Alcohol prices, the April effect, and the environment, in violence-related injury in England and Wales.

Violent injury varies widely across England and Wales as does the price of alcohol. While the links between alcohol consumption and violence are well established in the medical and epidemiological literature, a causal link is questionable. This paper cuts through the causative argument by reporting a link between the general price of alcohol and violence-related injury across the economic regions of England and Wales. It examines the influence of the real price of alcohol and identifies an 'April effect' that coincides with the annual uprating of alcohol prices for excise duties, on violence-related injuries recorded at Emergency Department attendance. The data are monthly frequency of violent injury rates covering the period 2005-2014 across the economic regions. The principal finding is that a one-way relationship between the real price of alcohol and violent injury is established, and tax policy can be used to reduce the incidence of violent injury and the associated health costs.

Injury resulting from targeted violence: An emergency department perspective.

BACKGROUND: Hate crimes - those perpetrated because of perceived difference, including disability, race, religion, sexual orientation or transgender status - have not been studied at the point of the victim's hospital emergency department (ED) use. AIM: To investigate the frequency, levels of physical harm and circumstances of targeted violence in those seeking treatment at EDs in three UK cities. METHOD: In a multimethods study, face-to-face semi-structured interviews were conducted with 124 adult ED attenders with violent injuries. Victim and perpetrator socio-demographics were recorded. Patient narratives about perceived motives and circumstances were transcribed, uploaded onto NVivo for thematic analysis. RESULTS: Nearly a fifth (23, 18.5%) of the injured patients considered themselves to have been attacked by others motivated by hostility or prejudice to their 'difference' (targeted violence). Thematic analyses suggested these prejudices were to appearance (7 cases), racial tension (5 cases), territorial association (3 cases) and race, religious or sexual orientation (8 cases). According to victims, alcohol intoxication was particularly relevant in targeted violence (estimated reported frequency 90% and 56% for targeted and non-targeted violence, respectively). CONCLUSIONS: Our findings support a broader concept of hate victimisation and suggest that emergency room violence surveys could act as a community tension sensor and early warning system in this regard. Tackling alcohol misuse seems as important in this as in other forms of violence perpetration. Copyright © 2017 John Wiley & Sons, Ltd.

The effectiveness of an intervention to reduce alcohol-related violence in premises licensed for the sale and on-site consumption of alcohol: a randomized controlled trial.

BACKGROUND AND AIMS: Premises licensed for the sale and consumption of alcohol can contribute to levels of assault-related injury through poor operational practices that, if addressed, could reduce violence. We tested the real-world effectiveness of an intervention designed to change premises operation, whether any intervention effect changed over time, and the effect of intervention dose. DESIGN: A parallel randomized controlled trial with the unit of allocation and outcomes measured at the level of individual premises. SETTING: All premises (public houses, nightclubs or hotels with a public bar) in Wales, UK. PARTICIPANTS: A randomly selected subsample (n = 600) of eligible premises (that had one or more violent incidents recorded in police-recorded crime data; n = 837) were randomized into control and intervention groups. INTERVENTION AND COMPARATOR: Intervention premises were audited by Environmental Health Practitioners who identified risks for violence and provided feedback by varying dose (informal, through written advice, follow-up visits) on how risks could be addressed. Control premises received usual practice. MEASUREMENTS: Police data were used to derive a binary variable describing whether, on each day premises were open, one or more violent incidents were evident over a 455-day period following randomization. FINDINGS: Due to premises being unavailable at the time of intervention delivery 208 received the intervention and 245 were subject to usual practice in an intention-to-treat analysis. The intervention was associated with an increase in police recorded violence compared to normal practice (hazard ratio = 1.34, 95% confidence interval = 1.20-1.51). Exploratory analyses suggested that reduced violence was associated with greater intervention dose (follow-up visits). CONCLUSION: An Environmental Health Practitioner-led intervention in premises licensed for the sale and on-site consumption of alcohol resulted in an increase in police recorded violence.

Preventing violence-related injuries in England and Wales: a panel study examining the impact of on-trade and off-trade alcohol prices.

OBJECTIVE: To examine the influence of real on-trade and off-trade alcohol prices and socioeconomic and environmental factors on rates of violence-related emergency department (ED) attendances in England and Wales over an 8-year period. METHODS: Anonymised injury data which included attendance date, age and gender of patients aged over 18 years who reported injury in violence were collected from a structured sample of 100 EDs across England and Wales between 1 January 2005 and 31 December 2012. Alcohol prices and socioeconomic measures were obtained from the UK Office for National Statistics. Panel techniques were used to derive a statistical model. RESULTS: Real on-trade (ß=-0.661, p<0.01) and off-trade (ß=-0.277, p<0.05) alcohol prices were negatively related with rates of violence-related ED attendance among the adult population of England and Wales, after accounting for the effects of regional poverty, income inequality, youth spending power and seasonal effects. It is estimated that over 6000 fewer violence-related ED attendances per year in England and Wales would result from a 1% increase in both on-trade and off-trade alcohol prices above inflation. Of the variables studied, changes in regional poverty and income inequality had the greatest effect on violence-related ED attendances in England and Wales. CONCLUSIONS: Small increases in the price of alcohol, above inflation, in both markets, would substantially reduce the number of patients attending EDs for treatment of violence-related injuries in England and Wales. Reforming the current alcohol taxation system may be more effective at reducing violence-related injury than minimum unit pricing.

Trends in violence in England and Wales 2010-2014.

BACKGROUND: The National Violence Surveillance Network (NVSN) of emergency departments (ED), minor injuries units and walk-in-centres in England and Wales has brought clarity to contradictory violence trends derived from crime survey and police data. Gender, age-specific and regional trends in violence-related injury in England and Wales since 2010 have not been studied. METHODS: Data on violence-related injury were collected from a structured sample of 151 EDs in England and Wales. ED attendance date and age and gender of patients who reported injury in violence from 1 January 2010 to 31 December 2014 were identified from attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends. RESULTS: In total, 247 016 (178 709 males: 72.3%) violence-related attendances were identified. Estimated annual injury rate across England and Wales was 4.4/1000 population (95% CI 3.9 to 4.9); males 6.5/1000 (95% CI 5.6 to 7.2) and females 2.4/1000 (95% CI 2.1 to 2.6). On average, overall attendances decreased by 13.8% per year over the 5 years (95% CI -14.8 to -12.1). Attendances decreased significantly for both genders and all age groups (0-10, 11-17, 18-30, 31-50, 51+ years); declines were greatest among children and adolescents. Significant decreases in violence-related injury were found in all but two regions. Violence peaked in May and July. CONCLUSIONS: From an ED perspective, violence in England and Wales decreased substantially between 2010 and 2014, especially among children and adolescents. Violence prevention efforts should focus on regions with the highest injury rates and during the period May-July.

All-Wales licensed premises intervention (AWLPI): a randomised controlled trial to reduce alcohol-related violence.

BACKGROUND: Alcohol-related violence in and in the vicinity of licensed premises continues to place a considerable burden on the United Kingdom's (UK) health services. Robust interventions targeted at licensed premises are therefore required to reduce the costs of alcohol-related harm. Previous evaluations of interventions in licensed premises have a number of methodological limitations and none have been conducted in the UK. The aim of the trial was to determine the effectiveness of the Safety Management in Licensed Environments intervention designed to reduce alcohol-related violence in licensed premises, delivered by Environmental Health Officers, under their statutory authority to intervene in cases of violence in the workplace. METHODS/DESIGN: A national randomised controlled trial, with licensed premises as the unit of allocation. Premises were identified from all 22 Local Authorities in Wales. Eligible premises were those with identifiable violent incidents on premises, using police recorded violence data. Premises were allocated to intervention or control by optimally balancing by Environmental Health Officer capacity in each Local Authority, number of violent incidents in the 12 months leading up to the start of the project and opening hours. The primary outcome measure is the difference in frequency of violence between intervention and control premises over a 12 month follow-up period, based on a recurrent event model. The trial incorporates an embedded process evaluation to assess intervention implementation, fidelity, reach and reception, and to interpret outcome effects, as well as investigate its economic impact. DISCUSSION: The results of the trial will be applicable to all statutory authorities directly involved with managing violence in the night time economy and will provide the first formal test of Health and Safety policy in this environment. If successful, opportunities for replication and generalisation will be considered. TRIAL REGISTRATION: UKCRN 14077; ISRCTN78924818.

Trends in community violence in England and Wales 2005-2009.

PURPOSE: Injury records from Emergency Departments (EDs) have been studied over the last decade as part of the work of the National Violence Surveillance Network (NVSN) and provide information about local, regional and national violence levels and trends in England and Wales. The purpose of the current study is to evaluate overall, gender, age-specific and regional trends in community violence in England and Wales from an ED perspective from January 2005 to December 2009. METHODS: Violence-related injury data were collected prospectively in a stratified sample of 77 EDs (Types 1, 3 and 4) in the nine Government Office Regions in England and in Wales. All 77 EDs were recruited on the basis that they had implemented and continued to comply with the provisions of the 1998 Data Protection Act and Caldicott guidance. Attendance date, age and gender of patients who reported injury in violence were identified using assault-related attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends. RESULTS: In total 221,673 (163,384 males: 74%) violence-related attendances were identified. Overall estimated annual injury rate was 6.5 per 1000 resident population (males 9.8 and females 3.4 per 1000). Violence affecting males and females decreased significantly in England and Wales over the 5-year period, with an overall estimated annual decrease of 3% (95% CI: 1.8-4.1%, p<0.05). Attendances decreased significantly for both genders across four out of the five age groups studied. Attendances were found to be highest during the months of May and July and lowest in February. Substantial differences in violence-related ED attendances were identified at the regional level. CONCLUSIONS: From this ED perspective overall violence in England and Wales decreased over the period 2005-2009 but increased in East Midlands, London and South West regions. Since 2006, overall trends according to Crime Survey for England and Wales (CSEW), police and ED measures were similar, though CSEW and ED measures reflect far greater numbers of violent incidents than police data. Causes of decreases in violence in regions need to be identified and shared with regions where violence increased.

Gender inequality in the risk of violence: material deprivation is linked to higher risk for adolescent girls.

OBJECTIVE: To investigate the association between material deprivation and injury sustained in violence by adolescents aged 11-17 years. METHODS: Computerised data relating to gender, attendance date and resident postcode of all patients aged 11-17 years who received treatment for violence-related injuries at seven emergency departments (ED) in South Wales over 12 months, 1 October 2005 to 30 September 2006, were studied. The resident populations, by electoral division of three unitary authorities in Wales, Cardiff, Swansea and Newport, were obtained from the NHS administrative register. The relationships between demographic variables and material deprivation as measured by the Townsend deprivation index were analysed. RESULTS: Altogether 699 (475 boys; 224 girls) adolescents aged 11-17 years resident in Cardiff, Swansea and Newport attended ED in South Wales following violence. Boys and girls living in the most deprived areas had higher assault injury rates compared with those living in the most affluent areas. In the context of sustaining violence-related injury, material deprivation affected girls aged 11-17 years to a much greater extent (Cardiff most deprived vs most affluent rate ratio 6.31, Swansea 10.11, Newport 2.90) than boys of the same age group (Cardiff most deprived vs most affluent rate ratio 2.02, Swansea 7.74, Newport 1.74). CONCLUSIONS: Material deprivation was associated with a higher risk of violence-related injury for adolescent girls compared with adolescent boys. Risk-taking behaviour for adolescent boys and girls may be different under different socioeconomic conditions. Violence prevention efforts should focus more on tackling neighbourhood inequalities, particularly those related to material deprivation in adolescent girls.

The roles of doctors and health services in community violence prevention.

Violence control and prevention have traditionally been led by criminal justice services. During the last decade, tackling violence has become a multi-agency effort supported by government and regulated according to new legislation, reflecting recognition that health services and local government can contribute uniquely to this.

An unusual cranial dislocation of the mandibular condyle.

We report an unusual case of a 20-year-old man who presented with a superolateral dislocation of the left condyle with intracranial penetration following a road traffic accident. Management included open reduction of the condyle, rigid intermaxillary fixation (IMF), and intensive jaw physiotherapy. One year after operation he had good functional outcome with an interincisal opening of 30mm.

Trends in violence in England and Wales 2000-2004: an accident and emergency perspective.

PURPOSE: To evaluate overall, gender and age-specific trends in violence in England and Wales from an accident and emergency (A&E) perspective. METHODS: Violence data were collected from a sample of 32 major A&E departments in the ten Government Office Regions of England and Wales over 5 years, 1st January 2000-31st December 2004. Attendance date, age, and gender of patients who reported injury in assault were studied. Time series statistical methods were used to detect national trends in overall violence and violence in which males and females were injured. Separate time series analyses were carried out for the five age groups (0-10, 11-17, 18-30, 31-50, and 50+ years). RESULTS: 203,819 (150,050 males: 74%) violence-related attendances were identified. Overall estimated annual injury rate was 6.4 per 1000 resident population (9.5 and 3.5 for males and females, respectively). There was a significant decrease in overall violence-related A&E attendance in England and Wales over the five-year period (p<0.05; 20% in Wales and 13% in England). There were significant decreases in A&E attendance for both males and females and all age groups (p<0.05). There were regional differences in violence-related A&E attendances with decreases in Wales, East Midland, London, North West and West Midland and increases in North East, Yorkshire and Humberside and South West regions. Violence-related A&E attendances were highest during the months of May to September and during December (p<0.05). CONCLUSIONS: This national study from the perspective of health services suggest that overall levels of violence decreased over the period 2000-2004 in England and Wales. Increases were not detected for any age group or gender. The reason for regional difference in trends in violence deserves further study.

The use of cone beam computed tomography in the management of isolated orbital floor fractures.

Isolated fractures of the orbital floor are diagnosed by a combination of clinical and radiographic findings. Computed tomography is considered the imaging method of choice. We describe the use of cone beam computed tomography for use in isolated fractures of the orbital floor. This shows defects in the orbital floor but with a lower dose of radiation than conventional computed tomography.

The effect of rugby match outcome on spectator aggression and intention to drink alcohol.

BACKGROUND: Alcohol, aggression and assault injury are strongly associated with popular sporting events, but mediating factors are not clear. AIMS: To explore aggression, happiness and plans to consume alcohol among spectators before and spectators after sports matches. METHODS: Cross-sectional surveys of male rugby football fans at an international stadium generated four groups: a pre-match group of 111 men, and three post-match groups of supporters, 17 whose team had won, 23 whose team had lost and 46 whose team had drawn. Consenting participants were assessed using the assault sub-scale of the Buss-Durkee Hostility Inventory, on a self-rating of happiness (Likert scale), for planned alcohol consumption and demographic variables. Pre- and post-match group mean responses were compared. RESULTS: Analyses were performed on 197 male spectators (mean age 42 years). Spectators in 'win' (z = 2.63, p < 0.01) and 'draw' (z = 2.76, p < 0.01) groups rated themselves as more aggressive than those in the pre-game group, but those in the losing group did not (z = -0.03, p > 0.05). No differences, however, were observed between pre-match, 'win', 'draw' or 'lose' groups on the decision to drink after the match. Winning did not increase happiness (t = 0.25, p > 0.05), but losing (t = 2.09, p < 0.05) or drawing (t = 7.64, p < 0.001) decreased it. CONCLUSIONS: This study suggests that team success but not failure may increase aggression among supporters, and that aggression, not celebration, drives post-match alcohol consumption. Losing and drawing decreased happiness but winning did not increase it. Better understanding of pathways to violence in these circumstances will pave the way for more effective prevention and management strategies.

Price of beer and violence-related injury in England and Wales.

OBJECTIVES: Relationships between violence-related injury and potential risk factors in England and Wales were investigated over a five-year period, 1st May 1995 to 30th April 2000. METHODS: Records from all 10 economic regions of England and Wales relating to price of alcohol, youth real income, wealth, ethnic density, dates of major sporting events and seasonality were studied with reference to violent injury data derived from 58 Emergency Departments (EDs) over the same period. Panel estimation and multi-level modelling was used to evaluate associations between variables. RESULTS: Overall, 353,443 violence-related A&E attendances were identified over the five-year period. High regional violence-related injury rates correlated with low real price of alcohol as measured by price of beer. Rates of violence were higher during summer months and on days of major sporting events. CONCLUSIONS: Risk of injury in violence was closely linked to alcohol price. Beer price rises should therefore reduce violent injury. Injury reduction efforts should be intensified during the summer and on days of major sports events.

Relations between violence, calendar events and ambient conditions.

National assault injury surveillance has identified major seasonal variation, but it is not clear whether assault injury is a seasonal problem in large cities. Relationships between community violence, calendar events and ambient conditions were investigated with reference to prospective, Accident and Emergency (A&E) derived information obtained from people injured in assaults in Cardiff between 1 May 1995 and 30 April 2000. Records of daily local ambient conditions included data relating to temperature, rainfall and sunshine hours and data of major local sporting events and annual holidays were studied. Pearson correlation coefficients were used to evaluate associations between variables. Overall, 19,264 assault-related A&E attendances were identified over the 5-year period. Almost three-quarters were males. Violence was clustered predominantly on Saturdays and Sundays, New Year and rugby international days. Temperature, rainfall and sunlight hours did not correlate significantly with violence (P > 0.05). The findings indicate that injury reduction effort should be intensified at the known risk times for violence and that in a capital city/regional centre violence cannot be predicted on the basis of ambient conditions.

Trends in violence in England and Wales 1995-2000: an accident and emergency perspective.

BACKGROUND: Prevention of violence-related injury has become an important public health issue but national, regional and local data are lacking. The aims of this study were to determine trends, seasonality and rates of violence-related injury according to Accident and Emergency (A&E) recorded data in England and Wales over a 5 year period, 1995-2000. METHODS: A stratified sample of 58 major A&E departments in England and Wales were recruited for the study. Electronic data on age, gender and date of attendance of all those reporting violence-related injury over a 5 year period, May 1995 to April 2000, were retrieved. Injury rates (number of injured per 100 resident population) were computed and ordinary least-squares regression analysis was used to evaluate linear and non-linear trends in these time series data. RESULTS: A total of 353442 (258719 males: 73 per cent) violence-related attendances were identified. Overall annual violence-related attendance did not change significantly (p > 0.05) but attendance of females aged 11-17 years increased steadily and significantly (p < 0.05) over the 5 year period. Health-region, gender- and age-specific increases in violence-related attendance slowed (p < 0.05). Compared with spring there were significantly lower levels of violence in autumn and winter for both males and females (p < 0.05). Violence affecting males aged 18-30 years was not subject to seasonality. Males, those aged 18-30 years and those living in the northern and western regions in England and Wales were at highest risk of violence-related injury. CONCLUSIONS: This national study from the perspective of health services suggests that violence did not increase over the period 1995-2000. Slowing of age-, gender- and health-region-specific increases in violence-related injury suggests that violence is coming under control. The reasons for significant trends in individual urban centres deserve further study, and could provide important new directions for violence prevention.