Objectives: The aims were to: 1) describe the seriously injured older adult; 2) characterize and compare the differences in injury characteristics and outcomes in three subgroups of seriously injured older adults: 65-74 years, 75-84 years, and >85 years of age; 3) identify risk factors for death, complications, and discharge placement at hospital discharge.Design: A retrospective secondary analysis of a statewide trauma data set from 1988-1997.Setting: Data submitted from all designated trauma centers in Pennsylvania.Participants: The data set yielded 38,707 patients with a mean age of 77.5 years with serious injury (mean number of injuries = 3.6, mean number of body systems involved = 2).Measurements: Key outcomes were mortality, complications, and discharge placement. Abbreviated Injury Score categorized injuries and Injury Severity Score (ISS) quantified anatomic severity of injury.Results: Mortality was 10%. Mean length of stay 11.5 days. 52.2% of survivors were discharged home and 25.4% to a skilled nursing facility. Injury severity, total number of injuries, complications and increasing age were predictors of mortality (p<.01). The presence of pre-existing co-morbid medical conditions increased the odds of experiencing a complication over three-fold. Increasing age, total number of injuries, injury to extremities or abdominal contents, injuries due to falls, and lower functional level predicted discharge to a skilled nursing facility (p<.01).Conclusions: Traumatic injury in older adults are typically multisystem, life-threatening, and affects older adults of all ages. The standard ISS does not fully capture the potential for mortality in older adults and does not predict discharge placement. The majority of older adults survive multisystem injury. Our findings indicate the need to examine outcomes beyond mortality and to make the identification and management of co-morbid conditions a priority. A geriatric consultation service could be an important additional to the interdisciplinary trauma team. AbstractObjectives: The aims were to: 1) describe the seriously injured older adult; 2) characterize and compare

Objectives. We analyzed urban–rural differences in intentional firearm death. Methods. We analyzed 584629 deaths from 1989 to 1999 assigned to 3141 US counties, using negative binomial regressions and an 11-category urban–rural variable. Results. The most urban counties had 1.03 (95% confidence interval [CI]=0.87, 1.20) times the adjusted firearm death rate of the most rural counties. The most rural counties experienced 1.54 (95% CI=1.29, 1.83) times the adjusted firearm suicide rate of the most urban. The most urban counties experienced 1.90 (95% CI=1.50, 2.40) times the adjusted firearm homicide rate of the most rural. Similar opposing trends were not found for nonfirearm suicide or homicide. Conclusions. Firearm suicide in rural counties is as important a public health problem as firearm homicide in urban counties. Policymakers should become aware that intentional firearm deaths affect all types of communities in the United States.

Studies of place and health often classify a subject's exposure status according to that which is present in their neighborhood of residence. One's neighborhood is often proxied by designating it to be an administratively defined unit such as census tract, to make analysis feasible. Although it is understood that residential space and actual lived space may not correspond and therefore exposure misclassification may result, few studies have the opportunity to investigate the implications of this issue concretely. A population-based case-control study that is currently underway provides one such opportunity. Adolescent victims of assault in Philadelphia, Pennsylvania, USA, and a control sample of adolescents drawn randomly from the community are being enrolled to study how alcohol consumption and time spent nearby alcohol outlets -individual-level and environmental-level risk factors for violence, respectively -over the course of daily activities relate to the likelihood of being assaulted. Data from a rapport-building exercise consist of hand-drawn sketches that subjects drew on street maps when asked to indicate the area considered their neighborhood. The main data consist of self-reported, detailed paths of the routes adolescents traveled from one location to the next over the course of one full day. Having noticed interesting patterns as the data collection phase proceeds, we present here an analysis conducted with the data of 55 control subjects between 15-19 years old. We found that hand-drawn neighborhoods and activity paths did not correspond to census tract boundaries, and time subjects spent in close proximity to alcohol outlets during their daily activities was not correlated with the prevalence of alcohol outlets in the census tract of their residence. This served as a useful example demonstrating how classifying subjects as exposed based solely on the prevalence of the exposure in the geographic area of their residence may misrepresent the exposure that is etiologically meaningful.

Trauma-informed interventions have been implemented in various settings, but trauma-informed care (TIC) has not been widely incorporated into the treatment of adult patients with traumatic injuries. The purpose of this study was to examine health care provider knowledge, attitudes, practices, competence, and perceived barriers to implementation of TIC. This cross-sectional study used an anonymous web-based survey to assess attitudes, knowledge, perceived competence, and practice of TIC among trauma providers from an urban academic medical center with a regional resource trauma center. Providers (nurses, physicians, therapists [physical, occupational, respiratory]) working in trauma resuscitation, trauma critical care, and trauma care units were recruited. Descriptive statistics summarized knowledge, attitudes, practice, competence, and perceived barriers to TIC and logistic regression analyses examined factors predicting the use of TIC in practice. Of 147 participants, the majority were nurses (65%), followed by therapists (18%) and physicians (17%), with a median 3 years of experience; 75% answered the knowledge items correctly and 89% held favorable opinions about TIC. Nineteen percent rated themselves as less than "somewhat competent." All participants rated the following as significant barriers to providing basic TIC: time constraints, need of training, confusing information about TIC, and worry about retraumatizing patients. Self-rated competence was the most consistent predictor of providers' reported use of specific TIC practices. Despite some variability, providers were generally knowledgeable and held favorable views toward incorporating TIC into their practice. TIC training for trauma providers is needed and should aim to build providers' perceived competence in providing TIC.

Background Recruiting and retaining human participants in cancer clinical trials is challenging for many investigators. Although we expect participants to identify and weigh the benefits and burdens of research participation for themselves, it is not clear what burdens adult cancer participants perceive in relation to benefits. We identify key attributes and develop an initial conceptual framework of benefit and burden based on interviews with individuals enrolled in cancer clinical research. Methods Semistructured interviews were conducted with a purposive sample of 32 patients enrolled in cancer clinical trials at a large northeastern cancer center. Krueger's guidelines for qualitative methodology were followed. Results Respondents reported a range of benefits and burdens associated with research participation. Benefits such as access to needed medications that subjects otherwise might not be able to afford, early detection and monitoring of the disease, potential for remission or cure, and the ability to take control of their lives through actively participating in the trial were identified. Burdens included the potentiality of side effects, worry and fear of the unknown, loss of job support, and financial concerns. Conclusions Both benefit and burden influence research participation, including recruitment and retention in clinical trials. Dimensions of benefit and burden include physical, psychological, economic, familial, and social. Understanding the benefit-burden balance involved in the voluntary consent of human subjects is a fundamental tenet of research and important to ensure that subjects have made an informed decision regarding their decision to participate in clinical research.

BACKGROUND:We conducted a population-based case-control study to better delineate the relationship between individual alcohol consumption, alcohol outlets in the surrounding environment, and being assaulted with a gun.

Objectives-We investigated the possible relationship between being shot in an assault and possession of a gun at the time.Methods-We enrolled 677 case participants that had been shot in an assault and 684 populationbased control participants within Philadelphia, PA, from 2003 to 2006. We adjusted odds ratios for confounding variables.Results-After adjustment, individuals in possession of a gun were 4.46 (P<.05) times more likely to be shot in an assault than those not in possession. Among gun assaults where the victim had at least some chance to resist, this adjusted odds ratio increased to 5.45 (P<.05).Conclusions-On average, guns did not protect those who possessed them from being shot in an assault. Although successful defensive gun uses occur each year, the probability of success may be low for civilian gun users in urban areas. Such users should reconsider their possession of guns or, at least, understand that regular possession necessitates careful safety countermeasures.Among a long list of issues facing the American public, guns are third only to gay marriage and abortion in terms of people who report that they are "not willing to listen to the other side." In concert with this cultural rift, scholarly discussion over guns has been similarly contentious. 1 Although scholars and the public agree that the roughly 100000 shootings each year in the United States are a clear threat to health, uncertainty remains as to whether civilians armed with guns are, on average, protecting or endangering themselves from such shootings. [2][3][4] Several case-control studies have explored the relationship between homicide and having a gun in the home, 5,6 purchasing a gun, 7,8 or owning a gun. 9 These prior studies were not designed to determine the risk or protection that possession of a gun might create for an Correspondence should be sent to Charles C. Branas, PhD, Department of Biostatistics and Epidemiology, University, of Pennsylvania School of Medicine, Room 936, Blockley Hall, 423 Guardian Dr, Philadelphia, PA, 19104-6021 (cbranas@upenn.edu). Reprints can, be ordered at http://www.ajph.org by clicking the, "Reprints/Eprints" link. ContributorsC. C. Branas originated the study idea, oversaw the implementation of the study, and analyzed the data. T. S. Richmond and D. P. Culhane advised the study's implementation and analyses. T. R. Ten Have and D. J. Wiebe advised the study's implementation and analyzed the data. All authors wrote this article. Human Participant ProtectionThe study was approved by both the University of Pennsylvania and the Philadelphia Department of Public Health institutional review boards. A federal certificate of confidentiality was also provided by the National Institutes of Health. NIH Public Access Author ManuscriptAm J Public Health. Author manuscript; available in PMC 2010 November 1. individual at the time of a shooting and have only considered fatal outcomes. This led a recent National Research Council committee to conclude that, although the observed associations in these case-...

The purpose of this study was to test an explanatory model of variables influencing functional status in chronic obstructive pulmonary disease (COPD). The sample consisted of 104 patients with COPD (85 males, 19 females, mean age = 65.5, SD = 7.7). The variables in the initial model were age, length of illness, pulmonary function, oxygen desaturation during exercise, dyspnea, depressed mood, anxiety, self-esteem, exercise capacity, and functional status. Path analysis revealed that exercise capacity (beta = .337, p = .0007), dyspnea (beta = .324, p = .0009), and depressed mood (beta = -.204, p = .011) directly influenced functional status Dyspnea (beta = .488, p < .0001), depression (beta = -.217, p = .003), and pulmonary function (beta = .421, p < .0001) indirectly influenced functional status through exercise capacity. Self-esteem (beta = -.492, p = .004) and anxiety (beta = .696, p < .0001) indirectly influenced functional status through depressed mood. The findings of this study suggest that efforts to improve functional status of individuals with COPD should focus on interventions that influence exercise capacity, dyspnea, anxiety, and depressed mood.