning (19%). Subgroup analysis showed: (1) suicide by hanging/suffocation increased by 104% among those aged 45-59 years and rose steadily in all age groups except those aged ≥70 years; (2) the largest increase in suicide by poisoning (85%) occurred among those aged 60-69 years; and (3) suicide by firearm decreased by 24% among those aged 15-24 years but increased by 22% among those aged 45-59 years. The case fatality rates for suicide by hanging/suffocation during 2000-2010 ranged from 69% to 84%, close to those for suicide by firearm. Analyses were conducted in 2012. CONCLUSIONS: Substantial increases in suicide by hanging/suffocation and poisoning merit attention from policymakers and call for innovations and changes in suicide prevention approaches.

Injury risk and severity in a sample of Maryland residents with serious mental illness.

OBJECTIVE: Adults with serious mental illness experience premature mortality and heightened risk for medical disease, but little is known about the burden of injuries in this population. The objective of this study was to describe injury incidence among persons with serious mental illness. METHODS: We conducted a retrospective cohort study of 6234 Maryl and Medicaid recipients with serious mental illness from 1994-2001. Injuries were classified using the Barell Matrix. Relative risks were calculated to compare injury rates among the study cohort with injury rates in the United States population. Cox proportional hazards modeling with time dependent covariates was used to assess factors related to risk of injury and injury-related death. RESULTS: Forty-three percent of the Maryland Medicaid cohort had any injury diagnosis. Of the 7298 injuries incurred, the most common categories were systemic injuries due to poisoning (10.4%), open wounds to the head/face (8.9%), and superficial injuries, fractures, and sprains of the extremities (8.6%, 8.5%, and 8.4%, respectively). Injury incidence was 80% higher and risk for fatal injury was more than four and a half times higher among the cohort with serious mental illness compared to the general population. Alcohol and drug abuse were associated with both risk of injury and risk of injury-related death with hazard ratios of 1.87 and 4.76 at the p<0.05 significance level, respectively. CONCLUSIONS: The superficial, minor nature of the majority of injuries is consistent with acts of minor victimization and violence or falls. High risk of fatal and non-fatal injury among this group indicates need for increased injury prevention efforts targeting persons with serious mental illness and their caregivers.

Gender and Age Differences among Teen Drivers in Fatal Crashes.

To identify age and gender differences among teen drivers in fatal crashes, we analyzed FARS data for 14,026crashes during 2007-2009. Compared with female teenagers, crashes of male teenagers were significantly more likely to involve BACs of 0.08% or more (21% vs. 12%), speeding (38% vs. 25%), reckless driving (17% vs. 14%), night driving (41% vs. 36%) and felony crashes (hit-and-run, homicide, or manslaughter) (8% vs. 6%) (all χ(2) p<0.001). Conversely, crashes of female teenagers were more likely to involve right angle ("t-bone") crashes (23% vs. 17%). Some crash characteristics associated with males and known to play a major role in crash causation also are more common in the youngest teenagers; for example, crashes of drivers age 15 or 16 were more likely than crashes of older teens to involve speeding or reckless driving. Crashes of drivers with BACs of 0.08% or higher increased with age in both genders. Some age effects differed by gender: for example, the proportion of crashes of female teens that involved speeding dropped from 38% to 22% between ages 15 and 19, while for males about 38% of crashes at each age involved speeding. The gender and age differences observed in teen drivers suggest opportunities for targeted driver training - for example, simulator training modules specifically tailored for male or female teenagers. Technology-based tools could also be developed to help parents to focus on the reckless driving tendencies of their sons. Insurance companies should consider ways to incentivize young males to drive more responsibly.

Injuries to deployed U.S. Army soldiers involved in HMMWV crashes, 2002-2006.

Highly mobile multipurpose wheeled vehicle (HMMWV or Humvee) crashes present an important issue for the U.S. military. The aim of this study was to provide a descriptive analysis of occupants of military motor vehicle (MMV) crashes involving HMMWVs that occurred among deployed U.S. Army Soldiers. Crash-related data were collected from the U.S. Army Combat Readiness/Safety Center on MMV crashes among active duty Army personnel between 1999 and 2006. Records for 964 occupants with injuries from HMMWV crashes were analyzed, which represented 52% of the total occupants of MMV crashes. A significant association was observed between injury and engagement in combat, odds ratio 1.49 (1.03, 2.16). The risk of injury was greatest for gunners, odds ratio 2.37 (1.43, 3.92), and injury cost related to the crash was significantly related to prior deployment status (p < 0.001) and role of Soldier in the vehicle (Operator p = 0.005, Gunner p = 0.003). There was also a decrease over time in the number of crashes resulting in injury (p < 0.001). These data support the development of interventions that address the specific risks detailed, including the use of combat simulation training, increased protection for vulnerable positions, and enforcement of safety regulations.

Should the IDC-9 Trauma Mortality Prediction Model become the new paradigm for benchmarking trauma outcomes?

BACKGROUND: Optimum quantification of injury severity remains an imprecise science with a need for improvement. The accuracy of the criterion standard Injury Severity Score (ISS) worsens as a patient's injury severity increases, especially among patients with penetrating trauma. The objective of this study was to comprehensively compare the mortality prediction ability of three anatomic injury severity indices: the ISS, the New ISS (NISS), and the DRG International Classification of Diseases-9th Rev.-Trauma Mortality Prediction Model (TMPM-ICD-9), a recently developed contemporary injury assessment model. METHODS: Retrospective analysis of patients in the National Trauma Data Bank from 2007 to 2008. The TMPM-ICD-9 values were computed and compared with the ISS and NISS for each patient using in-hospital mortality after trauma as the outcome measure. Discrimination and calibration were compared using the area under the receiver operator characteristic curve. Subgroup analysis was performed to compare each score across varying ranges of injury severity and across different types of injury. RESULTS: A total of 533,898 patients were identified with a crude mortality rate of 4.7%. The ISS and NISS performed equally in the groups with minor (ISS, 1-8) and moderate (ISS, 9-15) injuries, regardless of the injury type. However, in the populations with severe (ISS, 16-24) and very severe (ISS, ≥ 25) injuries for all injury types, the NISS predicted mortality better than the ISS did. The TMPM-ICD-9 outperformed both the NISS and ISS almost consistently. CONCLUSION: The NISS and TMPM-ICD-9 are both superior predictors of mortality as compared with the ISS. The immediate adoption of NISS for evaluating trauma outcomes using trauma registry data is recommended. The TMPM-ICD-9 may be an even better measure of human injury, and its use in administrative or nonregistry data is suggested. Further research on its attributes is recommended because it has the potential to become the basis for benchmarking trauma outcomes. LEVEL OF EVIDENCE: Prognostic study, level III.

An explanation for the recent increase in the fall death rate among older Americans: a subgroup analysis.

OBJECTIVE: We sought to explain the recent increase in the death rate from falls among Americans aged 65 years and older. METHODS: Using the CDC WONDER online database, a longitudinal analysis of subgroups of fall mortality based on the International Classification of Diseases, 10th Revision (ICD-10) was conducted in older adults and in younger people. We used linear regression to examine the statistical significance of trends in mortality rates during 1999-2007. RESULTS: The overall mortality rate from falls increased by 55% among older Americans (≥65 years of age) during 1999-2007, from 29 per 100,000 population to 45 per 100,000 population. For those aged ≥65 years, the largest increase by far (698%) occurred in the subgroup "other falls on the same level," followed by a moderate increase in falls involving wheelchairs or furniture (48%). The steepest increases at all ages occurred from 1999 to 2000, after ICD-10 took effect. State-level analysis confirmed the findings for the entire United States. From 1999 to 2007, total mortality from falls decreased by 5% in people younger than 45 years of age and increased by 44% for those aged 45-64 years; mortality from "other falls on the same level" increased by 202% and 431%, respectively, in these age groups. CONCLUSIONS: Because the reported minor increases in emergency department and hospitalization rates for falls were insignificant, the almost sevenfold increase in death rates from "other falls on the same level" strongly suggests an effect of improved reporting quality.

Association between helicopter vs ground emergency medical services and survival for adults with major trauma.

CONTEXT: Helicopter emergency medical services and their possible effect on outcomes for traumatically injured patients remain a subject of debate. Because helicopter services are a limited and expensive resource, a methodologically rigorous investigation of its effectiveness compared with ground emergency medical services is warranted. OBJECTIVE: To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study involving 223,475 patients older than 15 years, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers and whose data were recorded in the 2007-2009 versions of the American College of Surgeons National Trauma Data Bank. INTERVENTIONS: Transport by helicopter or ground emergency services to level I or level II trauma centers. MAIN OUTCOME MEASURES: Survival to hospital discharge and discharge disposition. RESULTS: A total of 61,909 patients were transported by helicopter and 161,566 patients were transported by ground. Overall, 7813 patients (12.6%) transported by helicopter died compared with 17,775 patients (11%) transported by ground services. Before propensity score matching, patients transported by helicopter to level I and level II trauma centers had higher Injury Severity Scores. In the propensity score-matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (odds ratio [OR], 1.16; 95% CI, 1.14-1.17; P < .001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13-1.17; P < .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P < .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P < .001). Fewer patients transported by helicopter left level II trauma centers against medical advice (0.5% vs 1.0%, P < .001). CONCLUSION: Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders.

Trends in US pediatric drowning hospitalizations, 1993-2008.

BACKGROUND: In the United States, drowning is the second leading cause of unintentional injury death in children aged 1 to 19 years, accounting for nearly 1100 deaths per year. Although a decline in overall fatal drowning deaths among children has been noted, national trends and disparities in pediatric drowning hospitalizations have not been reported. METHODS: To describe trends in pediatric drowning in the United States and provide national benchmarks for state and regional comparisons, we analyzed existing data (1993-2008) from the Nationwide Inpatient Sample, the largest, longitudinal, all-payer inpatient care database in the United States. Children aged 0 to 19 years were included. Annual rates of drowning-related hospitalizations were determined, stratified by age, gender, and outcome. RESULTS: From 1993 to 2008, the estimated annual incidence rate of pediatric hospitalizations associated with drowning declined 49% from 4.7 to 2.4 per 100 000 (P < .001). The rates declined for all age groups and for both males and females. The hospitalization rate for males remained consistently greater than for females at each point in time. Rates of fatal drowning hospitalization declined from 0.5 (95% confidence interval, 0.4-0.7) deaths per 100 000 in 1993-1994 to 0.3 (95% confidence interval, 0.2-0.4) in 2007-2008 (P < .01). No difference was observed in the mean hospital length of stay over time. CONCLUSIONS: Pediatric hospitalization rates for drowning have decreased over the past 16 years. Our study provides national estimates of pediatric drowning hospitalization that can be used as benchmarks to target and assess prevention strategies.

Epidemiologic approaches to injury and violence.

This volume of Epidemiologic Reviews features 13 articles covering a variety of injury problems and research topics. In this commentary, the authors highlight the remarkable achievements in injury control and the important role the Haddon Matrix has played in understanding injury causation and developing preventive strategies; comment on the individual articles included in this volume in the broad categories of research methods, childhood injury, motor-vehicle-related injury, alcohol-related injury, intentional injury, and occupational injury; and outline research gaps and future directions in injury epidemiology and prevention.

'It was a freak accident': an analysis of the labelling of injury events in the US press.

OBJECTIVES: Given that the news media shape our understanding of health issues, a study was undertaken to examine the use by the US media of the expression 'freak accident' in relation to injury events. This analysis is intended to contribute to the ongoing consideration of lay conceptualisation of injuries as 'accidents'. METHODS: LexisNexis Academic was used to search three purposively selected US news sources (Associated Press, New York Times and Philadelphia Inquirer) for the expression 'freak accident' over 5 years (2005-9). Textual analysis included both structured and open coding. Coding included measures for who used the expression within the story, the nature of the injury event and the injured person(s) being reported upon, incorporation of prevention information within the story and finally a phenomenological consideration of the uses and meanings of the expression within the story context. Results The search yielded a dataset of 250 human injury stories incorporating the term 'freak accident'. Injuries sustained by professional athletes dominated coverage (61%). Fewer than 10% of stories provided a clear and explicit injury prevention message. Stories in which journalists employed the expression 'freak accident' were less likely to include prevention information than stories in which the expression was used by people quoted in the story. CONCLUSIONS: Journalists who frame injury events as freak accidents may be an appropriate focus for advocacy efforts. Effective prevention messages should be developed and disseminated to accompany injury reporting in order to educate and protect the public.

Motor vehicle crashes among active duty U.S. Army personnel, 1999 to 2006.

In the U.S. Army, motor vehicle crashes (MVCs), both privately owned and military, are a leading cause of injury and death. Few studies have described the distribution and trends of MVCs among Army personnel, which may have been impacted by current military missions. This descriptive study of risk factors and select outcomes is from safety report data maintained by the U.S. Army Combat Readiness/Safety Center on 11,469 active duty Army personnel involved in MVCs, 1999-2006. The majority (66%) of Soldiers in MVCs were in military vehicles within the continental United States (68%). The average age of individuals involved in MVCs was 27.7 years old. Males had a consistently higher MVC rate than females. The average cost per MVC related to property damage and injuries was $36,039 and $24,038, respectively. Results suggest a need for additional exploration of MVCs involving Army vehicles, which were the most common and among the most costly.