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INTRODUCTION: Increasing rates of neonatal abstinence syndrome (NAS), most commonly linked to maternal opioid use, are a growing concern within clinical and public health domains. OBJECTIVES: The study aims to describe the statewide burden of NAS and maternal substance use, focusing on opioids in Wisconsin from 2009 to 2014. METHODS: Trends in NAS and maternal substance use diagnosis rates were calculated using Wisconsin's Hospital Discharge Data. Demographic and payer characteristics, health service utilization, and clinical outcomes were compared for newborns with and without NAS. Demographic and payer characteristics were compared between women with and without substance use identified at time of delivery. RESULTS: Rates of NAS and maternal substance use, most notably opioid use, increased significantly between 2009 and 2014. The majority of newborns diagnosed with NAS, and women identified with substance use, were non-Hispanic, white, and Medicaid-insured. Disproportionate rates of NAS and maternal opioid use were observed in American Indian/Alaska Native and Medicaid populations compared to white and privately insured groups, respectively. Women age 20-29 years had the highest rates of opioid use compared to the reference group (10-19 years). Odds of adverse clinical outcomes and levels of health service utilization were significantly higher for newborns with NAS. CONCLUSIONS: Similar to trends nationally, our findings show an increase in maternal opioid use and NAS rates in Wisconsin over time, with disproportionate effects in certain demographic groups. These findings support the need for targeted interventions in clinical and public health settings aimed at prevention and burden reduction of NAS and maternal substance use in Wisconsin.

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The over-representation of young drivers in road crashes remains an important concern worldwide. Cluster analysis has been applied to young driver sub-groups, but its application by analysing crash occurrence is just emerging. We present a classification analysis that advances the field through a holistic overview of crash patterns useful for designing youth-targeted road safety programmes. We compiled a database of 8644 New Zealand crashes from 2002 to 2011 involving at least one 15-24-year-old driver and a fatal or serious injury for at least one road user. We considered crash location, infrastructure characteristics, environmental conditions, demographic characteristics, driving behaviour, and pre-crash manoeuvres. The analysis yielded 15 and 8 latent classes of, respectively, single-vehicle and multi-vehicle crashes, and average posterior probabilities measured the odds of correct classification that revealed how the identified clusters contain mostly crashes of a particular class and all the crashes of that class. The results raised three major safety concerns for young drivers that should be addressed: (1) reckless driving and traffic law violations; (2) inattention, error, and hazard perception problems; and (3) interaction with road geometry and lighting conditions, especially on high-speed open roads and state highways.

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Young people are a risk to themselves and other road users, as motor vehicle crashes are the leading cause of their death. A thorough understanding of the most important factors associated with injury severity in crashes involving young drivers is important for designing well-targeted restrictive measures within youth-oriented road safety programs. The current study estimates discrete choice models of injury severity of crashes involving young drivers conditional on these crashes having occurred. The analysis examined a comprehensive set of single-vehicle and two-vehicle crashes involving at least one 15-24 year-old driver in New Zealand between 2002 and 2011 that resulted in minor, serious or fatal injuries. A mixed logit model accounting for heterogeneity and heteroscedasticity in the propensity to injury severity outcomes and for correlation between serious and fatal injuries proved a better fit than a binary and a generalized ordered logit. Results show that the young drivers' behavior, the presence of passengers and the involvement of vulnerable road users were the most relevant factors associated with higher injury severity in both single-vehicle and two-vehicle crashes. Seatbelt non-use, inexperience and alcohol use were the deadliest behavioral factors in single-vehicle crashes, while fatigue, reckless driving and seatbelt non-use were the deadliest factors in two-vehicle crashes. The presence of passengers in the young drivers' vehicle, and in particular a combination of males and females, dramatically increased the probability of serious and fatal injuries. The involvement of vulnerable road users, in particular on rural highways and open roads, considerably amplified the probability of higher crash injury severity.

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BACKGROUND: Motor vehicle crashes are a leading cause of serious trauma during pregnancy, but little is known about their relationships with pregnancy outcomes. PURPOSE: To estimate the association between motor vehicle crashes and adverse pregnancy outcomes. METHODS: A retrospective cohort study of 878,546 pregnant women, aged 16-46 years, who delivered a singleton infant in North Carolina from 2001 to 2008. Pregnant drivers in crashes were identified by probabilistic linkage of vital records and crash reports. Poisson regression modeled the association among crashes, vehicle safety features, and adverse pregnancy outcomes. Analyses were conducted in 2012. RESULTS: In 2001-2008, 2.9% of pregnant North Carolina women were drivers in one or more crashes. After a single crash, compared to not being in a crash, pregnant drivers had slightly elevated rates of preterm birth (adjusted rate ratio [aRR]=1.23, 95% CI=1.19, 1.28); placental abruption (aRR=1.34, 95% CI=1.15, 1.56); and premature rupture of the membranes (PROM; aRR=1.32, 95% CI=1.21, 1.43). Following a second or subsequent crash, pregnant drivers had more highly elevated rates of preterm birth (aRR=1.54, 95% CI=1.24, 1.90); stillbirth (aRR=4.82, 95% CI=2.85, 8.14); placental abruption (aRR=2.97, 95% CI=1.60, 5.53); and PROM (aRR=1.95, 95% CI=1.27, 2.99). Stillbirth rates were elevated following crashes involving unbelted pregnant drivers (aRR=2.77, 95% CI=1.22, 6.28) compared to belted pregnant drivers. CONCLUSIONS: Crashes while driving during pregnancy were associated with elevated rates of adverse pregnancy outcomes, and multiple crashes were associated with even higher rates of adverse pregnancy outcomes. Crashes were especially harmful if drivers were unbelted.

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BACKGROUND: Case reports and series have suggested an association between injury during pregnancy and several nervous system and nervous system-related adverse fetal/neonatal outcomes. This study's purpose is to further determine if there is an association between injury during pregnancy and nervous system birth defects in infancy. METHODS: Through a case-control study, the association between injury during pregnancy and nervous system birth defects was tested using the Texas Birth Defects Registry (1999-2003). Semiautomated probabilistic bias analysis was used to correct for systematic error from misclassification of injury during pregnancy. RESULTS: Of the 59,750 infants eligible for this study, 4144 (6.94%) were diagnosed with a nervous system birth defect and 315 (0.53%) of the infants' mothers were injured during pregnancy. Among these 315 women, 25 (7.94%) delivered an infant with a subsequent nervous system birth defect. The adjusted odds ratio for the association between injury during pregnancy and nervous system birth defects among all study infants was 1.00; 95% confidence interval, 0.63-1.56 and 2.44; 95% confidence interval, 1.08-5.53 among breech presentation infants. Probabilistic bias analysis supported these findings. CONCLUSION: No association between injury during pregnancy and nervous system birth defects was identified. Further exploration into the association among breech presentation infants is warranted.

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BACKGROUND: Motor vehicle crashes are the leading cause of maternal injury-related mortality during pregnancy in the United States, yet pregnant women remain an understudied population in motor vehicle safety research. METHODS: We estimated the risk of being a pregnant driver in a crash among 878,546 pregnant women, 16-46 years, who reached the 20th week of pregnancy in North Carolina (NC) from 2001 to 2008. We also examined the circumstances surrounding the crash events. Pregnant drivers in crashes were identified by probabilistic linkage of live birth and fetal death records and state motor vehicle crash reports. RESULTS: During the 8-year study period, the estimated risk of being a driver in a crash was 12.6 per 1000 pregnant women. Pregnant women at highest risk of being drivers in serious crashes were 18-24 years old (4.5 per 1000; 95% confidence interval, CI,4.3, 4.7), non-Hispanic black (4.8 per 1000; 95% CI=4.5, 5.1), had high school diplomas only (4.5 per 1000; 95% CI=4.2, 4.7) or some college (4.1 per 1000; 95% CI=3.9, 4.4), were unmarried (4.7 per 1000; 95% CI=4.4, 4.9), or tobacco users (4.5 per 1000; 95% CI=4.1, 5.0). A high proportion of crashes occurred between 20 and 27 weeks of pregnancy (45%) and a lower proportion of crashes involved unbelted pregnant drivers (1%) or airbag deployment (10%). Forty percent of crashes resulted in driver injuries. CONCLUSIONS: NC has a relatively high pregnant driver crash risk among the four U.S. states that have linked vital records and crash reports to examine pregnancy-associated crashes. Crash risks were especially elevated among pregnant women who were young, non-Hispanic black, unmarried, or used tobacco. Additional research is needed to quantify pregnant women's driving frequency and patterns.

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BACKGROUND: No one knows whether the temporality of nonfatal deliberate self-harm in the United States mirrors the temporality of suicide deaths. AIMS: To analyze day- and month-specific variation in population rates for suicide fatalities and, separately, for hospital admissions for nonfatal deliberate self-harm. METHODS: For 12 states, we extracted vital statistics data on all suicides (n = 11,429) and hospital discharge data on all nonfatal deliberate self-harm admissions (n = 60,870) occurring in 1997. We used multinomial logistic regression to analyze the significance of day-to-day and month-to-month variations in the occurrence of suicides and nonfatal deliberate self-harm admissions. RESULTS: Both fatal and nonfatal events had a 6%-10% excess occurrence on Monday and Tuesday and were 5%-13% less likely to occur on Saturdays (p < .05). Males were more likely than females to act on Wednesdays and Saturdays. Nonfatal admission rates were 6% above the average in April and May (p < .05). In contrast, suicide rates were 6% above the average in February and March and 8% below it in November (p < .05). CONCLUSIONS: Suicides and nonfatal hospital admissions for deliberate self-harm have peaks and troughs on the same days in the United States. In contrast, the monthly patterns for these fatal and nonfatal events are not congruent.

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Motor vehicle crashes during pregnancy are the leading cause of traumatic fetal mortality and serious maternal injury morbidity and mortality in the United States, injuring approximately 92,500 pregnant women each year. Little is known about the circumstances surrounding these crash events and the maternal characteristics that may increase women's vulnerability to crash-related injuries during pregnancy. Even less is known about the effects of crashes on fetal outcomes. Crash simulation studies using female anthropomorphic test devices and computational models have been conducted to better understand the mechanisms of maternal and fetal injuries and death resulting from motor vehicle crashes. In addition, several case reports describing maternal and fetal outcomes following crashes have been published in the literature. Only a few population-based studies have explored the association between motor vehicle crashes and adverse maternal and/or fetal outcomes and even fewer have examined the effectiveness of seat belts and/or airbags in reducing the risk of these outcomes. This paper reviews what is presently known about motor vehicle crashes during pregnancy, their effects on maternal and fetal outcomes, and the role of vehicle safety devices and other safety approaches in mitigating the occurrence and severity of maternal crashes and subsequent injuries. In addition, this paper suggests interventions targeted towards the prevention of crashes during pregnancy.

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OBJECTIVE: : To determine trends for in-hospital survival and functional outcomes at acute care hospital discharge for patients with severe adult traumatic brain injury (SATBI) in Pennsylvania, during 1998 to 2007. METHODS: : Secondary analysis of the Pennsylvania trauma outcome study database. MAIN OUTCOME MEASURES: : Survival and functional status scores of 5 domains (feeding, locomotion, expression, transfer mobility, and social interaction) fitted into logistic regression models adjusted for age, sex, race, comorbidities, injury mechanism, extracranial injuries, severity scores, hospital stay, trauma center, and hospital level. Sensitivity analyses for functional outcomes were performed. RESULTS: : There were 26 234 SATBI patients. Annual numbers of SATBI increased from 1757 to 3808 during 1998 to 2007. Falls accounted for 47.7% of all SATBI. Survival increased significantly from 72.5% to 82.7% (odds ratio [OR] = 1.10, 95% CI: 1.08-1.11, P < .001). In sensitivity analyses, trends of complete independence in functional outcomes increased significantly for expression (OR = 1.01, 95% CI: 1.00-1.02, P = .011) and social interaction (OR = 1.01, 95% CI: 1.00-1.03, P = .002). There were no significant variations over time for feeding, locomotion, and transfer mobility. CONCLUSIONS: : Trends for SATBI served by Pennsylvania's established trauma system showed increases in rates but substantial reductions in mortality and significant improvements in functional outcomes at discharge for expression and social interaction.

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OBJECTIVE: To describe birth outcomes following intentional acute poisoning during pregnancy. SETTING: California Linked Vital Statistics-Patient Discharge Database, 2000 to 2004. PARTICIPANTS: Pregnant women age 15 to 44, who had a singleton live birth or fetal death that occurred between gestational ages 20 and 42 weeks who were discharged from the hospital for an intentional poisoning were compared to pregnant women discharged from the hospital for any nonpoisoning diagnosis. Intentional acute poisoning hospital discharges were identifed by the presence of an ICD-9-CM E-Codes E950-E952 (suicide, attempted suicide and self-inflicted injuries specified as intentional.) METHODS: Through a retrospective cohort design, birth outcomes including low birth weight; preterm birth; fetal, neonatal, and infant death; and congenital anomalies were identified by the presence of ICD-9-CM diagnosis codes or by notation in the dataset. RESULTS: There were 430 hospital discharges for an intentional poisoning during pregnancy documented in the dataset (rate=25.87/100,000 person years). The rate of intentional poisoning was greatest in the first weeks of gestation and declined with increasing gestational age. Analgesics, antipyretics, and antirheumatics were most commonly implicated. Adverse birth outcomes associated with intentional poisoning included preterm birth (odds ratio [OR]=1.34; 95% Confidence Interval [CI] [1.01, 1.77]), low birth weight (OR=1.49; 95% CI [1.04, 2.12]), and circulatory system congenital anomalies (OR=2.17; 95% CI [1.02, 4.59]). CONCLUSION: Intentional acute poisoning during pregnancy was associated with several adverse birth outcomes; however, these relationships may be confounded by concomitant maternal substance abuse.

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BACKGROUND: Cali, Colombia, has a high incidence of interpersonal violence deaths. Various alcohol control policies have been implemented to reduce alcohol-related problems. The objective of this study was to determine whether different alcohol control policies were associated with changes in the incidence rate of homicides. METHODS: Ecologic study conducted during 2004-08 using a time-series design. Policies were implemented with variations in hours of restriction of sales and consumption of alcohol. Most restrictive policies prohibited alcohol between 2 a.m. and 10 a.m. for 446 non-consecutive days. Moderately restrictive policies prohibited alcohol between 3 a.m. and 10 a.m. for 1277 non-consecutive days. Lax policies prohibited alcohol between 4 a.m. and 10 a.m. for 104 non-consecutive days. In conditional autoregressive negative binomial regressions, rates of homicides and unintentional injury deaths (excluding traffic events) were compared between different periods of days when different policies were in effect. RESULTS: There was an increased risk of homicides in periods when the moderately restrictive policies were in effect compared with periods when the most restrictive policies were in effect [incidence rate ratio (IRR) 1.15, 90% confidence interval (CI) 1.05-1.26, P = 0.012], and there was an even higher risk of homicides in periods when the lax policies were in effect compared with periods when the most restrictive policies were in effect (IRR 1.42, 90% CI 1.26-1.61, P < 0.001). Less restrictive policies were not associated with increased risk of unintentional injury deaths. CONCLUSION: Extended hours of sales and consumption of alcohol were associated with increased risk of homicides. Strong restrictions on alcohol availability could reduce the incidence of interpersonal violence events in communities where homicides are high.

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The aims of this study were to describe and compare the epidemiology of acute poisoning hospital discharges in women of reproductive age and during pregnancy (aged between 15 and 44) to include the incidence rate, risk factors, substances involved, rates of intentional versus unintentional poisonings, and in pregnant women, distribution over trimesters. Through a cohort study design, the California patient discharge dataset and linked vital statistics-patient discharge database were used to identify cases of acute poisoning hospital discharges from 2000 to 2004 among women of reproductive age and among pregnant women. Odds ratios (OR) were calculated to identify risk factors using logistic regression. Of 4,436,019 hospital discharges in women of reproductive age, 1% were for an acute poisoning (115.3/100,000 person-years). There were 2,285,540 deliveries and 833 hospital discharges for an acute poisoning during pregnancy (48.6/100,000 person-years). Pregnancy was associated with a lower risk of acute poisoning (OR = 0.89, P = 0.0007). Poisonings were greatest among young black women regardless of pregnancy status and among those with substance abuse or mental health problems. Analgesic and psychiatric medications were most commonly implicated. The majority of poisonings among women of reproductive age (69.6%) and among pregnant women (61.6%) were self-inflicted. Efforts to reduce acute poisonings among women of reproductive age should include education regarding the use of over-the-counter medications and interventions to reduce self-inflicted harm.

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We analyzed alcohol involvement in 84,005 medically identified live discharges for self-inflicted intentional injuries (typically suicide acts) from hospitals in 20 U.S. states in 1997. Alcohol was involved in 27% of the discharges. Evidence of alcohol was significantly more prevalent in men than women, but generally men drink more than women. Blacks had the highest alcohol involvement in their suicide acts relative to their drinking patterns. Overall, alcohol involvement rose and subsequently fell with age, with involvement above 30% for ages 30-55. Lowering the minimum legal drinking age to 18 from 21 could potentially raise alcohol-involved suicide hospitalizations among youth by an estimated 27%.

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The rate of birth trauma in the US has been reported to range between 0.2 and 37 birth traumas per 1000 births. Because of the minimal number of population-based studies and the inconsistencies among the published birth trauma rates, the rate of birth trauma in the US remains unclear. This is a cross-sectional study that was conducted using 890 582 in-hospital birth discharges from the 2003 Healthcare Cost and Utilization Project Kids' Inpatient Database. A neonate was defined as having birth trauma if their hospital discharge record contained an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code from 767.0 to 767.9. Weighted data were used to calculate rates for all birth traumas and specific types of birth traumas, and rates and odds ratios by demographic, hospital and clinical variables. Weighted data represented a national estimate of 3 920 787 in-hospital births. Birth trauma was estimated to occur in 29 per 1000 births. The three most frequently diagnosed birth traumas were injuries to the scalp, other injuries to the skeleton and fracture of the clavicle. Significant univariable predictors for birth trauma included male gender, Asian or Pacific Islander race, living in urban or wealthy areas, being born in Western, urban and/or teaching hospital, a co-diagnosis of high birthweight, instrument delivery, malpresentation and other complications during labour and delivery. Birth trauma risk factors including those identified in this study may be useful to consider during labour and delivery. In conclusion, additional research is necessary to identify ways to reduce birth trauma and subsequent infant morbidity and mortality.

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To evaluate the 2003 repeal of Pennsylvania's motorcycle helmet law, we assessed changes in helmet use and compared motorcycle-related head injuries with non-head injuries from 2001-2002 to 2004-2005. Helmet use among riders in crashes decreased from 82% to 58%. Head injury deaths increased 66%; nonhead injury deaths increased 25%. Motorcycle-related head injury hospitalizations increased 78% compared with 28% for nonhead injury hospitalizations. Helmet law repeals jeopardize motorcycle riders. Until repeals are reversed, states need voluntary strategies to increase helmet use.

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BACKGROUND: Inflicted traumatic brain injury (inflicted TBI) in infants has been the subject of recent preventive interventions, yet the burden of this problem is poorly defined. This article estimates the national incidence of hospitalizations due to inflicted TBI in infants aged <1 year using hospital discharge databases (HDDs) over 3 years, compares findings to previous infant inflicted TBI studies, and assesses differences in case composition and coding over time. METHODS: The Kids' Inpatient Databases (KIDs) for 1997, 2000, and 2003 were used to estimate the incidence of inflicted TBI hospitalizations in infants. Cases were identified by the presence of ICD-9-CM codes indicating both TBI and abuse. Incidence estimates were generated by dividing the weighted number of inflicted TBI cases identified by the year-specific infant population. Changes over time were evaluated using Cochran-Armitage and ANOVA statistical tests. RESULTS: The 1997, 2000, and 2003 KIDs yielded infant inflicted TBI incidence estimates of 27.5 (95% CI=20.8-34.0), 27.5 (95% CI=22.6-32.3), and 32.2 (95% CI=26.9-37.4) cases per 100,000 infants per year, respectively. KIDs estimates were within the range of previous inflicted TBI incidence studies that used active surveillance. Over time, the proportion of cases covered by Medicaid increased (p<0.0001). CONCLUSIONS: The KIDs can be used to generate incidence estimates of infant inflicted TBI hospitalizations that are consistent with previously published active surveillance estimates. HDDs can be used to assess the scope of infant inflicted TBI as well as trends in case composition and coding practices. Such assessments may be useful for the evaluation of prevention programs.

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OBJECTIVE: Describe the demographics, injury types, mechanisms, and intents of emergency department (ED) injury visits by pregnant women and to quantify their risk of adverse birth outcomes. METHODS: Through a retrospective cohort study design, Utah ED, birth, and fetal death records were probabilistically linked to identify women seen in an ED with an injury during pregnancy among births and fetal deaths from 1999 to 2002. Logistic regression was used to assess the effect of having an injury-related ED visit on various adverse pregnancy outcomes. RESULTS: 7350 (3.9%) women experienced an injury-related ED visit during pregnancy. Motor vehicle occupant injuries were the leading mechanism of ED injury visits (22.4%). Controlling for known risks, pregnant women with an injury-related ED visit were more likely than non-injured pregnant women to experience preterm labor (OR=1.22, 95% CI=1.12-1.34), placental abruption (OR=1.33, 95% CI=1.08-1.65), and cesarean delivery (OR=1.27, 95% CI=1.19-1.36). Infants born to women who were injured during pregnancy were more likely to be born preterm (OR=1.23, 95% CI=1.12-1.34) and have low birth weight (OR=1.22, 95% CI=1.1-1.35). CONCLUSIONS: Most injured pregnant women are treated and released from the ED; however, significant increased risks remain for several maternal complications and birth outcomes.

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