Pregnancy loss and risk of incident CVD within 5 years: Findings from the Women's Health Initiative.

Background: Previous studies have demonstrated an increased risk of cardiovascular disease (CVD) in women with a history of pregnancy loss. Less is known about whether pregnancy loss is associated with age at the onset of CVD, but this is a question of interest, as a demonstrated association of pregnancy loss with early-onset CVD may provide clues to the biological basis of the association, as well as having implications for clinical care. We conducted an age-stratified analysis of pregnancy loss history and incident CVD in a large cohort of postmenopausal women aged 50-79 years old. Methods: Associations between a history of pregnancy loss and incident CVD were examined among participants in the Women's Health Initiative Observational Study. Exposures were any history of pregnancy loss (miscarriage and/or stillbirth), recurrent (2+) loss, and a history of stillbirth. Logistic regression analyses were used to examine associations between pregnancy loss and incident CVD within 5 years of study entry in three age strata (50-59, 69-69, and 70-79). Outcomes of interest were total CVD, coronary heart disease (CHD), congestive heart failure, and stroke. To assess the risk of early onset CVD, Cox proportional hazard regression was used to examine incident CVD before the age of 60 in a subset of subjects aged 50-59 at study entry. Results: After adjustment for cardiovascular risk factors, a history of stillbirth was associated with an elevated risk of all cardiovascular outcomes in the study cohort within 5 years of study entry. Interactions between age and pregnancy loss exposures were not significant for any cardiovascular outcome; however, age-stratified analyses demonstrated an association between a history of stillbirth and risk of incident CVD within 5 years in all age groups, with the highest point estimate seen in women aged 50-59 (OR 1.99; 95% CI, 1.16-3.43). Additionally, stillbirth was associated with incident CHD among women aged 50-59 (OR 3.12; 95% CI, 1.33-7.29) and 60-69 (OR 2.06; 95% CI, 1.24-3.43) and with incident heart failure and stroke among women aged 70-79. Among women aged 50-59 with a history of stillbirth, a non-significantly elevated hazard ratio was observed for heart failure before the age of 60 (HR 2.93, 95% CI, 0.96-6.64). Conclusions: History of stillbirth was strongly associated with a risk of cardiovascular outcomes within 5 years of baseline in a cohort of postmenopausal women aged 50-79. History of pregnancy loss, and of stillbirth in particular, might be a clinically useful marker of cardiovascular disease risk in women.

Prospective Associations between Childhood Exposure to Living with Adult Alcohol Misuse and Major Depressive Disorder in Adulthood: The Role of Child Maltreatment.

BACKGROUND: Many children grow up with adult alcohol misuse in the home. A clearer understanding of this exposure's long-term mental health consequences and the role of associated child maltreatment experiences and potential protective factors could guide relevant intervention strategies. OBJECTIVE: To prospectively evaluate the association between living with adult alcohol misuse during childhood and major depressive disorder (MDD) during adulthood; whether child maltreatment explains the association; and whether sex, school bonding, or neighborhood bonding moderate the association.Participants and setting: This study used longitudinal data from 783 individuals followed from childhood to age 39. METHODS: At grade 9, participants were asked whether they lived with adults who misused alcohol. Diagnostic assessments of MDD were conducted across three time-points during participants' thirties and participants were categorized as having met diagnostic criteria 0, 1, or 2 or more times. RESULTS: Ordinal logistic regressions found that children living with adult alcohol misuse showed greater chronicity of adult MDD (OR = 1.63; 95% CI: 1.05, 2.52). There was a 49% reduction in the odds ratio and the association was no longer statistically significant when child maltreatment was included in the model (OR = 1.32; 95% CI: 0.84, 2.07). No statistically significant moderation of associations was observed. CONCLUSIONS: Children exposed to adult alcohol misuse, and maltreatment often associated with this misuse, may be at risk for mental health challenges well into adulthood. Interventions that address childhood exposure to adult alcohol misuse and associated maltreatment may be important to mitigate long-term mental health challenges to exposed children.

Mother's and Father's Serious Mental Illness and Risk of Child Injury in a Taiwanese Birth Cohort.

Objective: Parental serious mental illness (SMI) is associated with childhood injury. This study investigated whether child injury risk differs according to which parent is affected, SMI diagnosis, or timing of SMI onset.Methods: This cohort study included 1,999,322 singletons born in 2004-2014 identified from the national Taiwanese registries. General estimating equation Poisson models were used to estimate incidence rate ratios (IRRs) of injury events and hospitalizations before the age of 5 years among children according to which parent was affected, SMI diagnosis (schizophrenia [ICD-9-CM codes: 295, 297, 298.3, 298.4, 298.9], bipolar disorder [296.00-296.16, 296.40-296.81, 296.89-296.99, 298.1, 648.4], or major depressive disorder [MDD; 296.20-296.36, 296.82, 298.0]), and timing of diagnosis (before or after childbirth, as a proxy of timing of onset). Data analysis was performed on data obtained from April 20, 2017, to May 6, 2020.Results: Relative to unexposed children, the IRRs of injury hospitalizations for children with two SMI-affected parents, maternal SMI only, and paternal SMI only were 1.85 (95% CI, 1.38-2.48), 1.58 (95% CI, 1.48-1.68), and 1.34 (95% CI, 1.23-1.46), respectively. The IRRs of injury hospitalizations for maternal schizophrenia, bipolar disorder, and MDD were 2.09 (95% CI, 1.82-2.40), 1.77 (95% CI, 1.56-2.00), and 1.38 (95% CI, 1.26-1.50), respectively. The IRRs for paternal schizophrenia, bipolar disorder, and MDD were 1.39 (95% CI, 1.20-1.60), 1.61 (95% CI, 1.39-1.87), and 1.19 (95% CI, 1.05-1.36), respectively. The magnitude of excess risk was similar for children whose parent(s) experienced SMI diagnosed before and after childbirth.Conclusions: We found children with two SMI-affected parents or at least one parent with schizophrenia or bipolar disorder to be at greatest risk of severe injury requiring hospitalization. These parents may benefit from extra parenting support and injury prevention coaching.

Assessment of Variation in US State Laws Addressing the Prevention of and Response to Teen Dating Violence in Secondary Schools.

Importance: Teen dating violence (TDV) is widespread and has adverse consequences across the life course. Many US states are actively seeking strategies to prevent and address TDV in schools, including enactment and implementation of TDV laws. These state laws are upstream, system-level interventions that lay the foundation for an array of downstream targeted interventions to be deployed in schools. Despite these laws gaining momentum in the past decade, there has been minimal research examining their content and variability. Objective: To assess the content and comprehensiveness of US state laws addressing prevention of and response to TDV in secondary schools. Design, Setting, and Participants: A team of public health and legal researchers used systematic policy surveillance methods to develop a comprehensive database of state laws addressing TDV in schools in all 50 US states and the District of Columbia (referred to hereinafter as "states") in effect as of September 30, 2020. Using LexisNexis and state legislature websites, state laws (statutes and administrative codes) were identified. Main Outcomes and Measures: Components for each law were coded within 5 categories: scope, prevention education, policy, response, and implementation. Results: Overall, 38 states (74.5%) had at least 1 law addressing TDV in secondary schools and 13 states (25.5%) did not. Fewer than half of states with a law (15 of 38 [39.5%]) defined TDV. All 38 states addressed prevention education, with 29 (76.3%) requiring and 9 (23.7%) encouraging these efforts. Prevention education was largely for students in most states (35 [92.1%]), but some states also required school staff (18 [47.4%]) and parents (8 [21.1%]) to receive prevention education. Fewer than half of states required (14 [36.8%]) or encouraged (3 [7.9%]) school districts to develop a policy addressing TDV. Very few states included requirements for how schools must respond to TDV incidents. Fewer than a third of states designated an individual to coordinate TDV efforts (12 [31.6%]), included a funding provision in their laws for TDV programs and policies (10 [26.3%]), and included explicit consequences for noncompliance with TDV laws (12 [31.6%]). Conclusions and Relevance: This cross-sectional study found that most US states had laws addressing TDV in schools, but there was significant variation in the content and comprehensiveness of the laws. These findings can inform the development of more comprehensive laws on TDV that may ultimately reduce such incidents.

Firearms and protective orders in intimate partner homicides.

PURPOSE: To determine differences among intimate partner homicides (IPH) by whether or not a firearm was used in and whether a protective order (PO) was filed prior to IPH. METHOD: We identified all incidents of IPH recorded in the National Violent Death Reporting System from 2003-2018, based on the relationship between victim and perpetrator. We characterized incidents, perpetrators and victims in IPH cases by whether or not a firearm was used, and whether a PO had been sought or issued prior to the IPH. RESULTS: We identified 8,375 IPH incidents with a total of 9,130 victims. Overall 306 (3.3%) victims were killed in a firearm IPH with PO, 4,519 (53.9%) in a firearm IPH without PO, 176 (2.1%) in a non-firearm IPH with PO and 3,416 (40.7%) in a non-firearm IPH without PO. Based on review of incident narratives, 5.4% (n=451) of incidents involved a previously-granted or sought PO, and none of which had explicitly mentioned firearm removal as a part of the PO. CONCLUSIONS: The majority of victims were killed with a firearm. Prior literature suggests that POs with firearm removal may be effective strategies for reducing risk of IPH, but we found no documentation in the narratives that firearm removal was a condition in the POs identified. As very few IPH narratives included documentation of a PO, it is likely that ascertainment of PO status is incomplete and could be an area for improvement in NVDRS data collection efforts.

Risk Factors for Child Death During an Intimate Partner Homicide: A Case-Control Study.

Corollary victims represent approximately 20% of all intimate partner homicides (IPH), and many are children. We used National Violent Death Reporting System (NVDRS) data (2003-2017) to compare all IPH incidents with a child corollary victim (n = 227) to all IPH incidents where a child was present but not killed (n = 350). We examined risk factors for child fatality during an IPH. For each risk factor, we calculated the odds ratio for child death during the IPH, adjusting for multiple comparisons. Perpetrator history of suicidal behavior, rape of the intimate partner victim, a non-biological child of the perpetrator living in the home, and perpetrator job stressors increased odds while prior separation of the IPV victim from the perpetrator decreased the odds of a child death during an IPH incident. To our knowledge, this is the first case-control study using live-controls within NVDRS and can help direct prevention efforts for child death during IPH.

Association of Parental Mental Illness With Child Injury Occurrence, Hospitalization, and Death During Early Childhood.

Importance: Injury is a leading cause of childhood morbidity and mortality worldwide. Serious mental illness (SMI) is a major contributor to the global burden of disease. Objective: To compare injury event rates in children from birth to 5 years of age among Taiwanese children with and without parents with SMI, including schizophrenia, bipolar disorder, and major depressive disorder. Design, Setting, and Participants: This population-based, retrospective cohort study of an 11-year Taiwanese birth cohort used data from the Taiwan National Health Insurance Research Database (covering 99% of Taiwanese citizens), the Maternal and Child Health Database, and birth and death certificate databases. The study included 1 999 322 singletons with Taiwanese citizenship born from January 1, 2004, to December 31, 2014, and followed up from birth to their fifth birthday, December 31, 2014, or the date of death, yielding a total of 7 741 026 person-years. Data analysis was performed from April 20, 2017, to September 24, 2019. Exposures: Physician-diagnosed parental SMI defined using outpatient and inpatient records from 6 years before the child's birth to 5 years after delivery. Main Outcome and Measures: Rates of medically attended injury events, injury hospitalization, and injury death retrieved from outpatient records, inpatient records, and death certificates. Generalized estimating equation for log-linear models estimated injury incidence rate ratios (IRRs) comparing parental SMI-exposed children and unexposed children. Results: The study cohort included 1 999 322 singletons (52.1% males without parental SMI and 52.2% males with parental SMI). Incidence rates of child injury-related outcomes were higher among children exposed to parental SMI (294.8 injury events per 1000 person-years) compared with children who were unexposed (256.1 injury events per 1000 person-years). After adjustment for sociodemographic factors, children with parental SMI had higher rates of injury events (IRR, 1.14; 95% CI, 1.13-1.15), injury hospitalization (IRR, 1.49; 95% CI, 1.42-1.57), and injury death (IRR, 1.82; 95% CI, 1.38-2.39) compared with unexposed children. The results were confirmed in sensitivity analyses. Appendicitis, a negative control outcome, was not associated with parental SMI (IRR, 1.10; 95% CI, 0.94-1.28). In addition, children with and without parental SMI had similar patterns of preventive health care. The mean (SD) number of prenatal visits was 8.09 (2.50) for children with parental SMI and 8.17 (2.47) among unaffected children. The mean (SD) number of well-child visits was 5.70 (2.24) for children with parental SMI and 5.80 (2.21) among unaffected children. Conclusions and Relevance: In this study, children with parental SMI had increased risk of injury, particularly serious injury. Excess risk may be reduced by providing effective mental health treatment, parenting support, and home safety education to parents with SMI who are raising young children.

Variation in State Laws on Access to Civil Protection Orders for Adolescents Experiencing Intimate Partner Violence.

PURPOSE: Intimate partner violence (IPV) is prevalent among adolescents. Civil protection orders (CPOs) are the most common legal remedy used by individuals experiencing IPV to prevent recurrence. However, laws on whether adolescents can access CPOs vary by state. We assessed the landscape of state legislation regarding adolescents' access to CPOs for IPV. METHODS: We systematically assessed statutes across all 50 U.S. states and the District of Columbia for 5 indicators: whether minors can be granted CPOs, whether minors can file on their own behalf, whether dating relationships are eligible, definitions of abuse qualifying for CPOs, and whether a CPO prohibits firearm possession and requires surrender of firearms. RESULTS: A total of 48 states (94%) explicitly allow minors to obtain CPOs. Fourteen states (27%) explicitly allow minors to file for a CPO on their own behalf. Forty-four states (86%) recognize dating relationships as qualifying relationships for a CPO. A CPO may be issued for physical violence in all 51 states (100%), sexual violence in 46 states (90%), threats of physical or sexual violence in 47 states (92%), stalking in 44 states (86%), and psychological/emotional violence in 28 states (55%). In 22 states (43%), an individual subject to a CPO is prohibited from possessing firearms and is required to surrender firearms they already have. CONCLUSIONS: There is a significant variation in states' CPO statutes related to adolescent IPV. Improvements in legislation that reduce the barriers to legal relief for those experiencing violence can be an important part of a comprehensive solution to reducing IPV among adolescents.

The impact of exposure to parental intimate partner violence on adolescent precocious transitions to adulthood.

INTRODUCTION: Precocious transitions can create stress by placing excessive demands on adolescents and are associated with adverse outcomes that extend into adulthood. The current study assessed whether exposure to parental intimate partner violence (IPV) is associated with adolescent precocious transitions to adulthood. METHODS: Data come from 33,360 individuals aged 18+ years in the United States who participated in the National Epidemiologic Surveys of Alcohol and Related Conditions. Six precocious transitions (leaving home early, early sex, early marriage, early parenthood, early full-time employment, and dropping out of high school) were examined. Robust Poisson regression was used to calculate relative risks for the association between IPV exposure and each precocious transition, adjusting for confounders. We assessed effect modification by gender and by exposure to childhood abuse or neglect. RESULTS: Participants exposed to IPV in childhood were at higher risk of engaging in early sex; dropping out of high school; entering into early full-time employment; entering into early marriage; and entering into early parenthood relative to participants not exposed to IPV. Significant interactions between gender and exposure to IPV were detected for early sex and early full-time work outcomes, such that the associations were stronger for females compared to males. Participants exposed to more frequent or more severe IPV in childhood were at even higher risk for experiencing precocious transitions. CONCLUSIONS: Individuals exposed to IPV in childhood are more likely to experience precocious transitions to adulthood. Findings highlight the need for interventions to mitigate adverse outcomes in adolescence for children exposed to IPV.

Use of multiple failure models in injury epidemiology: a case study of arrest and intimate partner violence recidivism in Seattle, WA.

BACKGROUND: Single-failure survival models are commonly used in injury research. We aimed to demonstrate the application of multiple failure survival models in injury research by measuring the association between arrest and IPV recidivism. METHODS: We used data from a population-based cohort of 5466 male-female couples with a police-reported, male-perpetrated incident of IPV against their female partners that occurred in Seattle, WA during 1999-2001. We estimated the risk of physical and psychological IPV recidivism (separately) for the 12 months following the index event, according to perpetrator arrest or non-arrest for the index event. We used time-dependent extended Cox regression analyses for time-to-first IPV event and Prentice, Williams and Peterson model-based analyses for time-to-multiple IPV events. RESULTS: Arrest was associated with a reduction in time-to-first physical IPV recurrence but was not associated with time-to-first psychological IPV recurrence during the 12-month follow-up. Arrest was associated with a significantly decreased risk of physical and psychological IPV during the 12-month follow-up in the multiple failure models. The association between arrest and lower risk of physical IPV recidivism increased with increasing number of follow-up IPV events. CONCLUSIONS: We found arrest to be a plausible deterrent for recurrent IPV reduction. Our study also illustrates the use of multiple failure survival analyses in injury research. Such techniques facilitate inference about estimands that may have greater public health relevance and properly account for injury recurrence. By using multiple failure models, we were able to more deeply understand the relationship between arrest and IPV over time.

Intimate Partner Homicide of Adolescents.

Importance: Intimate partner violence during adolescence is widespread, and consequences can be severe. Intimate partner homicide (IPH) is the most extreme form of intimate partner violence, but literature on IPH has almost exclusively focused on adults. Objectives: To determine the proportion of adolescent homicides that is perpetrated by intimate partners and to describe the victim, perpetrator, and incident characteristics of these IPHs. Design, Setting, and Participants: Analysis of quantitative and qualitative surveillance data from the National Violent Death Reporting System from 2003 to 2016. Data represent 32 states that contributed to the system for 1 year or longer. There were 8048 homicides of victims aged 11 to 24 years with a known relationship between the victim and perpetrator. For persons aged 11 to 18 years, there were 2188 homicides. Analysis began September 2018. Main Outcomes and Measures: An incident was identified as an IPH if the relationship between the perpetrator and victim was coded as spouse, ex-spouse, girlfriend or boyfriend, ex-girlfriend or ex-boyfriend, or girlfriend or boyfriend (unspecified current or former). Variables of interest included demographic characteristics (age, sex, race/ethnicity) for the victim and perpetrator, relationship status at time of death, homicide-suicide, homicide method, firearm type, and location of homicide. Contextual categories were created from the qualitative narratives. Results: Of adolescent homicides, 150 (6.9%) were classified as IPH. A total of 135 victims (90%) were female (mean [SD] age, 16.8 [1.3] years). Overall, 102 perpetrators (77.9%) were 18 years and older (mean [SD] age, 20.6 [5.0] years), and 94 (62.7%) were current intimate partners of the victim. Firearms, specifically handguns, were the most common mechanism of injury. Compared with IPHs of young adults aged 19 to 24 years, perpetrators of adolescent victims were younger and less likely to be a current intimate partner. The most common categories of adolescent IPH homicides were broken/desired relationship or jealousy and an altercation followed by reckless firearm behavior and pregnancy related. Conclusions and Relevance: Adolescents, particularly girls, in dating relationships may face risk of homicide, especially in circumstances of a breakup or jealousy and when perpetrators have access to firearms. Understanding homicide in early dating relationships can inform prevention and intervention efforts tailored to adolescents.

Variation in Adult Traumatic Brain Injury Outcomes in the United States.

OBJECTIVE: To ascertain the degree of variation, by state of acute care hospitalization, in outcomes associated with traumatic brain injury (TBI) in an adult population. SETTING: All acute care hospitals in 21 states in the United States in the year 2010. PARTICIPANTS: Adult (> 18 years) patients (N = 95 546) admitted to a hospital with a moderate or severe TBI. DESIGN: Retrospective cohort study using data from State Inpatient Databases from Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. MAIN MEASURES: Inpatient mortality and discharge to inpatient rehabilitation. RESULTS: The adjusted risk of inpatient mortality varied between states by as much as 40%, with age, severity of injury, and insurance status as significant factors in both outcomes. The adjusted risk of discharge to inpatient rehabilitation varied between by more than 100% among the states measured. CONCLUSIONS: There was clinically significant variation between states in inpatient mortality and rehabilitation discharge after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the causes of this state-to-state variation, how these causes affect patient outcomes, and may serve as a guide to further standardization of treatment for traumatic brain injury across the United States.

Traumatic Events Associated With Posttraumatic Stress Disorder: The Role of Race/Ethnicity and Depression.

This study sought to examine specific types of potentially traumatic experiences as predictors of posttraumatic stress disorder (PTSD) and the moderating effect of race/ethnicity and major depressive disorder (MDD) among non-Hispanic White, non-Hispanic Black, and Hispanic U.S. women. The study sample was drawn from two waves of the National Epidemiologic Surveys of Alcohol and Related Conditions. Sexual assault, intimate partner violence, and childhood trauma were the strongest predictors of PTSD compared with the reference group (indirect/witnessed trauma). Similar patterns were revealed across racial/ethnic groups, although the estimates were most robust among White women. Findings also suggest that MDD moderates the effect of traumatic experiences on PTSD.

Posttraumatic stress disorder and alcohol misuse among women: effects of ethnic minority stressors.

PURPOSE: The aims of this study were to examine the relationship between adult-onset posttraumatic stress disorder (PTSD) and subsequent alcohol use outcomes (frequent heavy drinking, alcohol abuse, and alcohol dependence) in non-Hispanic white, non-Hispanic black, and Hispanic US women, and whether this relationship was moderated by ethnic minority stressors (discrimination and acculturation). METHODS: The study sample was drawn from two waves of the National Epidemiologic Surveys of Alcohol and Related Conditions, employing time-dependent data to conduct multiple extended Cox regression. RESULTS: Women with PTSD were over 50 % more likely than those without PTSD to develop alcohol dependence [adjusted hazards ratio (aHR) 1.55; 95 % confidence interval (CI) 1.15, 2.08]. Hispanic and black women were at lower risk of most alcohol outcomes than white women. In race-/ethnic-specific analyses, however, PTSD only predicted alcohol abuse among Hispanic women (aHR 3.02; CI 1.33, 6.84). Higher acculturation was positively associated with all alcohol outcomes among Hispanic women and discrimination was associated with AUD among Hispanic and black women. Acculturation and discrimination modified the effect of PTSD on AUD among Hispanic women: PTSD predicted alcohol dependence among those with low acculturation (aHR 10.2; CI 1.27, 81.80) and alcohol abuse among those without reported discrimination (aHR 6.39; CI 2.76, 16.49). CONCLUSIONS: PTSD may influence the development of hazardous drinking, especially among Hispanic women. The influence of PTSD on alcohol outcomes is most apparent, however, when ethnic minority stressors are not present.

Validation of ICDPIC software injury severity scores using a large regional trauma registry.

BACKGROUND: Administrative or quality improvement registries may or may not contain the elements needed for investigations by trauma researchers. International Classification of Diseases Program for Injury Categorisation (ICDPIC), a statistical program available through Stata, is a powerful tool that can extract injury severity scores from ICD-9-CM codes. We conducted a validation study for use of the ICDPIC in trauma research. METHODS: We conducted a retrospective cohort validation study of 40,418 patients with injury using a large regional trauma registry. ICDPIC-generated AIS scores for each body region were compared with trauma registry AIS scores (gold standard) in adult and paediatric populations. A separate analysis was conducted among patients with traumatic brain injury (TBI) comparing the ICDPIC tool with ICD-9-CM embedded severity codes. Performance in characterising overall injury severity, by the ISS, was also assessed. RESULTS: The ICDPIC tool generated substantial correlations in thoracic and abdominal trauma (weighted κ 0.87-0.92), and in head and neck trauma (weighted κ 0.76-0.83). The ICDPIC tool captured TBI severity better than ICD-9-CM code embedded severity and offered the advantage of generating a severity value for every patient (rather than having missing data). Its ability to produce an accurate severity score was consistent within each body region as well as overall. CONCLUSIONS: The ICDPIC tool performs well in classifying injury severity and is superior to ICD-9-CM embedded severity for TBI. Use of ICDPIC demonstrates substantial efficiency and may be a preferred tool in determining injury severity for large trauma datasets, provided researchers understand its limitations and take caution when examining smaller trauma datasets.

Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.

OBJECTIVE: The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. DESIGN: Retrospective multicenter cohort study. SETTING: Five regional pediatric trauma centers affiliated with academic medical centers. PATIENTS: Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86). CONCLUSIONS: Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.

Variation in pediatric traumatic brain injury outcomes in the United States.

OBJECTIVE: To ascertain the degree of variation, by state of hospitalization, in outcomes associated with traumatic brain injury (TBI) in a pediatric population. DESIGN: A retrospective cohort study of pediatric patients admitted to a hospital with a TBI. SETTING: Hospitals from states in the United States that voluntarily participate in the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. PARTICIPANTS: Pediatric (age ≤ 19 y) patients hospitalized for TBI (N=71,476) in the United States during 2001, 2004, 2007, and 2010. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Primary outcome was proportion of patients discharged to rehabilitation after an acute care hospitalization among alive discharges. The secondary outcome was inpatient mortality. RESULTS: The relative risk of discharge to inpatient rehabilitation varied by as much as 3-fold among the states, and the relative risk of inpatient mortality varied by as much as nearly 2-fold. In the United States, approximately 1981 patients could be discharged to inpatient rehabilitation care if the observed variation in outcomes was eliminated. CONCLUSIONS: There was significant variation between states in both rehabilitation discharge and inpatient mortality after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.

Informing policy on open water drowning prevention: an observational survey of life jacket use in Washington State.

OBJECTIVE: To assess life jacket use among Washington State boaters and to examine the relationship between life jacket use and boating laws. METHODS: A statewide observational survey of boaters was conducted between August 2010 and September 2010. Data collection included age, sex, life jacket use, boat type, and weather and water conditions. RESULTS: Among 5157 boaters, 30.7% wore life jackets. Life jacket use was highest among groups required by state law: personal watercraft users (96.8%), people being towed (eg, water-skiers) (95.3%) and children 0-12 years old (81.7%). Children and youth were more likely to use a life jacket if any adult in the boat wore a life jacket: 100% versus 87.2% for 0-5 years, 92.8% versus 76.7% for 6-12 years and 81.4% versus 36.1% for 13-17 years. Adult role modelling was particularly beneficial for adolescents aged 13-17 years, who were not covered by a life jacket law. In multivariable analysis, the presence of at least one adult wearing a life jacket was associated with a 20-fold increased likelihood that adolescents were also wearing a life jacket. CONCLUSIONS: Highest life jacket use was strongly associated with laws requiring use and with adult role modelling. Legislation requiring life jackets for ages 13-17 years and social marketing encouraging adult life jacket wear in the company of children and youth are promising strategies to increase life jacket use in Washington State.

Intimate partner violence and neighborhood income: a longitudinal analysis.

This investigation used a longitudinal design to examine the relationship between neighborhood-level income, individual-level predictors, and police-reported intimate partner violence in 5,994 urban couples followed over 2 years. At the baseline abuse incident, intimate partner violence rates were highest in the poorest neighborhoods (13.8 per 1,000 women in the lowest income quartile, followed by 12.1, 8.2, and 5.0 in the respective higher income quartiles). However, in the longitudinal analysis, weapon use at the baseline abuse event was a much stronger predictor of repeat abuse (incident rate ratios ranging from 1.72 for physical abuse to 1.83 for non-physical abuse) than neighborhood income.

Compulsive cell phone use and history of motor vehicle crash.

PURPOSE: Few studies have examined the psychological factors underlying the association between cell phone use and motor vehicle crash. We sought to examine the factor structure and convergent validity of a measure of problematic cell phone use, and to explore whether compulsive cell phone use is associated with a history of motor vehicle crash. METHODS: We recruited a sample of 383 undergraduate college students to complete an online assessment that included cell phone use and driving history. We explored the dimensionality of the Cell Phone Overuse Scale (CPOS) using factor analytic methods. Ordinary least-squares regression models were used to examine associations between identified subscales and measures of impulsivity, alcohol use, and anxious relationship style, to establish convergent validity. We used negative binomial regression models to investigate associations between the CPOS and motor vehicle crash incidence. RESULTS: We found the CPOS to be composed of four subscales: anticipation, activity interfering, emotional reaction, and problem recognition. Each displayed significant associations with aspects of impulsivity, problematic alcohol use, and anxious relationship style characteristics. Only the anticipation subscale demonstrated statistically significant associations with reported motor vehicle crash incidence, controlling for clinical and demographic characteristics (relative ratio, 1.13; confidence interval, 1.01-1.26). For each 1-point increase on the 6-point anticipation subscale, risk for previous motor vehicle crash increased by 13%. CONCLUSIONS: Crash risk is strongly associated with heightened anticipation about incoming phone calls or messages. The mean score on the CPOS is associated with increased risk of motor vehicle crash but does not reach statistical significance.