Injury and fatality risks for child pedestrians and cyclists on public roads.

BACKGROUND: Pedestrians and cyclists are often referred to as "vulnerable road users," yet most research is focused on fatal crashes. We used fatal and nonfatal crash data to examine risk factors (i.e., relationship to an intersection, urbanicity, crash circumstances, and vehicle type) for police-reported pedestrian and cyclist injuries on public roads among children aged 0-9 and aged 10-19. We also compared risk factors among these two age groups with adults aged 20-29 and aged 30-39. METHODS: Crash data were obtained for 2016-2020 from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System for fatal crash injuries and Crash Report Sampling System for nonfatal crash injuries. We collected data on victim demographics, roadway, and vehicle- and driver-related factors. Descriptive analyses were conducted between and within pedestrian and cyclist victims. RESULTS: We analyzed 206,429 pedestrian injuries (36% in children aged 0-19) and 148,828 cyclist injuries (41% in children aged 0-19) from 2016 to 2020. Overall, child pedestrians had lower injury rates than adults, but children aged 10-19 had greater cycling crash rates than adults. Almost half of the pedestrian injuries in children aged 0-9 were "dart-out" injuries (43%). In the majority of the cyclist injuries, children in both age groups failed to yield to vehicles (aged 0-9 = 40% and aged 10-19 = 24%). For children and all ages included in the study, the fatality risk ratio was highest when pedestrians and cyclists were struck by larger vehicles, such as trucks and buses. Further exploration of roadway factors is presented across ages and transportation mode. CONCLUSION: Our findings on child, driver, vehicle, and roadway factors related to fatal and nonfatal pedestrian and cyclist injuries may help to tailor prevention efforts for younger and older children.

Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019.

Importance: Stroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies. Objective: To present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location. Design, Setting, and Participants: An in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020. Exposures: In this study, no particular exposure was specifically targeted. Main Outcomes and Measures: The primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals. Results: In 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota). Conclusions and Relevance: In this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country.

Hearing Loss Prevalence, Years Lived With Disability, and Hearing Aid Use in the United States From 1990 to 2019: Findings From the Global Burden of Disease Study.

OBJECTIVES: This article describes key data sources and methods used to estimate hearing loss in the United States, in the Global Burden of Disease study. Then, trends in hearing loss are described for 2019, including temporal trends from 1990 to 2019, changing prevalence over age, severity patterns, and utilization of hearing aids. DESIGN: We utilized population-representative surveys from the United States to estimate hearing loss prevalence for the Global Burden of Disease study. A key input data source in modeled estimates are the National Health and Nutrition Examination Surveys (NHANES), years 1988 to 2010. We ran hierarchical severity-specific models to estimate hearing loss prevalence. We then scaled severity-specific models to sum to total hearing impairment prevalence, adjusted estimates for hearing aid coverage, and split estimates by etiology and tinnitus status. We computed years lived with disability (YLDs), which quantifies the amount of health loss associated with a condition depending on severity and creates a common metric to compare the burden of disparate diseases. This was done by multiplying the prevalence of severity-specific hearing loss by corresponding disability weights, with additional weighting for tinnitus comorbidity. RESULTS: An estimated 72.88 million (95% uncertainty interval (UI) 68.53 to 77.30) people in the United States had hearing loss in 2019, accounting for 22.2% (20.9 to 23.6) of the total population. Hearing loss was responsible for 2.24 million (1.56 to 3.11) YLDs (3.6% (2.8 to 4.7) of total US YLDs). Age-standardized prevalence was higher in males (17.7% [16.7 to 18.8]) compared with females (11.9%, [11.2 to 12.5]). While most cases of hearing loss were mild (64.3%, 95% UI 61.0 to 67.6), disability was concentrated in cases that were moderate or more severe. The all-age prevalence of hearing loss in the United States was 28.1% (25.7 to 30.8) higher in 2019 than in 1990, despite stable age-standardized prevalence. An estimated 9.7% (8.6 to 11.0) of individuals with mild to profound hearing loss utilized a hearing aid, while 32.5% (31.9 to 33.2) of individuals with hearing loss experienced tinnitus. Occupational noise exposure was responsible for 11.2% (10.2 to 12.4) of hearing loss YLDs. CONCLUSIONS: Results indicate large burden of hearing loss in the United States, with an estimated 1 in 5 people experiencing this condition. While many cases of hearing loss in the United States were mild, growing prevalence, low usage of hearing aids, and aging populations indicate the rising impact of this condition in future years and the increasing importance of domestic access to hearing healthcare services. Large-scale audiometric surveys such as NHANES are needed to regularly assess hearing loss burden and access to healthcare, improving our understanding of who is impacted by hearing loss and what groups are most amenable to intervention.

Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol.

BACKGROUND: Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail. METHODS: This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data. CONCLUSIONS: This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

Managed Care Updates of Subscriber Jail Release to Prompt Community Suicide Prevention: Clinical Trial Protocol.

Background: Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail. Methods: This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data. Conclusions: This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk. Trial Registration: The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023, https://beta.clinicaltrials.gov/study/NCT05579600?cond=Suicide&term=Managed%20Care&rank=1.

Study protocol for the ROSE Scale-Up Study: Informing a decision about ROSE as universal postpartum depression prevention.

PURPOSE: To examine the effectiveness, cost-outcome, equity, scalability, and mechanisms of the Reach Out, Stay strong, Essentials for mothers of newborns (ROSE) postpartum depression prevention (PPD) program as universal versus selective or indicated prevention. BACKGROUND: The United States Preventive Services Task Force (USPSTF) currently recommends PPD prevention for pregnant people at risk of PPD (i.e., selective/indicated prevention). However, universal prevention may be more scalable, equitable, and cost-beneficial. DESIGN: Effectiveness of ROSE for preventing PPD among people at risk is known. To assess ROSE as universal prevention, we need to determine the effectiveness of ROSE among all pregnant people, including those screening negative for PPD risk. We will enroll 2320 pregnant people, assess them with commonly available PPD risk prediction tools, randomize everyone to ROSE or enhanced care as usual, and assess ROSE as universal, selective, and indicated prevention in terms of: (1) effectiveness (PPD prevention and functioning), (2) cost-benefit, (3) equity (PPD cases prevented by universal prevention that would not be prevented under selective/indicated for minority vs. non-Hispanic white people), (4) quantitative and qualitative measures of scalability (from 98 agencies previously implementing ROSE), (5) ROSE mechanisms across risk levels. We will integrate results to outline pros and cons of the three prevention approaches (i.e., universal, selective, indicated). CONCLUSION: This will be the first trial to assess universal vs. selective/indicated PPD prevention. Trial design illustrates a novel, efficient way to make these comparisons. This trial, the largest PPD prevention trial to date, will examine scalability, an understudied area of implementation science.

Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

Cost-Effectiveness of Smoking Cessation Approaches in Emergency Departments.

INTRODUCTION: Americans of lower SES use tobacco products at disproportionately high rates and are over-represented as patients of emergency departments. Accordingly, emergency department visits are an ideal time to initiate tobacco treatment and aftercare for this vulnerable and understudied population. This research estimates the costs per quit of emergency department smoking-cessation interventions and compares them with those of other approaches. METHODS: Previously published research described the effectiveness of 2 multicomponent smoking cessation interventions, including brief negotiated interviewing, nicotine replacement therapy, quitline referral, and follow-up communication. Study 1 (collected in 2010-2012) only analyzed the combined interventions. Study 2 (collected in 2017-2019) analyzed the intervention components independently. Costs per participant and per quit were estimated separately, under distinct intervention with dedicated staff and intervention with repurposed staff assumptions. The distinction concerns whether the intervention used dedicated staff for delivery or whether time from existing staff was repurposed for intervention if available. RESULTS: Data were analyzed in 2021-2022. In the first study, the cost per participant was $860 (2018 dollars), and the cost per quit was $11,814 (95% CI=$7,641, $25,423) (dedicated) and $227 per participant and $3,121 per quit (95% CI=$1,910, $7,012) (repurposed). In Study 2, the combined effect of brief negotiated interviewing, nicotine replacement therapy, and quitline cost $808 per participant and $6,100 per quit (dedicated) (95% CI=$4,043, $12,274) and $221 per participant and $1,669 per quit (95% CI=$1,052, $3,531) (repurposed). CONCLUSIONS: Costs varied considerably per method used but were comparable with those of other smoking cessation interventions.

Screening and brief intervention for alcohol use disorder risk in three middle-income countries.

BACKGROUND: This study examined the prevalence of screening and brief intervention (SBI) for alcohol use disorder (AUD) risk in samples of adult drinkers in three middle-income countries (Brazil, China, South Africa), and the extent to which meeting criteria for AUD risk was associated with SBI. METHODS: Cross-sectional survey data were collected from adult samples in two cities in each country in 2018. Survey measures included past-year alcohol use, the CAGE assessment for AUD risk, talking to a health care professional in the past year, alcohol use screening by a health care professional, receiving advice about drinking from a health care professional, and sociodemographic characteristics. The prevalence of SBI was determined for past-year drinkers in each country and for drinkers who had talked to a health care professional. Logistic regression analyses were conducted to examine whether meeting criteria for AUD risk was associated with SBI when adjusting for sociodemographic characteristics. RESULTS: Among drinkers at risk for AUD, alcohol use screening rates ranged from 6.7% in South Africa to 14.3% in Brazil, and brief intervention rates ranged from 4.6% in South Africa to 8.2% in China. SBI rates were higher among drinkers who talked to a health care professional in the past year. In regression analyses, AUD risk was positively associated with SBI in China and South Africa, and with brief intervention in Brazil. CONCLUSION: Although the prevalence of SBI among drinkers at risk for AUD in Brazil, China, and South Africa appears to be low, it is encouraging that these drinkers were more likely to receive SBI.

Locked Down: Economic and Health Effects of COVID-19 Response on Residents of a South African Township.

Background: Little research has examined how pandemics affect residents in under-resourced communities. This study investigated how COVID-19 and lockdown policies affected residents of Alexandra, one of Johannesburg, South Africa's lowest-income townships. Methods: We conducted a telephone survey May 11-22, 2020, while the lockdown and alcohol ban were in effect, of a spatially stratified sample of 353 adult Alexandra residents drawn randomly from voter registration, credit card application, and prior studies' sampling frames. We examined economic consequences; health experiences, including COVID-19 exposure and mental health symptoms; alcohol use; and personal experiences with violence. Results: Respondents were aged 18 to 89 and 47% female. About 70% of those employed before the lockdown were no longer working. Over half of households lost at least one source of income. About 50% of respondents reported stockpiling food. A majority reported price rises and declines in availability of food. Smaller percentages reported such changes for other items. Over 80% reported stress or anxiety, or depression due to the pandemic. The prevalence of past-week alcohol use fell from over 50% before the lockdown to less than 10% during the lockdown. Self-reported physical violence victimization increased. Discussion: COVID-19 and the lockdown disrupted Alexandra residents' lives through unemployment, lost income, mental health problems, and increased violence. The differences between these outcomes and those in more advantaged communities deserve investigation. Research should also seek to identify tailored responses to effectively address the challenges of marginalized communities that often have limited resources to deal with pandemics and policies to contain them.

Monetised estimated quality-adjusted life year (QALY) losses for non-fatal injuries.

BACKGROUND: Quality-adjusted life years (QALYs) provide a means to compare injuries using a common measurement which allows quality of life and duration of life from an injury to be considered. A more comprehensive picture of the economic losses associated with injuries can be found when QALY estimates are combined with medical and work loss costs. This study provides estimates of QALY loss. METHODS: QALY loss estimates were assigned to records in the 2018 National Electronic Injury Surveillance System - All Injury Program. QALY estimates by body region and nature of injury were assigned using a combination of previous research methods. Injuries were rated on six dimensions, which identify a set of discrete qualitative impairments. Additionally, a seventh dimension, work-related disability, was included. QALY loss estimates were produced by intent and mechanism, for all emergency department-treated cases, by two disposition groups. RESULTS: Lifetime QALY losses ranged from 0.0004 to 0.388 for treated and released injuries, and from 0.031 to 3.905 for hospitalised injuries. The 1-year monetary value of QALY losses ranged from $136 to $437 000 among both treated and released and hospitalised injuries. The lifetime monetary value of QALY losses for hospitalised injuries ranged from $16 000 to $2.1 million. CONCLUSIONS: These estimates provide information to improve knowledge about the comprehensive economic burden of injuries; direct cost elements that can be measured through financial transactions do not capture the full cost of an injury. Comprehensive assessment of the long-term cost of injuries, including quality of life losses, is critical to accurately estimate the economic burden of injuries.

Racial/Ethnic Differences in Preceding Circumstances of Suicide and Potential Suicide Misclassification Among US Adolescents.

PURPOSE: There is a paucity of research on racial/ethnic differences in preceding circumstances of suicide among adolescents aged 10-19 years and consequential potential misclassification of suicide deaths (i.e., manner of death classified as injury of undetermined intent). This study (1) examined preceding circumstances of suicide among non-Hispanic White, non-Hispanic Black, non-Hispanic Asian/Pacific Islander (A/PI), non-Hispanic American Indian/Alaskan Native (AI/AN), and Hispanic adolescent decedents; and (2) investigated potential suicide misclassification of racial/ethnic minority decedents. METHODS: We used data from the 2006-2015 National Violent Death Reporting System Restricted Access Database. Multivariable logistic regression analyses examined differences in depressed mood, mental health problem and treatment, crisis in the past 2 weeks, problems with school, intimate partner, family relationship, and other relationships (e.g., friend) among racial/ethnic minority decedents compared to White decedents. A separate logistic regression analysis assessed potential suicide misclassification of racial/ethnic minority decedents relative to White counterparts. RESULTS: Adjusting for sex and suicide history and circumstances, all racial/ethnic minority decedents had significantly lower odds of documented mental health problem and treatment compared to White decedents. Racial/ethnic differences in relationship problems were also identified. Black decedents had significantly higher odds of manner-of-death classification as undetermined intent than did White decedents, suggesting greater likelihood of suicide misclassification. CONCLUSIONS: Circumstances contributing to suicide among adolescents differ by race/ethnicity, indicating the need for culturally tailored suicide prevention efforts.

Compliance with a law to reduce alcoholic beverage sales and service in Zacatecas, Mexico.

BACKGROUND: Research on the effects of restricting bar opening hours and alcohol sales in middle-income countries is very limited. We assessed compliance with and possible effects of a law enacted in Zacatecas, Mexico on December 30, 2017 and implemented in 2018 and 2019 that established a 2 AM bar closing time and 10 PM cut-off for alcohol sales by off-premises stores. METHODS: Monthly observations of bars and off-premises stores and alcohol mystery shopping visits from 2018 to early 2020 were conducted to assess compliance with the law. Breath tests were conducted in 2018 and 2019 with samples of pedestrians in the nighttime entertainment districts of Zacatecas and a comparison city (Aguascalientes). Surveys of bar owners/managers and staff, emergency medical personnel (EMP), and police officers were conducted in Zacatecas in 2018 and 2019 to assess awareness and support of the law and possible effects of the law on alcohol-related problems such as violence and injuries. RESULTS: Monthly observations indicated that a substantial percentage of bars and off-premises package stores did not comply with the law. Pedestrian breath tests in 2018 and 2019 indicated significant reductions in blood alcohol concentration and heavy drinking among pedestrians in Zacatecas from 11 PM to 2 AM compared to Aguascalientes, but not after 2 AM. Surveys of bar owners/managers indicated that most were aware and supportive of the law. EMP surveys indicated reductions in incidents of physical fighting and drunk or injured customers during the annual September fair in Zacatecas. CONCLUSIONS: This study suggests that restricting bar opening hours and alcohol sales may not result in full compliance by bars and off-premises stores, but may help to reduce excessive alcohol use and related harms in a middle-income country. A more rigorous evaluation with pre-intervention data is needed, however, to fully address this latter question.

Nonfatal Firearm Injuries by Intent in the United States: 2016-2018 Hospital Discharge Records from the Healthcare Cost and Utilization Project.

INTRODUCTION: In addition to the nearly 40,000 firearm deaths each year, nonfatal firearm injuries represent a significant public health burden to communities in the United States. We aimed to describe the incidence and rates of nonfatal firearm injuries. METHODS: We calculated nonfatal firearm injury estimates using the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, including the Nationwide Emergency Department Samples and the National Inpatient Samples. We used the International Classification of Diseases, 10th Revision, Clinical Modification to identify firearm injury episodes. Deaths in the emergency department (ED) or as inpatients were excluded. RESULTS: In addition to the 118,171 persons shot and killed by firearms from 2016-2018, 228,380 people were shot (ratio 1.9:1) and treated at a hospital ED or admitted to hospital, a rate of 23.4 nonfatal firearm injury episodes per 100,000 population. The number of nonfatal injury episodes varied by year: 2018 had the lowest at 69,692, compared to 84,776 in 2017 and 73,912 in 2016. Unintentional injury episodes were the most frequent, accounting for 58.5% (n = 81,217) and 38.9% (n = 34,820) of total nonfatal firearm hospital discharges from the ED and inpatients, respectively. Assault episodes were the next most frequent, at 36.3% (n = 50,482) of ED and 49.5% (n = 44,290) of inpatient discharges. The highest rate of nonfatal firearm injury by five-year age group was for 20- to 24-year-olds. With an annual rate of 73.53 per 100,000 population, the rates for ages 20-24 were more than 10 times higher than the rates for patients younger than 15 or 60 years and older. More than half (53.4%, n = 121,884) of hospital-treated, nonfatal firearm injury episodes were patients living in ZIP codes with a median household income in the lowest quartile, compared to 7.5% (n = 17,102) for patients residing in the highest income quartile ZIP codes, a sevenfold difference. CONCLUSION: For every person shot and killed by a gun in the US, two more are wounded. Unlike firearm deaths, which are predominantly suicides, most nonfatal firearm injury episodes are unintentional or with an assault intent. Having a reliable source of nonfatal injury data is essential to understanding the incidence of firearm injuries.

A Comparison of Chinese Adults Who Consume Homemade versus Commercial Alcohol.

BACKGROUND: Little is known about adults in China who drink homemade alcohol, and whether they are at elevated risk of harms relative to those who drink alcohol from commercial sources. Purpose: We describe and contrast adults in China who regularly consume either homemade or commercially available alcohol, or both. Methods: Household-based in-person interviews were conducted in 2018 with adults in Jiangshan and Lanxi. We examined the characteristics of 833 adults who had consumed alcohol within the previous 30 days, comparing those who drank commercial alcohol only with those who drank homemade alcohol only and alcohol from both sources. Results: Regression analyses revealed that drinkers of both homemade and commercial alcohol consumed more drinks and were more likely to report heavy drinking than did drinkers of commercial or homemade alcohol only and were also more likely to meet criteria for alcohol use disorder. We also found that homemade-only alcohol drinkers were at elevated risk for this disorder. Conclusions: Drinkers of both homemade and commercial alcohol in China may be at risk for alcohol-related problems and constitute a little understood population for whom further research is needed. The AB InBev Foundation supported this study.

Burden of Neurological Disorders Across the US From 1990-2017: A Global Burden of Disease Study.

Importance: Accurate and up-to-date estimates on incidence, prevalence, mortality, and disability-adjusted life-years (burden) of neurological disorders are the backbone of evidence-based health care planning and resource allocation for these disorders. It appears that no such estimates have been reported at the state level for the US. Objective: To present burden estimates of major neurological disorders in the US states by age and sex from 1990 to 2017. Design, Setting, and Participants: This is a systematic analysis of the Global Burden of Disease (GBD) 2017 study. Data on incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) of major neurological disorders were derived from the GBD 2017 study of the 48 contiguous US states, Alaska, and Hawaii. Fourteen major neurological disorders were analyzed: stroke, Alzheimer disease and other dementias, Parkinson disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, traumatic brain injury, spinal cord injuries, brain and other nervous system cancers, meningitis, encephalitis, and tetanus. Exposures: Any of the 14 listed neurological diseases. Main Outcome and Measure: Absolute numbers in detail by age and sex and age-standardized rates (with 95% uncertainty intervals) were calculated. Results: The 3 most burdensome neurological disorders in the US in terms of absolute number of DALYs were stroke (3.58 [95% uncertainty interval [UI], 3.25-3.92] million DALYs), Alzheimer disease and other dementias (2.55 [95% UI, 2.43-2.68] million DALYs), and migraine (2.40 [95% UI, 1.53-3.44] million DALYs). The burden of almost all neurological disorders (in terms of absolute number of incident, prevalent, and fatal cases, as well as DALYs) increased from 1990 to 2017, largely because of the aging of the population. Exceptions for this trend included traumatic brain injury incidence (-29.1% [95% UI, -32.4% to -25.8%]); spinal cord injury prevalence (-38.5% [95% UI, -43.1% to -34.0%]); meningitis prevalence (-44.8% [95% UI, -47.3% to -42.3%]), deaths (-64.4% [95% UI, -67.7% to -50.3%]), and DALYs (-66.9% [95% UI, -70.1% to -55.9%]); and encephalitis DALYs (-25.8% [95% UI, -30.7% to -5.8%]). The different metrics of age-standardized rates varied between the US states from a 1.2-fold difference for tension-type headache to 7.5-fold for tetanus; southeastern states and Arkansas had a relatively higher burden for stroke, while northern states had a relatively higher burden of multiple sclerosis and eastern states had higher rates of Parkinson disease, idiopathic epilepsy, migraine and tension-type headache, and meningitis, encephalitis, and tetanus. Conclusions and Relevance: There is a large and increasing burden of noncommunicable neurological disorders in the US, with up to a 5-fold variation in the burden of and trends in particular neurological disorders across the US states. The information reported in this article can be used by health care professionals and policy makers at the national and state levels to advance their health care planning and resource allocation to prevent and reduce the burden of neurological disorders.

Evaluation of a Mystery Shopper Intervention to Reduce Sales of Alcohol to Minors in Zacatecas and Guadalupe, Mexico.

We report the results of a quasi-experimental evaluation of a mystery shopper intervention in Zacatecas and Guadalupe, Mexico. Underage youth attempted to purchase beer at 50 Modelorama stores and 32 Oxxo stores (intervention groups), and at 19 comparison convenience stores in March, July, and August 2018. After each attempt, intervention store operators were informed if a sale was made. Modelorama operators also received training and were warned that repeated sales to minors could jeopardize their franchise. Average sales rates to minors were 63.8% at Modeloramas, 86.5% at Oxxo stores, and 98.2% at comparison stores. The findings suggest that mystery shopper interventions with training, feedback to store operators, and sanctions after repeated sales to underage youth may reduce sales to minors in low- and middle-income countries.

Efficacy and cost-effectiveness of subsidized ridesharing as a drunk driving intervention in Columbus, OH.

BACKGROUND: No economic evaluations exist of free or subsidized ridesharing services designed to reduce impaired driving. OBJECTIVES: To evaluate the effects and economics of a 17-weekend program that provided rideshare coupons good for free one-way or round trips to/from the hospitality zones in Columbus, Ohio, coupled with a modest increase in enforcement and a media campaign that used messaging about enforcement to promote usage. METHODS: Web surveys of riders and intercept surveys of foot traffic in the hospitality zones yielded data on the reduction in driving after drinking and the change in alcohol consumption associated with coupon use. We estimated crash changes from trip data using national studies, then confirmed with an ARIMA analysis of monthly police crash reports. Costs and output data came from program and rideshare company records. RESULTS: 70.8% of 19,649 responding coupon redeemers said coupon use reduced the chance they would drive after drinking. An estimated 1 in 4,310 drink-driving trips results in an alcohol-attributable crash, so the coupons prevented an estimated 3.2 crashes. Consistent with that minimal change, the ARIMA analysis did not detect a drunk-driving crash reduction. Self-reports indicated alcohol consumption rose by an average of 0.4 drinks per coupon redeemer, possibly with an equal rise among people who rode with the redeemer. The program cost almost $650,000 and saved an estimated 1.8 years of healthy life. Across a range of discount rates and values for a year of healthy life, it cost $366,000 to $791,000 per year of healthy life saved. Its estimated benefit-cost ratio was between 0.31 and 0.59, meaning it cost far more than it saved. CONCLUSIONS: Ridesharing, coupled with a media campaign and increased enforcement, was not a cost-effective drunk-driving intervention. Although it reduced drink-driving crashes and saved years of healthy life, those savings were modest and expensive. Moreover, the self-reported increase in participant drinking imposed countervailing risks. Even sensitivity analyses that potentially overestimate the benefits and underestimate the costs indicate a significant imbalance between program costs and savings. Any funding devoted to ridesharing would divert scarce resources from interventions with benefit-cost ratios above 1. Thus, our evaluation suggests that governments should not devote energy or resources to ridesharing programs if their primary objective is to reduce drink-driving or harmful alcohol use.

Alcohol Availability, Use, and Harms Among Adolescents in Three Mexican Cities.

Alcohol remains readily available to youth in most countries. We examined the associations between both the on- and off-premises commercial availability of alcohol to youth and their alcohol use, heavy episodic drinking, and alcohol-related harms. We conducted the study using data from a survey of a sample of 594 students in central Mexico between 12 and 17 years of age in 2016. Both the perceived availability of alcohol and the purchasing of alcohol at an off-premises establishment were positively related to past-30-day alcohol use and heavy episodic drinking, as well as to alcohol-related harms in the past year. Consumption at on-premises establishments was also positively associated with alcohol-related harms. Preventive efforts to reduce the availability of alcohol at off- and on-premises establishments, by such strategies as mystery shopper and responsible beverage service programs, are imperative.

Computerized intervention for reducing intimate partner victimization for perinatal women seeking mental health treatment: A multisite randomized clinical trial protocol.

Intimate partner victimization (IPV) is a significant social and public health problem among perinatal women. Research suggests that 21% to 33% of perinatal women report IPV and there is an enormous amount of morbidity associated with IPV. Moreover, IPV places women at high risk for several psychiatric disorders, which transforms the perinatal period from an already challenging process into a potentially overwhelming one. Further, IPV and untreated mental illness during the perinatal period pose a dual risk of adverse physical and emotional outcomes for women and their developing fetus/infant. Given the high rates of IPV among women who seek mental health treatment, mental health clinics compared to other medical settings are more effective sites for focused case finding and intervention. Our team has successfully tested an innovative, computerized intervention, Strength for U in Relationship Empowerment (SURE). SURE is a brief, interactive program consistent with motivational interviewing and incorporates empowerment strategies. The proposed multisite randomized clinical trial (N = 186) will test whether SURE relative to control is associated with reduced IPV, greater positive affect and well-being, and greater perceived emotional support. We will also evaluate the role of theoretical mediators of empowerment and self-efficacy. Finally, we will estimate the resources needed and costs to deliver SURE, as well as the incremental cost effectiveness of SURE compared with treatment as usual. If SURE is found to be efficacious and cost effective, it can be easily integrated into clinical care and will fill a critical gap for a vulnerable, high-risk population.