Impact of the availability of midurethral slings on treatment strategies for stress urinary incontinence: a cost-effectiveness analysis.

OBJECTIVE: To perform a cost-effectiveness analysis for the surgical and non-surgical management of stress urinary incontinence (SUI) with and without the availability of midurethral sling. DESIGN: Cost-effectiveness analysis. SETTING: USA, 2019. POPULATION: Women with stress urinary incontinence. METHODS: We modelled SUI treatment pathways with and without the availability of midurethral slings, including no treatment, incontinence pessary, pelvic floor muscle physical therapy, urethral bulking injection, open and laparoscopic Burch colposuspension, and pubovaginal autologous sling. Time horizon was 2 years after initial treatment. MAIN OUTCOME MEASURES: Costs (2019 US$) included index surgery, surgical retreatment, and complications including urinary retention, de novo urgency and mesh exposure. The incremental cost-effectiveness ratio (ICER) was calculated for non-dominated treatment strategies. RESULTS: The least costly treatment strategies were incontinence pessary, pelvic floor physical therapy, no treatment and midurethral sling, respectively. Midurethral slings had the highest effectiveness. The strategy with the lowest effectiveness was no treatment. The three cost-effective strategies included pessary, pelvic floor muscle physical therapy and midurethral slings. No other surgical options were cost-effective. If midurethral slings were not available, all other surgical options were still dominated by pelvic floor muscle physical therapy. Multiple one-way sensitivity analyses confirmed model robustness. The only reasonable threshold in which outcomes would change, was if urethral bulking costs decreased 12.6%. CONCLUSIONS: The midurethral sling is the most effective SUI treatment and the only cost-effective surgical option. TWEETABLE ABSTRACT: Midurethral sling is the only cost-effective surgical treatment option for stress urinary incontinence.

A cost-effectiveness analysis of sentinel lymph node detection in vulvar cancer by preoperative lymphoscintigraphy versus intraoperative detection alone.

OBJECTIVE: To determine cost-effectiveness of preoperative lymphoscintigraphy (LSG) for detection of inguinofemoral sentinel lymph nodes (SLN). METHOD: We compared the use of preoperative LSG prior to SLN excision versus omission of preoperative LSG. The two outcomes were death or survival. Costs associated with the procedure were determined by CPT code and published estimates. Cost analysis was performed using Treeage software, and incremental cost-effectiveness ratios (ICERs) were calculated. The measure of effectiveness was incremental survival benefit. ICER thresholds for considering LSG to be cost-effective were based on the value of a statistical life (VSL). RESULTS: Using a baseline probability of 0.93 for finding SLN with LSG, our model estimated LSG costs were $2783.84 with 84.7% survival. Our model then estimated the cost and survival without LSG by varying the SLN detection rate. Survival was equivalent when probability of SLN detection without LSG was 0.93. If detection without LSG was >0.93, not performing LSG was the dominant strategy. Costs were equal when probability of finding SLN without LSG was 0.6. For any SLN detection without LSG below 0.6, performing LSG was the dominant strategy. Formal cost-effectiveness analysis was performed using ICERs for probabilities from 0.60 to 0.93. In this range, costs were higher with LSG, but survival was improved. As long as the incremental detection with LSG was at least 1.05% to 1.47% higher, LSG was cost-effective with ICERs below the VSL. CONCLUSION: In our model, LSG is cost-effective as long as it increases detection of SLN by at least 1.05-1.47%.

The effect of age on complications in women undergoing minimally invasive sacral colpopexy.

INTRODUCTION AND HYPOTHESIS: Previous research has demonstrated similar complication rates in older and younger women undergoing abdominal sacral colpopexy via laparotomy. The objective of this study was to compare perioperative complications in older and younger women undergoing minimally invasive sacral colpopexy. METHODS: This was a retrospective study of laparoscopic and robotic sacral colpopexies performed from January 2009 to May 2012 at a large academic center. Patient demographics, surgical data, and perioperative complications were compared in women < 65 and ≥65 years of age. Primary outcome was the difference in major complications. RESULTS: A total of 302 women underwent minimally invasive sacral colpopexy during the study period. Mean age was 58.5 ± 8.8 years and 84 subjects (27.8 %) were ≥65 years. Older women were more likely to have had a prior hysterectomy (60.7 vs 39.0 %, p = 0.001) and had more severe preoperative prolapse (86.9 % vs 71.9 % ≥ POPQ stage III, p = 0.01). There was no significant difference in duration of hospitalization (1.4 vs 1.4 days, p = 0.54). Overall, there were significantly more major complications in women ≥ 65 years (unadjusted OR 1.84, 95 % CI 1.02-3.35, p = 0.04). After controlling for BMI, route of surgery, estimated blood loss (EBL), and operating room time, age ≥ 65 remained a significant predictor of complications (adjusted OR 2.28, 95 % CI 1.21-4.29, p = 0.01). CONCLUSIONS: Our findings suggest that older women have a higher rate of major complications following minimally invasive sacral colpopexy, even after controlling for BMI, route of surgery, EBL, and operating room time. This increased risk should be addressed during preoperative counseling and may influence surgical planning.

Meglitinide analogues for type 2 diabetes mellitus.

BACKGROUND: In type 2 diabetes mellitus, impairment of insulin secretion is an important component of the disease. Meglitinide analogues are a class of oral hypoglycaemic agents that increase insulin secretion, in particular, during the early phase of insulin release. OBJECTIVES: The aim of this review was to assess the effects of meglitinide analogues in patients with type 2 diabetes mellitus. SEARCH STRATEGY: We searched several databases including The Cochrane Library, MEDLINE and EMBASE. We also contacted manufacturers and searched ongoing trials databases, and the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) websites. SELECTION CRITERIA: We included randomised controlled, parallel or cross-over trials comparing at least 10 weeks of treatment with meglitinide analogues to placebo, head-to-head, metformin or in combination with insulin. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed trial quality. MAIN RESULTS: Fifteen trials involving 3781 participants were included. No studies reported the effect of meglitinides on mortality or morbidity. In the eleven studies comparing meglitinides to placebo, both repaglinide and nateglinide resulted in a reductions in glycosylated haemoglobin (0.1% to 2.1% reduction in HbA1c for repaglinide; 0.2% to 0.6% for nateglinide). Only two trials compared repaglinide to nateglinide (342 participants), with greater reduction in glycosylated haemoglobin in those receiving repaglinide. Repaglinide (248 participants in three trials) had a similar degree of effect in reducing glycosylated haemoglobin as metformin. Nateglinide had a similar or slightly less marked effect on glycosylated haemoglobin than metformin (one study, 355 participants). Weight gain was generally greater in those treated with meglitinides compared with metformin (up to three kg in three months). Diarrhoea occurred less frequently and hypoglycaemia occurred more frequently but rarely severely enough as to require assistance. AUTHORS' CONCLUSIONS: Meglitinides may offer an alternative oral hypoglycaemic agent of similar potency to metformin, and may be indicated where side effects of metformin are intolerable or where metformin is contraindicated. However, there is no evidence available to indicate what effect meglitinides will have on important long-term outcomes, particularly mortality.

Non-firearm weapon use and injury severity: priorities for prevention.

OBJECTIVES: To test the hypothesis that weapon-related violence (excluding firearms) results in more severe injury relative to the use of body parts (fists, feet and other body parts), and to rank order of injury severity by assault mechanism. DESIGN: Retrospective cohort study. PARTICIPANTS: 24,660 patients who were treated in a UK emergency department for violence-related injury. MAIN OUTCOME MEASURE: Score on the Manchester Triage Scale. RESULTS: The use of a weapon resulted in significantly more serious injury (adjusted odds ratio (AOR) 1.13, 95% confidence interval (CI) 1.00 to 1.28). However, of all mechanisms of violent injury, the use of feet resulted in most severe injury (AOR 1.41, 95% CI 1.17 to 1.70), followed by blunt objects (AOR 1.35, 95% CI 1.14 to 1.58), other body parts (AOR 1.22, 95% CI 1.06 to 1.40) and sharp objects (AOR 1.09, 95% CI 0.91 to 1.5), compared with use of fists. CONCLUSIONS: Use of weapons resulted in more severe injury than use only of body parts. The use of feet caused the most serious injuries, whereas the use of fists caused the least severe injuries. Injury severity varied by number of assailants and age of the patient--peaking at 47 years--but not by number of injuries. Preventing the use of feet in violence, and preventing group violence should be major priorities.

Relations between alcohol, violence and victimization in adolescence.

BACKGROUND: Compared to links between alcohol and aggression, links between alcohol and vulnerability are poorly understood. OBJECTIVES: To determine whether there is a significant relationship between vulnerability to physical violence and alcohol consumption in adolescence independent of a relationship between alcohol consumption and violent behaviour. DESIGN, SETTING, PARTICIPANTS: Cross-sectional study of 4187 adolescents aged 11-16 in a stratified sample of 13 English schools. RESULTS: Fighting decreased with age whereas hitting others and being hit increased. Relationships between fighting, hitting others and vulnerability to being hit and frequency of drinking and drunkenness were all highly significant (p<0.0001), and were evident at all ages. The outcome most strongly related to frequency of drunkenness was hitting others (odds ratio (OR) 6.62), followed by being hit (OR 4.01) and fighting (OR 2.10). Alcohol consumption and drunkenness remained significantly and independently associated with vulnerability to being hit after adjusting for violent behaviour as well as age and sex. CONCLUSIONS: These findings indicate an association between alcohol and victimization independent of associations of both with physical aggression. Reducing intoxication may reduce victimisation without necessarily affecting violent behaviour. Violence reduction should focus as much on preventing alcohol misuse among victims or potential victims as among offenders.

Confidential registration in health services: randomised controlled trial.

BACKGROUND: Human rights legislation safeguards the privacy and dignity of patients. OBJECTIVE: To assess the effectiveness in terms of patient assessed privacy of confidential registration. DESIGN: Randomised controlled trial. SETTING: Emergency Department, University Hospital of Wales. PARTICIPANTS: A total of 302 patients aged over 15 years. MAIN OUTCOME MEASURES: Binary choices and ordinal visual analogue scores from a validated questionnaire on self reported measures: patient ability and preference to speak to receptionists and disclose confidential information without being overhead and concern about disclosure of items of confidential personal information. RESULTS: Patients who registered in a screened area felt significantly more able to tell receptionists things they did not want others to hear. Control patients were significantly more concerned than intervention patients that others heard their name, address, date of birth, reason for emergency department attendance, and telephone number, but not their marital status. Overall, intervention patients were less concerned about disclosure of information and that they had been overheard. CONCLUSIONS: Patients value privacy when they register and are concerned if others can hear them tell receptionists who they are, how to contact them, and why they are there. Confidential registration should be instituted in health services. Confidential registration increased patient privacy and should be instituted in health services.

Tackling alcohol related violence in city centres: effect of emergency medicine and police intervention.

OBJECTIVES: To identify correlates of alcohol related assault injury in the city centre of a European capital city, with particular reference to emergency department (ED) and police interventions, and number and capacity of licensed premises. METHODS: Assaults resulting in ED treatment were studied using a longitudinal controlled intervention, a three stage design during a three year period of rapid expansion in the night-time economy, when ED initiated targeted police interventions were delivered. A controlled ED intervention targeted at high risk night-clubs was carried out. Main outcome measure was ED treatment after assault in licensed premises and the street. RESULTS: Targeted police intervention was associated with substantial reductions in assaults in licensed premises but unexpected increases in street assault were also observed (34% overall: 105% in the principal entertainment thoroughfare). Combined police/ED intervention was associated with a significantly greater reduction compared with police intervention alone (OR = 0.61, 95% CI 0.40 to 0.91). Street assault correlated significantly with numbers and capacity of premises. Risk of assault was 50% greater in and around licensed premises in the city centre compared with those in the suburbs, although dispersion of violence to more licensed premises was not observed. CONCLUSIONS: Marked decreases in licensed premises assaults resulting from targeted policing were enhanced by the intervention of ED and maxillofacial consultants. Capacity of licensed premises was a major predictor of assaults in the city centre street in which they are clustered. City centre assault injury prevention can be achieved through police/ED interventions targeted at high risk licensed premises, which should also target the streets around which these premises are clustered.

Winning, losing, and violence.

BACKGROUND: Although international sports events attract huge interest, and results can be a barometer of popular national standing, their impact on violent behaviour has not been investigated. METHODS: Associations between assault related emergency department (ED) attendances and international sporting events (home and away rugby and soccer matches) in a European capital city (Cardiff) served by one ED, between 1 May 1995 and 30 April 2002 were investigated. The frequency of assault related ED attendances were studied relative to whether the national team won or lost, controlling for potential covariates: match attendance, match location (home/away), results (win/lose), net scores, and day of match (weekend/weekday). Multiple linear regression was used to identify significant associations with ED assault related attendances. RESULTS: Matches which the Wales team won (p = 0.03), match attendance (p<0.001), and weekend matches (p<0.001) were positively associated with ED assault related injury attendances. Assault frequency measured in this way was no different for home and away matches. CONCLUSIONS: Assault injury resulting in ED treatment was more frequent when national teams won than when they lost. Sport type made no difference. Violence prevention efforts should be increased on international match days, when the national team is expected to win, when match attendance is large, and for away as well as home matches.

Development, utilisation, and importance of accident and emergency department derived assault data in violence management.

OBJECTIVES: To develop formal processes for the collection, disclosure, and effective use of accident and emergency (A&E) department derived assault injury data for city violence reduction. METHODS: Over a four year period, managed by a multi-agency steering group, A&E data collection, collation, and disclosure processes were developed, instituted, and refined. Consultations and negotiations between agencies identified the most effective and ethical methods, appropriate recipients, and the nature of the information of most use. RESULTS: Disclosure of A&E data to city authorities, the police, and local media drew substantial attention and crime prevention resources to the locations of violence. As a result, a police task force responsible for targeting city street crime was funded, which analysed both A&E and police information. Monthly, electronic transfer of raw, anonymous data to the task force crime analyst informed and prompted violence prevention initiatives by several agencies. Police mounted overt and covert interventions targeted at violence hotspot licensed premises and used the data to oppose, on injury grounds, drinks/entertainment licence applications. Transport authorities established new half hourly night time city centre bus services. The local authority mounted an assault awareness campaign in schools and public libraries, and licensing magistrates used the data to measure, for example, the impact of continuous 36 hour drinks licensing on public safety. CONCLUSIONS: The principal finding of this evaluation was that judicious sharing of unique information about locations and times of violence derived from A&E patients was a powerful and effective means of targeting police and other local resource to bring about violence reduction.

Effect of urban closed circuit television on assault injury and violence detection.

OBJECTIVE: To evaluate the effect of closed circuit television (CCTV) surveillance on levels of assault injury and violence detection. DESIGN: Intervention versus control study design. SETTING: Five town/cities with CCTV surveillance and five, matched control centres without CCTV surveillance in England. INTERVENTION: CCTV installation and surveillance. METHODS: Assault related emergency department attendances and violent offences recorded by the police in CCTV and control centres in the four years, 1995-99, two years before and two years after CCTV installation, were compared. RESULTS: Assault related emergency department attendances decreased in intervention centres (3% decrease, ratio 0.96; 95% confidence interval (CI) 0.93 to 0.99) and increased in control centres (11% increase, ratio 1.11; 95% CI 1.08 to 1.14). Overall, changes in emergency department assault attendance in CCTV and control centres were significantly different (t test, p<0.05). Police recorded violence increased in CCTV (11% increase, ratio 1.16; 95% CI 1.08 to 1.24) and control centres (5% increase, ratio 1.06; 95% CI 0.99 to 1.13). Overall, changes in police recording in CCTV and control centres were not significantly different (t test, p>0.05). In CCTV centres, decreases in assault related emergency department attendances and increases in police violence detection were not uniform. CONCLUSION: CCTV surveillance was associated with increased police detection of violence and reductions in injury or severity of injury. CCTV centre variation deserves further study.

Predictors and severity of injury in assaults with barglasses and bottles.

BACKGROUND: Although glasses and bottles are frequently used as weapons in assaults, there is little knowledge on which prevention strategies can be based. DESIGN: Scrutiny of a random sample of 1288 criminal injury compensation applications. OBJECTIVE: To identify predictors and relative severity of glass and bottle injury. METHOD: Injury site, severity, treatment, and demographic characteristics of victims and assailants were studied with reference to awards from the UK national Criminal Injuries Compensation Authority (CICA). MAIN OUTCOME MEASURES: Gender of victims and assailants, injury sites, treatment, and award (UK pounds) as indices of injury severity. RESULTS: Annual CICA awards to all victims of assaults in licensed premises during 1996-98 amounted to pound 4.08 million (for all glass/bottle assaults: pound 1.15 million = 28%). The mean cost of 746 glass assaults was pound 2347, compared with pound 2007 for 542 injuries from bottle assaults (mean difference pound 340; p<0.01). This difference largely reflected more eye injuries with glasses (26 cases: 3% of all glass assaults) than with bottles (eight cases: 1% of all bottle assaults). Bottle assault was significantly associated with unidentified assailants and scalp injuries; whereas glass injury was significantly linked to pub opening hours (midday to midnight), Thursdays, eye and face injuries, and treatment requiring sutures. Mean age of bottle assault victims (26.1 years) was lower than of glass victims (27.3 years; p<0.01), and same gender assaults were more frequent than between gender assaults for both bottle (p<0.001) and glass (p<0.001) assaults. Female victims were allocated to lower compensation awards more frequently than male victims; this was the case for both bottle (p<0.05) and glass (p<0.01) assaults. CONCLUSIONS: Assaults with bottles caused less serious injury and resulted in lower compensation costs. Injury distribution was linked to victim gender and weapon choice, but not to assailant gender. Prevention strategies should focus on both bottle and glass assaults and should take account of the setting and time in which drinking occurs.

A randomized controlled trial of a brief intervention after alcohol-related facial injury.

AIM: To evaluate the effectiveness of a brief motivational intervention on alcohol consumption and misuse in young males with alcohol-related face injury. DESIGN: Randomized controlled trial. SETTING: Oral and maxillofacial surgery out-patient clinic in an urban teaching hospital. PARTICIPANTS: One hundred and fifty-one participants were randomized to motivational intervention and control conditions. INTERVENTIONS: Control was treatment as usual. The intervention was treatment as usual plus a one-session brief motivational intervention administered by a nurse. MEASUREMENTS: Three sets of measurements were taken at baseline, 3-month and 1-year follow-up. Collateral measurements were also taken at 1-year follow-up. Primary outcome measures were total alcohol consumption, typical weeks consumption and days abstinent in preceding 3 months. Other outcome measures included the Alcohol Use Disorders Identification Test, a short form of the Alcohol Problems Questionnaire, and a measure of satisfaction with social relationships. RESULTS: There was a significant decrease in 84-day total alcohol consumption across the year (P < 0.006) and further, a significant effect for the motivational intervention was demonstrated (P < 0.029). This pattern was repeated for days abstinent and alcohol consumption in a typical week as well as alcohol-related problems. There was a significantly greater reduction in the percentage of hazardous drinkers in the motivational intervention group (from 60% to 27%, P < 0.009) compared to the control group (from 54% to 51%, NS). CONCLUSION: A proportion of young men change their alcohol consumption following alcohol-related injury. A nurse-led psychological intervention adds significantly to the proportion and magnitude of response.

Recording of community violence by medical and police services.

OBJECTIVES: To determine the extent to which community violence that results in injury treated in emergency departments appears in official police records and to identify age/gender groups at particular risk of under-recording by the police. METHODS: Non-confidential data for patients with assault related injury treated in the emergency departments of two hospitals in one South Wales city (Swansea) during a six month period were compared with data relating to all recorded crimes in the category "Violence against the person" in the police area where the hospitals were located. RESULTS: Over the six month period a total of 1513 assaults were recorded by Swansea emergency departments and the police (1019, 67.3% injured males and 494, 32.7% injured females). The majority of these assaults (993, 65.6%) were recorded exclusively by emergency departments; 357 (23.6%) were recorded only by the police and 163 (10.8%) were recorded by both emergency departments and the police. Equal proportions of males (67.3%) and females (67.5%) injured in assaults were recorded by both emergency departments and the police, but men were more likely to have their assault recorded exclusively in emergency departments (odds ratio (OR) 2.1, 95% confidence interval (CI) 1.7 to 2.7) while women were more likely to have their assault recorded exclusively by the police (OR 2.5, 95% CI 2.0 to 3.2). There were no significant relationships between exclusive emergency department recording and increasing age (OR 1.0, 95% CI 0.9 to 1.2), exclusive police recording and increasing age (OR 1.1, 95% CI 1.0 to 1.2), or between age and dual recording (OR 0.9, 95% CI 0.8 to 1.0). CONCLUSIONS: Most assaults leading to emergency department treatment, particularly in which males were injured, were not recorded by the police. Assaults on the youngest group (0-10, particularly boys) were those least likely to be recorded by police and females over age 45, the most likely. Emergency department derived assault data provide unique perspectives of community violence and police detection.

Adolescents' beliefs about future substance use: a comparison of current users and non-users of cigarettes, alcohol and illicit drugs.

OBJECTIVES: To explore the expectations of adolescents about their future cigarette, alcohol and illicit drug use. It was hypothesized that differences would be found between current substance users and non-users and that younger children would have less realistic beliefs about their future use than older children. DESIGN, SETTING, PARTICIPANTS: Survey of 7022 pupils (aged 11-16) in 13 non-randomly selected schools from three Local Education Authority areas in Northern England, the Midlands and London, relating to current substance use and beliefs about future use of cigarettes, alcohol and illicit drugs. MEASURES: Respondents were asked confidentially about occasions of cigarette, alcohol and illicit drugs use as well as about their belief about use in the year following the survey. RESULTS: Substantial differences were found in relation to all substances. Of those children who currently smoked, 73% believed it likely they would be doing so in a year's time. Only 3% of non-smokers believed they would begin to smoke in the year following the survey. Eighty-three per cent of alcohol drinkers believed they would be drinking in a year's time compared with 20% of non-drinkers and 63% of illicit drug users believed in their continued use. Only 3% of non-drug users believed they would initiate use in the year following the survey. More non-smoking girls than boys responded "don't know" when asked about their future beliefs regarding cigarette use (15.6% vs. 11.3%), a position which was reversed for current smokers (15.4% vs. 19.3%). 13.1% of drinkers and 30.7% of non-drinkers did not know if they would be drinking a year after the survey and 23.2% of illicit drug users did not know what their drug using status would be in a year compared to 9.7% of current non-users. Of those who were drinking alcohol, but not using illicit drugs or smoking cigarettes, 33% thought it likely that they would have a problem with either drugs or alcohol at some time in the future compared to 7% of non-drinkers. Seventy-four per cent of children currently using illicit drugs thought it likely they could have a substance abuse problem in the future compared with 8.9% of non-drug users. CONCLUSION: Based on prevalence data from this sample, these results found that non-smokers had unrealistic beliefs about their likelihood of taking up smoking within a year and that many current smokers had equally unrealistic beliefs about giving up the habit. Adolescents had more realistic expectations about future alcohol use. When it came to illicit drug use, adolescents were clear in their beliefs about future use: very few non-users believed they would initiate use whilst current users believed they would continue to use. Many young people were uncertain about future substance use, a position which provides opportunity for drug-education programmes. The hypothesis that younger children would have less realistic beliefs about future use than older children was not supported.

Alcohol-related violence and the role of oral and maxillofacial surgeons in multi-agency prevention.

The maxillofacial region is by far the most frequently selected target in assaults on adults. There is a causal link between alcohol intoxication and injury. Therefore, oral and maxillofacial surgery is, in effect, the lead speciality for those injured in violence and has a responsibility to orchestrate holistic care that takes into account mental health needs. Recent years have also seen a determined effort by oral and maxillofacial surgeons to get involved in wider issues of prevention, exemplified by the national UK BAOMS Facial Injuries Awareness Week. Multi-agency prevention, not just with mental health professionals in the case of individual patients, but also with emergency medicine, public health, local government, the police and the voluntary sector is key to success. Given the potential complexity of collaborations like this, it is important to understand what works in multi-agency prevention. This paper reviews successful interventions: their rationale and how oral and maxillofacial surgeons can contribute to local injury prevention.

Criminal deterrence as a public health strategy.

Deterrence is an established theme in criminal justice, but its role in prevention of assault has been treated with ambivalence and even hostility in medicine. The extent to which offenders can be persuaded, through knowledge of criminal and health risks, not to injure others is emerging from studies of the health effects of firearm and other crime legislation, and from macro-level studies and controlled experiments of police interventions. There is convincing evidence that motorists can be deterred from alcohol-impaired driving, and recognition that specific, targeted, and visible police work and increasing certainty of punishment are effective interventions. By contrast, duration of imprisonment and generic police initiatives such as blanket increases in police numbers seem to have little effect on deterrence, at least in the context of the decline in US homicide rates since 1991, to which demographic and economic factors seem to have contributed little. Together with established and cost-effective preschool education and early family support, targeted policing and increasing rates of conviction should be integrated into strategies for injury prevention.

Emergency medicine and police collaboration to prevent community violence.

An important responsibility of emergency departments is the management of injuries sustained in assaults. Most assaults, including many causing serious injury, are not reported and not recorded by the police. This is important because police investigation and the conviction of offenders has a substantial deterrent effect and because information about the circumstances of intentional injury is key to prevention. Recent investigation of ED-police collaboration has shown that many of the injured, and ED staff want offenses to be reported but that there are attitudinal, logistic, and ethical-legal obstacles to achieving this. Organized joint efforts by emergency medicine personnel and police departments, on the basis of a sound legal and ethical framework to protect the rights of both victims and offenders, should deter more violent offenders and would-be violent offenders. They also provide the police with unique aggregate, nonconfidential information that is of substantial help in tackling violence. ED data can be used to measure and refine violence prevention initiatives and are being developed as the basis of a new, independent measure of police performance. Strategies, practical ideas to overcome obstacles, and directions for future research are suggested.

The prevalence of alcohol, cigarette and illicit drug use in a stratified sample of English adolescents.

OBJECTIVES: The aim of this study was to assess current levels of regular cigarette, alcohol and illicit drug use in adolescents in light of reported research by Goddard & Higgins (1999). DESIGN, SETTING, SUBJECTS: Survey of 9742 pupils (aged 11-16) in a stratified sample of 28 schools in four Local Education Authority areas in Northern England, the Midlands and London. Data were collected during the latter part of 1999 and the first 3 months of 2000. MEASURES: Respondents were asked confidentially about their use, and extent of use, of psychotropic substances (cigarettes, alcohol and illicit drugs). RESULTS: The prevalence of reported daily cigarette use rose from 4.8% at age 11 to 24.1% at age 16. More girls than boys smoked (13.7%, 9.5%, chi(2) = 39.1, p < 0.0001). Reported monthly use of alcohol rose from 5.1% at age 11 to 36% at 16. Alcohol was drunk more by boys than girls (16.4% and 12.8% respectively, chi(2) = 23.0, p < 0.0001) Reported monthly illicit drug use rose from 0.9% at age 11 to 14.5% at age 16. No overall differences were found between boys and girls. CONCLUSIONS: The results confirm that rates of cigarette smoking, alcohol and illicit drug use rise rapidly in the early teenage years, with higher rates of smoking in girls and drinking in boys.