Faculty Bibliography

OBJECTIVES: We estimated the number of deaths attributable to social factors in the United States. METHODS: We conducted a MEDLINE search for all English-language articles published between 1980 and 2007 with estimates of the relation between social factors and adult all-cause mortality. We calculated summary relative risk estimates of mortality, and we obtained and used prevalence estimates for each social factor to calculate the population-attributable fraction for each factor. We then calculated the number of deaths attributable to each social factor in the United States in 2000. RESULTS: Approximately 245,000 deaths in the United States in 2000 were attributable to low education, 176,000 to racial segregation, 162,000 to low social support, 133,000 to individual-level poverty, 119,000 to income inequality, and 39,000 to area-level poverty. CONCLUSIONS: The estimated number of deaths attributable to social factors in the United States is comparable to the number attributed to pathophysiological and behavioral causes. These findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations.

AIMS: To assess the role of drug violations in aviation accidents. DESIGN: Case-control analysis. SETTING: Commercial aviation in the United States. PARTICIPANTS: Aviation employees who were tested for drugs during 1995-2005 under the post-accident testing program (cases, n = 4977) or under the random testing program (controls, n = 1 129 922). MEASUREMENTS: Point prevalence of drug violations, odds ratio of accident involvement and attributable risk in the population. A drug violation was defined as a confirmed positive test for marijuana (>/=50 ng/ml), cocaine (>/=300 ng/ml), amphetamines (>/=1000 ng/ml), opiates (>/=2000 ng/ml) or phencyclidine (>/=25 ng/ml). FINDINGS: The prevalence of drug violations was 0.64% [95% confidence interval (CI): 0.62-0.65%] in random drug tests and 1.82% (95% CI: 1.47-2.24%) in post-accident tests. The odds of accident involvement for employees who tested positive for drugs was almost three times the odds for those who tested negative (odds ratio 2.90, 95% CI: 2.35-3.57), with an estimated attributable risk of 1.2%. Marijuana accounted for 67.3% of the illicit drugs detected. The proportion of illicit drugs represented by amphetamines increased progressively during the study period, from 3.4% in 1995 to 10.3% in 2005 (P < 0.0001). CONCLUSIONS: Use of illicit drugs by aviation employees is associated with a significantly increased risk of accident involvement. Due to the very low prevalence, drug violations contribute to only a small fraction of aviation accidents.

AIMS: In the United States, transportation employees who are suspected of using alcohol and drugs are subject to reasonable-cause testing. This study aims to assess the validity of suspected alcohol and drug violations in aviation employees. METHODS: Using reasonable-cause testing and random testing data from the Federal Aviation Administration for the years 1995-2005, we calculated the positive predictive value (PPV) and positive likelihood ratio (LR+) of suspected alcohol and drug violations. The true status of violations was based on testing results, with an alcohol violation being defined as a blood alcohol concentration of >/=0.04 mg/dl and a drug violation as a test positive for marijuana, cocaine, amphetamines, phencyclidine or opiates. RESULTS: During the 11-year study period, a total of 2284 alcohol tests and 2015 drug tests were performed under the reasonable-cause testing program. The PPV was 37.7% [95% confidence interval (CI), 35.7-39.7%] for suspected alcohol violations and 12.6% (95% CI, 11.2-14.1%) for suspected drug violations. Random testing revealed an overall prevalence of 0.09% for alcohol violations and 0.6% for drug violations. The LR+ was 653.6 (95% CI, 581.7-734.3) for suspected alcohol violations and 22.5 (95% CI, 19.6-25.7) for suspected drug violations. CONCLUSION: The discriminative power of reasonable-cause testing suggests that, despite its limited positive predictive value, physical and behavioral observation represents an efficient screening method for detecting alcohol and drug violations. The limited positive predictive value of reasonable-cause testing in aviation employees is due in part to the very low prevalence of alcohol and drug violations.

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.

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.