BACKGROUND:Emergency medical service (EMS) encounters for non-fatal opioid overdose in the USA increased from 2018 to 2022, and persons treated for an overdose by EMS increasingly refuse EMS transport to emergency departments after an overdose. Understanding where non-fatal overdoses occur can inform overdose prevention and response efforts. METHODS:EMS data from biospatial by ImageTrend were queried from 888 counties reporting consistently during January 2022 to December 2024, representing approximately 30.6% of the US population. Frequencies and proportions of non-fatal opioid-involved overdose (hereafter, 'non-fatal overdose') EMS encounters were calculated by location, sex, race and ethnicity, age group and US Census Bureau region. Quarterly trends in proportions were also examined. RESULTS:Private residences (55.3%) were the most common location of non-fatal overdoses, followed by streets and highways (19.5%), across all demographic groups. Non-fatal overdose encounters were also common in schools and public administrative buildings among persons aged < 19 years, and in healthcare facilities among persons ≥ 55 years. Minor declines (average quarterly percent change (AQPC): -0.9) were observed from January 2022 through September 2024 in private residences but not in streets and highways. DISCUSSION AND CONCLUSIONS:Tailoring risk reduction efforts, such as training potential bystanders on opioid overdose reversal medication (OORM) administration and increasing OORM availability in public and private locations, to settings where non-fatal overdose is most common may help reduce overdose morbidity and mortality.
Since the turn of the century, there has been a drumbeat among those opposed to regulations, including safety regulations, to talk about a "law" of unintended consequences. The law claims that regulations commonly have large negative unanticipated effects. But in the injury prevention field, regulations actually seem to have few such large negative unintended consequences and many positive unintended consequences. This essay describes a half dozen instances of beneficial unanticipated consequences that appear to have been caused by regulations, such as that motorcycle helmet laws not only reduced head injuries to cyclists but also seem to have reduced the theft of motorcycles; a higher minimum legal drinking age not only reduced motor vehicle deaths for those aged 18-20 but also likely reduced suicides among that age group; a successful Air Force suicide prevention initiative not only reduced suicide but also seems to have reduced interpersonal violence and seat belt laws not only increased seat belt wearing but also appear to have increased positive attitudes about both seat belt use and mandatory seat belt laws. The "law" of unintended consequences seems similar to "Murphy's Law" (ie, anything that can go wrong will go wrong) in that while both laws correctly warn that policymaker overconfidence can lead to unwanted and detrimental outcomes, both are less similar to empirical laws than they are to humorous adages that are usually incorrect. While there are many actual empirical economic "laws", the "law" of unintended consequences does not appear to be one of them.
BACKGROUND:Injury-provoking violence is an important concern among police officers, and it influences their decisions about using force in their encounters with civilians. We sought to estimate the occurrence and trends in non-fatal assaults on police officers in the USA. METHODS:We estimated rates and frequencies of assaults directed against working police officers during four periods: 1993-1999, 2000-2005, 2007-2015 and 2016-2021. The data were from the US National Crime Victimization Survey. RESULTS:Police reported annual average criminal attack rates of 796.3 per 1000 officers during 1993-1999, falling to 87.5 per 1000 during 2016-2021. Civilians reported much lower rates of 62.4 per 1000 persons and 19.3 per 1000 persons during these periods. Most assaultive violence directed against police officers (78%) consisted of simple assaults and these became a larger part of total violence over time. A majority (70%) of attacks on police-and especially of simple assaults-involved similar repeated offences. Criminal assaults overall declined during the study period, but the reductions were greater for the police (89%) than for civilians (69%). DISCUSSION AND CONCLUSIONS:While remaining elevated, US police officers experienced large decreases in assaultive violence between 1993 and 2021. Police victimisation patterns differed from those for civilians, falling more steeply and more often involving minor harm. While calling for additional research, these results suggest that further improvements in police safety might help create conditions favourable to less frequent use of force against civilians.
BACKGROUND:To improve timeliness of detailed data on suicides and violent deaths, the Centers for Disease Control and Prevention (CDC) developed the National Violent Death Reporting System (NVDRS) Rapid Reporting Feature (RRF) in 2024 to provide insights earlier than finalised NVDRS data for state/jurisdictional VDRS programmes. This study is the first to use data from the RRF, describing provisional suicide data by selected characteristics. METHODS:Provisional suicide data from CDC's NVDRS RRF meeting data completeness thresholds from 1 January to 30 June 2024 were examined by selected demographic and incident characteristics. RESULTS:NVDRS captured 21 281 suicide deaths from 50 states, the District of Columbia and Puerto Rico during the study period. Most incidents involved a single suicide; approximately 80% of suicide decedents were males and over 84% were white. Over 75% of suicide deaths meeting data quality thresholds occurred in houses/apartments. Firearms were the leading injury method overall (58.9%), and for males (64.0%) and females (38.5%). Among suicide deaths with known circumstances, leading circumstances were related to known current diagnosed mental health problems (51.9%), alcohol or other substance use (33.5%), intimate partner problems (23.1%) and contributing physical health problems (21.3%). Almost 65% of decedents had a recent/upcoming crisis. Over one-third of decedents had a history of suicidal thoughts/plans; 28.2% left a suicide note. DISCUSSION AND CONCLUSIONS:Although findings are provisional, the NVDRS RRF improves the timeliness of suicide surveillance data by up to a year, providing earlier insights into recent patterns and circumstances of suicide deaths, which can inform timelier suicide prevention and response efforts.
BACKGROUND:Drowning among school-aged children remains a burden in low- and middle-income countries (LMICs). Survival swim training is a WHO-recommended intervention that enables children to survive water-related mishaps. The project piloted the SwimSafe programme in two schools in the high-burden state of Kerala, India, and assessed for feasibility of implementation in this context. METHODS:Children aged 5-12 years with no swimming ability were enrolled in 12 sessions which taught float and swim skills in portable pools. Quantitative performance was assessed at baseline and endline against international standards, including the 30-second float and 25-metre swim. Qualitative data from participants, implementers and policy stakeholders assessed feasibility and acceptability. Data was analysed against the Acceptability, Practicability, Effectiveness, Affordability, Safety, Equity (APEASE) framework to assess context suitability and opportunities for scalability. RESULTS:309 children participated, of which 68% attended all sessions and were assessed at endline. Of these, 15.9% passed all criteria though 53.1% swam at least 10 m. Lower success was attributed to an inadequate number of classes. The programme was found to be acceptable and feasible to implement, provided long-term funding was identified for instructor salaries and pool maintenance. Lower performance was identified in younger children aged 6-7 years and girls. Younger children may have experienced discomfort due to chlorine and water depth, affecting learning. The infrastructure cost per pool was US$3600, and the running cost per student was US$8. No safety issues were identified. CONCLUSIONS:The SwimSafe pilot provided insights on how a broader drowning-prevention programme may be sustained in a school setting in high-risk LMIC regions.
Background Sport and recreation provide important health benefits but can occasionally result in fatal events, making accurate surveillance essential to estimate their burden and inform prevention strategies. In Québec, Canada, coronial data are commonly used for this purpose, but the performance of different identification approaches remains uncertain. Methods This retrospective observational study used the Bureau du coroner du Québec database to review all 2019 coronial records, including unintentional injury and natural deaths (n=3719). Three methodologies for identifying sport-related and recreation-related deaths were compared: International Classification of Diseases, 10th Revision (ICD-10) activity codes, a three-condition algorithm combining activity codes, underlying cause-of-death codes, and keywords, and a manual review serving as the reference standard. Sensitivity and positive predictive value (PPV) were calculated overall and by death type. Results The manual review identified 175 deaths, including 26 natural deaths and 149 unintentional injury deaths. ICD-10 activity codes identified 91 confirmed cases (52.0% sensitivity), with higher detection for natural deaths (76.9%) than for unintentional injury deaths (47.7%). The PPV of activity codes was 90.1%. The three-condition algorithm identified 162 confirmed cases, achieving 92.6% sensitivity and higher detection of unintentional injury deaths (95.3%), with a PPV of 85.7%. Discussion and conclusions ICD-10 activity codes alone substantially underestimated sport-related and recreation-related deaths in Québec, particularly for unintentional injuries. A multi-component algorithm integrating activity codes, underlying cause-of-death codes, and keywords markedly improves case detection while maintaining acceptable accuracy, supporting its use for routine surveillance. Consistent activity coding and detailed documentation by health records professionals remain essential, especially for identifying natural deaths.
Background The National Collegiate Athletic Association Injury Surveillance Program (NCAA ISP) is among the longest-standing sport injury surveillance systems in the world. The NCAA ISP relies on a convenience sample of reporting institutions to estimate population-level injury metrics by scaling reported counts by an inverse school-reporting fraction and a fixed under-reporting correction. We propose a new method for improving population estimates of injury incidence obtained in the NCAA ISP, through a quasi-bootstrapping algorithm that capitalises on the historically archived NCAA ISP data. Methods We employed a phased approach including both a simulation study and a practical application, grounded in the operational methods of the NCAA ISP. Results Across a range of simulated conditions, the proposed method approximated true population values with near-zero bias, produced more stable estimates than the current method and generated valid uncertainty intervals for both injuries and exposures. We also noted that when applied to real-world data, the proposed method produced plausible and credible estimates of injury and exposure counts. Discussion By incorporating real-world variability from archived data, this approach improves point and interval estimation even under conditions of low or biased reporting. Conclusions The proposed method demonstrates strong potential as a scalable and statistically robust alternative to current population estimation practices in injury surveillance systems that rely on convenience samples.
BACKGROUND:Both suicides and unintentional drug overdose deaths have risen dramatically over the last two decades in the USA. However, the classification of death manner intent can be a challenge for death investigators in drug poisoning deaths. This study assessed whether county death investigation system type was a predictive factor in the likelihood of 'undetermined' intent death classifications. METHODS:This study examines the association between undetermined intent classifications and death investigation systems among drug poisoning deaths in the USA. With novel data from the Centres for Disease Control and Prevention and from the State Unintentional Drug Overdose Reporting System in nine states, we used logistic regression models to analyse whether county coroner systems were differentially associated with 'undetermined' intent death classifications as compared with county medical examiner systems. RESULTS:County coroner systems were associated with increased odds of undetermined intent classifications in drug poisoning deaths as compared with county medical examiner systems (OR: 1.79; 95% CI 1.43 to 2.27). Even after a full set of county and individual decedent controls, the association remained (adjusted OR: 1.60; 95% CI 1.25 to 2.05). CONCLUSIONS:Future work should examine ways to identify suicides in drug poisoning deaths, as the consequences of misclassification echo forward into data used for prevention. The type of death investigation system may be an important factor in how drug poisoning deaths are classified.
BACKGROUND:Cycling-related injuries are a growing public health concern. Although bicycle helmets are intended to reduce head injury severity, evidence regarding traumatic brain injury and mortality remains limited in large emergency department (ED)-based datasets. METHODS:This matched case-control study used South Korean ED-based Injury In-depth Surveillance data from 2011 to 2021. Cases were injured cyclists who died in the ED; controls were injured cyclists whose ED disposition was not coded as death. Controls were matched to cases at a 1:4 ratio by age, sex and year of visit. Conditional logistic regression assessed associations of recorded helmet use with traumatic brain injury, the primary outcome and ED mortality, the secondary outcome. RESULTS:Among 1394 injured cyclists, 282 were cases and 1112 were controls; 155 patients (11.1%) were recorded as wearing helmets. Recorded helmet use was associated with lower odds of traumatic brain injury, but the association was not statistically significant after adjustment (adjusted OR: 0.76, 95% CI 0.40 to 1.44). It was also associated with lower odds of ED mortality (adjusted OR: 0.30, 95% CI 0.14 to 0.65); however, only 11 helmeted patients died in the Evening crashes:ED arrival during evening hours (18:00-24:00) was associated with higher odds of ED mortality compared with daytime hours (06:00-18:00), and motor vehicle collisions were associated with higher odds of ED mortality. CONCLUSIONS:Recorded helmet use was not significantly associated with traumatic brain injury after adjustment. Its association with lower ED mortality was based on only 11 helmeted deaths and may reflect limited precision, residual confounding and unmeasured crash severity. This finding should be interpreted cautiously and confirmed in larger studies with detailed crash data.
BACKGROUND:Adolescents represent a high-risk group for road traffic injuries, particularly in rapidly motorising cities in India. This study aimed to document the travel patterns and understand the road safety knowledge, practices and safety perceptions of adolescents during their school commutes in Delhi, India. METHODS:A cross-sectional survey was conducted with students from four public schools. Schools were selected based on proximity to high-crash road segments, and all eligible students were invited to participate. A questionnaire was administered via the Research Electronic Data Capture (REDCap) tool within the school premises between December 2023 and February 2024. Descriptive statistics were used to summarise participant characteristics and outcomes, and χ2 tests were used to assess associations between various factors and adolescent road safety knowledge. RESULTS:A total of 4789 adolescents aged 10-19 participated in the survey. Household vehicle ownership was 66%, with 85% owning motorised two-wheelers. Walking was the predominant mode of transport (77% males, 38% females), followed by cycling and public bus. The prevalence of helmet and seatbelt use was low among those who travelled on motorised two-wheelers and cars, respectively. Most participants reported feeling safe (males 70%, females 65%), yet many also reported fears of crashes, speeding vehicles, robbery and harassment. Knowledge of road safety signage was poor. DISCUSSION AND CONCLUSIONS:The results highlight the urgent need for interventions that combine education, infrastructure improvements, enforcement and gender-sensitive approaches. Strengthening institutional mechanisms and leveraging school-based platforms can help embed adolescent-friendly road safety planning in India's broader road injury prevention agenda.
BACKGROUND:Road traffic crashes cause substantial global mortality and disability. Conventional injury severity scores may not fully capture the complex interactions among demographic, clinical, crash and environmental factors. Artificial intelligence and machine learning may improve mortality prediction by modelling non-linear patterns in traffic crash data. METHODS:This systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidance. PubMed/MEDLINE, Web of Science, Scopus and IEEE Xplore were searched on 7 August 2025 for English-language peer-reviewed studies published from 2014 to 2025 that applied artificial intelligence or machine learning to predict mortality after road traffic crashes. Two reviewers screened records and extracted data on study characteristics, data sources, algorithms, predictors, validation, imbalance handling and performance. Methodological quality was assessed using the Qiao quality assessment tool. Because of substantial heterogeneity, findings were synthesised narratively. RESULTS:18 studies met the inclusion criteria. Most were retrospective studies using structured tabular data. Common objectives were binary mortality prediction, multiclass injury severity prediction including death and death risk assessment. National or regional databases were the most frequent data sources, followed by hospital records and police or insurance datasets. Regression-based models and decision trees remained common, while ensemble methods including random forest and gradient boosting increased in recent years. Frequently reported predictors included age, Injury Severity Scores, body region injured, crash mechanism, temporal factors and geographical characteristics. Only two studies reported external validation. CONCLUSIONS:Artificial intelligence and machine learning show promise for traffic crash mortality prediction, but clinical translation remains limited by insufficient external validation, inconsistent handling of class imbalance, incomplete reporting of tuning and missing data strategies and limited use of explainability methods. Future work should prioritise prospective, externally validated, interpretable models developed using standardised reporting frameworks.
BACKGROUND:Motor vehicle collisions remain a persistent public health challenge, with risks often concentrated in specific locations rather than distributed randomly. While the COVID-19 pandemic altered mobility patterns and traffic volumes, limited research has examined how the spatial distribution of severe collisions evolved across pre-pandemic, pandemic and post-pandemic periods. METHODS:This study analysed injury and fatal collisions in Halifax Regional Municipality, Nova Scotia, using road collision records from 2018 to 2025. Collision records were aggregated into 1.5 km × 1.5 km spatial grids and divided into three periods: Pre-COVID (January 2018 to February 2020), COVID (March 2020 to June 2021) and Post-COVID (July 2021 to December 2025). Annualised collision counts were calculated to standardise time durations across periods. Spatial clustering was evaluated using the Getis-Ord hotspot statistic in a GIS environment, and hotspot transition analysis was used to identify persistent, emerging and diminishing clusters across periods. RESULTS:Injury-related hotspots remained concentrated in the Halifax-Dartmouth-Bedford urban core across all periods. The spatial extent of these clusters declined during the COVID period but expanded again afterwards. Fatal collision hotspots were more spatially dispersed, with several freeway-associated hotspots diminishing during the pandemic. In the Post-COVID period, fatal hotspots re-emerged in the urban core and expanded into surrounding inland areas, indicating shifting spatial risk patterns. CONCLUSIONS:Pandemic-related disruptions temporarily altered collision hotspot patterns, but clustering re-emerged as travel activity resumed. Persistent urban hotspots and emerging peripheral clusters highlight the value of spatiotemporal hotspot analysis for guiding targeted road safety interventions.
BACKGROUND/AIMS:Falls among paediatric inpatients represent a significant safety concern, contributing to prolonged hospitalisations and increased healthcare costs. This systematic review and meta-analysis aimed to evaluate the effectiveness of hospital-based fall prevention interventions for paediatric inpatients. METHODS:Nine studies, including quality improvement projects, experimental/quasi-experimental studies and retrospective analyses, were included after a comprehensive search of Scopus, Web of Science and PubMed databases. Interventions such as risk-stratified protocols, visual identifiers, enhanced surveillance and caregiver education were assessed. Two reviewers independently performed screening, data extraction and risk of bias assessment, and disagreements were resolved by consensus. RESULTS:The meta-analysis (random-effects model with Hartung-Knapp adjustment) showed no statistically significant association between hospital-based interventions and fall outcomes (OR=1.81, 95% CI 0.57 to 5.77), with substantial heterogeneity (I²=91.4%, p<0.0001). Evidence on commonly used paediatric fall-risk screening tools was summarised narratively, indicating high sensitivity but limited specificity for the Humpty Dumpty Fall Scale and more balanced diagnostic performance for the Paediatric Fall Assessment Scale. Multicomponent interventions combining risk assessment, caregiver involvement, staff education and environmental modifications showed the most consistent effects, while single-component or short-term interventions were less effective. Contextual factors such as hospital infrastructure, staffing patterns and safety culture also appeared to influence outcomes. CONCLUSIONS:Despite promising results, short-term interventions and lack of standardisation highlight the need for tailored, evidence-based strategies. Our findings underscore the importance of integrating both targeted high-risk approaches and universal hospital-wide safety measures. PROSPERO REGISTRATION NUMBER:CRD420251071227.
BACKGROUND:Adverse childhood experiences (ACEs) are preventable, potentially traumatic events occurring before age 18, and are linked to numerous negative outcomes throughout life. Recent national studies report that ACEs are common among US high school students, but the prevalence of ACEs by state and local jurisdiction is unknown. The study objective was to estimate the prevalence of individual and cumulative ACEs among high school students in 16 US jurisdictions. METHODS:Using 2023 Youth Risk Behavior Survey data, we estimated the self-reported prevalence of eight individual (emotional, physical or sexual abuse; physical neglect; witnessed intimate partner violence; parental substance use problems; parental mental health problems; incarcerated or detained parent/guardian) and cumulative ACEs (0, 1, 2‒3, ≥4) among high school students <18 years in 16 US jurisdictions that included ACEs questions on their survey. RESULTS:Emotional abuse was the most reported ACE (range: 49.3%-64.0%) in all jurisdictions. In 13 of 16 jurisdictions, the other most common ACEs included physical abuse (20.8%-46.9%), parental mental health problems (23.6%-38.6%) and parental substance use problems (17.6%-33.1%). Jurisdiction-specific variation in the relative commonality and prevalence of individual and cumulative ACEs was present. DISCUSSION AND CONCLUSIONS:While some estimates overlapped, individual ACEs prevalence varied widely by site, highlighting the need for local data to inform prevention strategies. Local estimates can help decision makers understand communities' unique risks and strengths and evaluate progress towards preventing and mitigating ACEs using strategies from Centers for Disease Control and Prevention's Preventing Adverse Childhood Experiences Resource for Action.
BACKGROUND:Queensland, Australia, is a popular tourist destination known for its beaches and exotic flora and fauna; however, travel also carries injury risk. This study aimed to describe the epidemiology of ambulance-attended adult tourist injuries among domestic and international visitors to inform travel safety strategies. METHODS:Data were extracted from Queensland Ambulance Service (QAS) records for injury-related cases involving non-Queensland residents aged ≥15 years attended between 1 January 2009 and 31 December 2018. Ambulance pick-up location coordinates were used as a proxy for injury location. Geospatial analysis was conducted, and χ2 tests examined differences between visitor groups by age, sex and injury characteristics. Age-standardised rates were calculated annually using population data from Tourism Research Australia's national and international visitor surveys. RESULTS:There were 27 687 visitor injuries aged ≥15 years attended by QAS, with males accounting for 52.5% of cases. Injury-related ambulance attendance rates were similar for domestic (IR=32.3 per 100 000 per annum; n=21 685) and international visitors (IR=29.5 per 100 000 per annum; n=6002). The highest injury rates occurred among young males aged 15-24 years and older females aged ≥65 years. Falls and transport incidents were the leading injury mechanisms among both visitor groups. DISCUSSION:Findings suggest differences according to age, sex and visitor type, with young males and older females representing higher risk groups. These results highlight the need for targeted prevention strategies and further investigation into the circumstances surrounding tourist injuries. CONCLUSION:Understanding the burden and characteristics of tourist injuries is crucial to informing health service provision, targeted travel health advice and injury prevention strategies.
BACKGROUND:As global temperatures increase, ice formation on water bodies might slow and/or be of shorter duration, increasing risk for drowning injury and mortality during wintertime activities. This research explores the state of the scholarly literature on ice-related drownings and applies that knowledge to vital records data from Michigan in the Great Lakes region of the USA. METHODS:We conducted a systematic review of the scholarly literature on wintertime drownings to characterise the current state of the scholarly literature. Using death records from the Great Lakes region of the USA, we identify risk factors and describe temporal patterns of mortality. RESULTS:Out of 469 unique articles, nine were included in this study. Papers were from the United States, Canada, Scandinavia and one multi-country study. Study lengths ranged from 5 to 30 years, including victims of all ages. Risk factors included alcohol use, particularly while operating snowmobiles. Results from Michigan, a Great Lakes state in the USA, suggest that while ice-related drownings are few (less than four per year), most deaths occur when driving snowmobiles or other kinds of motor vehicles onto frozen water bodies that might insufficiently support the weight of the vehicle. CONCLUSIONS:Both the literature and mortality records from Michigan indicate that ice-related drowning mortality incidents are preventable and occur during recreational activities often associated with snowmobile use. With warming temperatures and unpredictable freezing patterns along with increasing wintertime recreational activities and snowmobile use, public health professionals should proactively consider new ways to prevent injuries and deaths.
BACKGROUND:Effective 1 July 2022, the state of Iowa enacted House File 2130, authorising the use of All-Terrain and Utility Task Vehicles (ATV/UTV) on secondary roadways and state highways. Widely recognised safety guidelines identify roadway operation on both paved and unpaved surfaces as a significant risk factor for injuries and fatalities. We hypothesised that this legislation would be associated with increased ATV/UTV-related trauma, greater injury severity and worse clinical outcomes. METHODS:This retrospective study reviewed ATV/UTV crashes reported by the Department of Transportation, admissions for crash-related injuries at a level 1 trauma centre and statewide hospital admissions from 1 January 2020 to 31 December 2024. Crash counts and circumstances were analysed. Demographics, comorbidities, substance use, injury characteristics, hospital course, complications and hospitalisation costs were collected and compared pre and post-legislation. A p<0.05 was considered significant. RESULTS:There were 241 crashes prelegislation and 339 postlegislation, a 40.7% increase. Crashes on concrete surfaces (61.1% vs 48.5%; p=0.004) and state routes (7.1% vs 1.7%; p=0.047) rose significantly. Fatal crashes doubled postlegislation (11.8% vs 6.2%; p=0.008). Trauma centre admissions increased by 11%. Abdominal (26.1% vs 12.9%; p=0.001), chest (37.7% vs 27.4%; p=0.032) and upper extremity injuries (67.6% vs 45.2%; p<0.001) also rose. Unplanned reoperations and intensive care unit admissions increased to 7.2% from 0.5% (p<0.001). Adjusted hospitalisation costs rose (US$50 820 vs US$38 021; p<0.011). DISCUSSION:Implementation of House File-2130 was associated with increased ATV/UTV crashes, more severe injuries, higher mortality, greater need for unplanned interventions and elevated hospitalisation costs. CONCLUSIONS:Prospective, multicentre studies and real-time surveillance systems would further strengthen evaluation of the public health impact of legislative changes and guide evidence-based policy development.
This feature comprises an essay written by an experienced injury epidemiologist, and three commentaries representing perspectives from psychiatry and population health, sociology and forensic pathology. At issue is an apparent decline during the new millennium in the quality of suicide statistics in the USA. Perpetually stigmatised and often socially condemned, suicide is highly prone to under-reporting. The ongoing opioid and suicide epidemics and the recent COVID-19 pandemic have overwhelmed already-stressed and under-resourced medical examiners and coroners (ME/Cs), who must distinguish suicide from other external manners of death (eg, homicide, 'accident' and undetermined intent). The frequent absence or paucity of corroborative evidence, such as an authenticated suicide note or a well-documented psychological/psychiatric history, makes the medicolegal determination of suicide especially fraught when ME/Cs must discern intent among decedents of drug intoxication, as compared with deaths due to less ambiguous methods (eg, firearms, jumping and hanging). A common result is the default determination of 'accident', especially when investigative resources are limited. Accurate measurement is essential for optimising mental health treatment and suicide prevention. Bias and differential bias implicit in suicide detection would be mitigated by an expansion of the self-injury mortality domain, which emphasises antemortem behaviours of decedents rather than postmortem inference of their intentionality towards death.
BACKGROUND:Isolated extremity gunshot wounds cause a significant number of deaths annually despite exsanguinating extremity haemorrhage being potentially treatable and thus the deaths preventable. We sought to compare differences between children and young adult decedents of isolated extremity gunshot wounds to decedents from other-site gunshot wounds in terms of demographics, incident circumstances and disposition. METHODS:A retrospective analysis of the National Violent Death Reporting System database was performed for the years 2012-2021. Extremity gunshot wound decedents were compared with other-site gunshot wound decedents in patients 0-24 years old. Variables analysed included race, sex, incident, emergency medical services response, transportation to the emergency department and survival times. Analysis was conducted using bivariate inferential statistics: χ2 and Wilcoxon rank-sum. RESULTS:Of 40 746 firearm injuries, 39 878 (97.9%) were other-site gunshot wound decedents and 868 (2.1%) were extremity gunshot wound decedents. Black individuals comprised the majority of both cohorts but more commonly extremity gunshot wound decedents (75.3% vs 66.6%, p<0.0001). More extremity gunshot wound decedents were male (90.3% vs 87.1%, p=0.006) and in single homicides (89.9% vs 86.1%, p=0.0001). Both groups were admitted to the hospital at similar rates (12.1% vs 12.8%, p=0.34). 72.0% extremity gunshot wound decedents survived minutes after injury and 20.9% survived hours. A subgroup analysis was performed for decedents <18 years old and mirrored these trends. DISCUSSION AND CONCLUSIONS:This national analysis demonstrated disparities in race and sex among young decedents of isolated extremity gunshot wounds compared with other-site gunshot wounds. One-fifth of decedents with extremity gunshot wounds survived hours. Targeted intervention programmes such as Stop the Bleed training may help to improve survival of isolated extremity gunshot wounds. LEVEL OF EVIDENCE:IV.
BACKGROUND:Pedestrian fatalities remain a public health burden. Risky behaviours by pedestrians such as alcohol or drug use are understudied. This study aims to quantify the prevalence and characteristics of substance use among pedestrian fatalities in New York State, USA. METHODS:The Fatality Analysis Reporting System was used to capture New York State pedestrian deaths from 2018 to 2020. Substance use was defined as the presence of alcohol, drugs, or both. Pedestrian death rates were calculated by age and sex. Statistical analyses used χ2, Fisher's exact test or t-test with significance defined as p<0.05. RESULTS:Of 771 pedestrian deaths, 43.8% involved substance use. Drug-only involvement accounted for 18.3% of all deaths, which was slightly higher than alcohol-only involvement (13.7%) and alcohol and drug co-use (11.8%). Substance-involved deaths were more common among males than females and varied by circumstances such as time of day and pedestrian location. CONCLUSIONS:Nearly half of pedestrian deaths in New York State involved substance use by the pedestrian. Public safety campaigns that traditionally emphasise drinking and driving should also address the dangers of walking while impaired. Interventions should encourage planning for safe travel and target high-risk groups.
