Faculty Bibliography

Previous studies concerned with the relation of proximity to the September 11, 2001 terrorist attacks and subsequent psychopathology have produced conflicting results. The goals of this analysis are to assess the appropriateness of using Bayesian hierarchical spatial techniques to answer the question of the role of proximity to a mass trauma as a risk factor for psychopathology. Using a set of individual-level Medicaid data for New York State, and controlling for age, gender, median household income and employment-related exposures, we applied Bayesian hierarchical modeling methods for spatially aggregated data. We found that distance from the World Trade Center site in the post-attack time period was associated with increased risk of anxiety-related diagnoses. In the months following the attack, each 2-mile increment in distance closer to the World Trade Center site was associated with a 7% increase in anxiety-related diagnoses in the population. No similar association was found during a similar time period in the year prior to the attack. We conclude that spatial variables help more fully describe post-terrorism psychiatric risk and may help explain discrepancies in the existing literature about these attacks. These methods hold promise for the characterization of disease risk where spatial patterning of ecologic-level exposures and outcomes merits consideration.

Recent animal studies have shown that commonly used anesthetic agents may have serious neurotoxic effects on the developing brain. The purpose of this study was to assess the association between surgery for hernia repair and the risk of behavioral and developmental disorders in young children. We performed a retrospective cohort analysis of children who were enrollees of the New York State Medicaid program. Our analysis involved following a birth cohort of 383 children who underwent inguinal hernia repair during the first 3 years of life, and a sample of 5050 children frequency-matched on age with no history of hernia-repair before age 3. After controlling for age, sex, and complicating birth-related conditions such as low birth weight, children who underwent hernia repair under 3 years of age were more than twice as likely as children in the comparison group to be subsequently diagnosed with a developmental or behavioral disorder (adjusted hazard ratio 2.3, 95% confidence interval 1.3, 4.1). Our findings add to recent evidence of the potential association of surgery and its concurrent exposure to anesthetic agents with neurotoxicity and underscore the need for more rigorous clinical research on the long-term effects of surgery and anesthesia in children.

Mandatory alcohol testing programs for motor carrier drivers were implemented in the United States in 1995 and have not been adequately evaluated. Using data from the Fatality Analysis Reporting System during 1982-2006, the authors assessed the effectiveness of mandatory alcohol testing programs in reducing alcohol involvement in fatal motor carrier crashes. The study sample consisted of 69,295 motor carrier drivers and 83,436 non-motor-carrier drivers who were involved in 66,138 fatal multivehicle crashes. Overall, 2.7% of the motor carrier drivers and 19.4% of the non-motor-carrier drivers had positive blood alcohol concentrations. During the study period, the prevalence of alcohol involvement in fatal crashes decreased by 80% among motor carrier drivers and 41% among non-motor-carrier drivers. With adjustment for driver age, sex, history of driving while intoxicated, and survival status, implementation of the mandatory alcohol testing programs was found to be associated with a 23% reduced risk of alcohol involvement in fatal crashes by motor carrier drivers (odds ratio = 0.77, 95% confidence interval: 0.62, 0.94). Results from this study indicate that mandatory alcohol testing programs may have contributed to a significant reduction in alcohol involvement in fatal motor carrier crashes.

AIM: To conduct a comprehensive analysis of the conflicting evidence on substance use and misuse following mass traumas such as terrorist incidents. METHODS: We reviewed and synthesized evidence from 31 population-based studies using Bayesian meta-analysis and meta-regression. RESULTS: The majority of the studied were conducted in the aftermath of the terrorist attacks of 11 September 2001. Controlling for exposure, type of incident and time since the event occurred, 7.3% [95% credible interval (CrI) 1.1-32.5%] of a population can be expected to report increased alcohol consumption in the first 2 years following a terrorist event. There is, however, a 20% probability that the prevalence will be as high as 14%. The unadjusted prevalence of increased cigarette smoking following a terrorist event is 6.8% (95% Cr I 2.6-16.5%). Unadjusted reports of mixed drug use (including narcotics and prescription medications) was 16.3% (95% Cr I 1.3-72.5%). CONCLUSIONS: These results underscore the potentially pervasive behavioral health effects of mass terrorism, and suggest that public health interventions may usefully consider substance use as an area of focus after such events.

OBJECTIVE: To develop, implement, and assess a web-based simulation training program for emergency medical services (EMS) personnel on recognition and treatment of ocular injuries resulting from weapons of mass destruction (WMD) attacks. DESIGN: The training program consisted of six modules: WMD knowledge and event detection, ocular anatomy, ocular first aid (ie, flushing, cupping, and patching), and three WMD simulations (ie, sarin gas release, anthrax release, and radioactive dispersal device). Pretest, post-test, and 1-month follow-up test and a program evaluation were used to measure knowledge gain and retention and to assess the effectiveness of the program. SETTING: New York State EMS. PARTICIPANTS: Four hundred and sixty-four individuals participated in the training program and all waves of the testing (86 percent retention rate). MAIN OUTCOME VARIABLES: The effectiveness of the training intervention was measured using pretest and post-test questionnaires and analyzed using dependent t-tests. RESULTS: Assessment scores for overall knowledge increased from the pretest (mean = 15.7, standard deviation [SD] = 2.1) to the post-test (mean = 17.8, SD = 1.3), p < 0.001, and from pretest (mean = 15.7, SD = 2.1) to 1-month follow-up test (mean = 16.6, SD = 2.0), p < 0.001. Ninety-two percent of respondents indicated that the program reinforced understanding of WMDs. CONCLUSIONS: This training method provides an effective and low-cost approach to educate and evaluate EMS personnel on emergency treatment of eye trauma associated with the use of WMD. Online training should also be supplemented with hands-on practice and refresher trainings.

To illustrate how spatial modeling methods may provide insight about the relation between proximity to mass trauma and substance use, we examined the role of proximity to a terrorist event in determining risk of substance use related diagnoses. Previous analyses that have assessed changes in substance use following mass traumas such as terrorist attacks have produced conflicting results. We used Bayesian hierarchical modeling methods to assess whether distance from the World Trade Center (WTC) site in the aftermath of the September 11, 2001 terrorist attacks was associated with risk of substance use related diagnoses. In analyses controlling for age, gender, median household income, and employment-related exposure to the terrorist attacks, we found that each two mile increment in distance away from the WTC site was associated with 18% more substance use related diagnoses in the population we studied; this relation between distance from the WTC and substance use related disorder was the opposite of the relations observed one year before the same attacks in the same area. By accounting for spatial relationships that may influence the population risk of substance use health disorder, this approach helps explain some of the conflicting observations in the extant literature. These methods hold promise for the characterization of disease risk where spatial patterning of exposures and outcomes may matter.

Emergency physicians are likely to be first-line responders in any local or regional terrorist event. In addition to preparing for the potential physical conditions and injuries that are associated with terrorism, they should be aware of the behavioral and mental health implications as well. It is helpful to be familiar with the characteristics that predict who may be at increased risk for mental illness after such events and how they may be identified in an Emergency Department setting. Although most people in the general population with behavioral conditions stemming from a terrorist event can be expected to recover spontaneously within several months, other individuals are at increased risk of developing more debilitating mental health conditions that have been associated with post-terrorist and disaster environments. Screening tools are available to help emergency practitioners identify them and refer patients for more formal psychiatric evaluation and potential interventions to facilitate and speed the recovery process.

Data from existing administrative databases and ongoing surveys or surveillance methods may prove indispensable after mass traumas as a way of providing information that may be useful to emergency planners and practitioners. The analytic approach, however, may affect exposure prevalence estimates and measures of association. We compare Bayesian hierarchical modeling methods to standard survey analytic techniques for survey data collected in the aftermath of a terrorist attack. Estimates for the prevalence of exposure to the terrorist attacks of September 11, 2001, varied by the method chosen. Bayesian hierarchical modeling returned the lowest estimate for exposure prevalence with a credible interval spanning nearly 3 times the range of the confidence intervals (CIs) associated with both unadjusted and survey procedures. Bayesian hierarchical modeling also returned a smaller point estimate for measures of association, although in this instance the credible interval was tighter than that obtained through survey procedures. Bayesian approaches allow a consideration of preexisting assumptions about survey data, and may offer potential advantages, particularly in the uncertain environment of postterrorism and disaster settings. Additional comparative analyses of existing data are necessary to guide our ability to use these techniques in future incidents.