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Background: Alcohol is a contributing factor in a large proportion of traffic crashes. However, the role of other drugs is unknown. The objectives of this study are to determine the prevalence of recent drug use among drivers injured in traffic crashes, and to determine the extent to which drugs are responsible for crashes., Methods: We studied 414 injured drivers who presented to an urban emergency department within 1 hour of their crash. Demographic and injury data were collected from medical records. Urine toxicologic assays were conducted for legal and illegal drugs. Traffic crash reports were analyzed for crash responsibility by a trained crash reconstructionist. The causal role of drugs in traffic crashes was measured by comparing drug assay results in drivers judged responsible for their crashes (cases) and those not responsible (controls). Odds ratios and 95% confidence intervals (CIs) were calculated., Results: Thirty-two percent (95% CI = 27-37) of the urine samples were positive for at least one potentially impairing drug. Marijuana was detected most frequently (17%), surpassing alcohol (14%). Compared with drug- and alcohol-free drivers, the odds of crash responsibility were higher in drivers testing positive for alcohol alone (odds radio [OR] = 3.2, 95% CI = 1.1-9.4) and in drivers testing positive for alcohol in combination with other drugs (OR = 3.5, 95% CI = 1.2-11.4). Marijuana alone was not associated with crash responsibility (OR = 1.1, 95% CI = 0.5-2.4). In a multivariate analysis, controlling for age, gender, seat belt use, and other confounding variables, only alcohol predicted crash responsibility., Conclusion: Alcohol remains the dominant drug associated with injury-producing traffic crashes. Marijuana is often detected, but in the absence of alcohol, it is not associated with crash responsibility.

Background: Recently (1996-98), Colorado added 15 questions pertaining to injury related risks and behaviors to the behavioral risk factor surveillance system (BRFSS). Questions addressed bicycle helmet use, traffic crashes, exposure to violence, suicidal behavior, and gun storage., Objective: To measure the test-retest reliability of these injury related questions., Methods: Of 330 BRFSS participants, 229 (69%) were called a second time and reasked nine selected injury questions. Retests were completed 7-28 days after the original interview., Results: Test-retest agreement was very high (kappa >0.80) for bicycle helmet use, domestic police visits, and gun ownership. All other injury risk questions had substantial agreement (kappa >0.60)., Conclusions: The injury related questions added to the Colorado BRFSS have high test-retest reliability.

Study Objectives: To determine the rates of alcohol-related morbidity and mortality in a cohort of intoxicated ED patients 5 years after presentation and to compare them with those of non-intoxicated ED patients., Methods: The study group comprised 150 consecutive ED patients who presented with intoxication (blood alcohol level higher than 100 mg/dL) in June 1986 and 50 control patients matched for age, sex, ED arrival time, and date. The setting was an urban university hospital ED. Morbidity and mortality over a 5-year follow-up period were measured using hospital ED and admission records from all state Level I trauma centers and computerized statewide databases., Results: The 5-year mortality rate among alcohol-intoxicated patients was 2.4 times that of the comparison group (95% confidence interval, .3 to 18.9). The 5-year death rate among intoxicated patients aged 40 to 69 years was especially high (19%). Thirty-seven percent of the intoxicated patients made at least one alcohol-related ED revisit during the follow-up period, compared with 6% of the comparison group (P < .001). Intoxicated patients were more likely to revisit EDs because of suicidal behavior or domestic violence (P = .001). Admission to an alcohol detoxification unit during the follow-up period occurred in 24% of the intoxicated patients, compared with 10% of the sober controls (P = .03). At least one arrest for drunk driving occurred in 47% of the intoxicated group; the rate was lower, but still substantial, in the comparison group (20%, P < .001)., Conclusion: A single alcohol-related ED visit is an important predictor of continued problem drinking, alcohol-impaired driving and, possibly, premature death.

Background: Motorcycle riders have a high risk of traumatic brain injury, disability, and death. Epidemiologic studies have proven that helmets reduce the severity of brain injuries and the cost of care. Yet, Colorado remains one of three states with no helmet law for riders., Objectives: This study measured public support for (1) a mandatory motorcycle helmet use law and (2) mandatory motorcycle operator safety training. We also sought to ascertain citizens' attitudes toward traffic safety mandates from the federal government., Methods: Structured telephone interviews were conducted with 407 Colorado adults selected by random-digit dialing., Results: Sixty-five percent of respondents believed that motorcycle riders of all ages should be required to wear helmets. An additional 18% believed that only riders under age 21 should be required to wear helmets. Only 17% of respondents opposed all helmet laws. Even among motorcyclists, most supported helmet laws for all riders (47%) or for those <21 years of age (26%). In a multiple logistic regression, there were three significant independent predictors of a pro-helmet law stance: older age, female gender, and not possessing a motorcycle operator's license. Most respondents also supported mandatory motorcycle operator safety training. Despite supporting state helmet use regulations, a large proportion (41%) opposed mandatory Federal mandates to enact them., Conclusion: Even in Colorado, a state with no helmet use requirements, there is strong public support for a regulatory strategy of motorcycle helmet use laws.

Objective: To devise a brief screening instrument to detect partner violence and to partially validate this screen against established instruments., Design: Prospective survey., Setting: Two urban, hospital-based emergency departments., Participants: Of 491 women presenting during 48 randomly selected 4-hour time blocks, 322 (76% of eligible patients) participated. Respondents had a median age of 36 years; 19% were black, 45% white, and 30% Hispanic, while 6% were of other racial or ethnic groups; 54% were insured., Interventions: We developed a partner violence screen (PVS), consisting of 3 questions about past physical violence and perceived personal safety. We administered the PVS and 2 standardized measures of partner violence, the Index of Spouse Abuse (ISA) and the Conflict Tactics Scale (CTS)., Main Outcome Measures: Sensitivity, specificity, and predictive values of the PVS were compared with the ISA and the CTS as criterion standards., Results: The prevalence rate of partner violence using the PVS was 29.5% (95% confidence interval [CI], 24.6%-34.8%). For the ISA and CTS, the prevalence rates were 24.3% (95% CI, 19.2%-30.1 %) and 27.4% (95% CI, 21.7%-33.6%), respectively. Compared with the ISA, the sensitivity of the PVS in detecting partner abuse was 64.5%; the specificity was 80.3%. When compared with the CTS, sensitivity of the PVS was 71.4%; the specificity was 84.4%. Positive predictive values ranged from 51.3% to 63.4%, and negative predictive values ranged from 87.6% to 88.7%. Overall, 13.7% of visits were the result of acute episodes of partner violence., Conclusion: Three brief directed questions can detect a large number of women who have a history of partner violence.

Objective: To determine whether antidotes for poisoning and overdose are available in hospitals that provide emergency department care., Design: Written survey of hospital pharmacy directors, each of whom reported the amount currently in stock of 8 different antidotes: antivenin (Crotalidae) polyvalent, cyanide kit, deferoxamine mesylate, digoxin immune Fab, ethanol, naloxone hydrochloride, pralidoxime chloride, and pyridoxine hydrochloride., Participants: Pharmacy directors of all hospitals with emergency departments in Colorado, Montana, and Nevada., Main Outcome Measures: Proportions of hospitals with insufficient stocking of each antidote, defined as complete lack of the antidote or an amount inadequate to initiate treatment of 1 seriously poisoned 70-kg patient., Results: Questionnaires were mailed to 137 hospital pharmacy directors and 108 (79%) responded. Only 1 (0.9%) of the 108 hospitals stocked all 8 antidotes in adequate amounts. The rate of insufficient stocking for individual antidotes ranged from 2% (for naloxone) to 98% (for digoxin immune Fab). In a multiple regression analysis, smaller hospital size and lack of a formal review of antidote stocking were independent predictors of the number of antidotes stocked insufficiently., Conclusions: Insufficient stocking of antidotes is a widespread problem in Colorado, Montana, and Nevada. Although these states are served by a certified regional poison center, potentially lifesaving antidotes are frequently not available when and where they might be needed to treat a single poisoned patient.

Background: Control of motor vehicle-related injuries depends upon passage of mandatory safety belt and other injury control laws. Unfortunately, state legislators often oppose these laws., Methods: In 1988, a 62-item questionnaire was mailed to the 97 Colorado legislators who voted on a 1987 safety belt law to identify factors (knowledge, experiences, attitudes, and beliefs) associated with "yes" and "no" votes. To test for associations between these attributes and the legislators' recorded votes, odds ratios (OR) and 95% confidence intervals (CIs) were calculated. A stepwise logistic regression identified independent predictors of "vote.", Results: Fifty-three (55%) of the legislators responded. Responders and nonresponders were demographically similar. "Vote" was not associated with age; sex; having young children in the family; perceived injury risk; recent traffic tickets; family or personal crash experience; or knowledge of the fatality risk reductions attributable to wearing safety belts. Ninety-six percent of the legislators knew that safety belts reduce the risk of death and 87% believed a safety belt law would save lives. The strongest predictors of a "yes" vote were impression that constituents favored the law (OR = 31, CI 95 = 3.5, 270); belief that a mandatory safety belt law will save lives (OR = 20, CI 95 = 2.1, 203); and "extreme" importance paid in the voting decision to effectiveness of the law in reducing deaths (OR = 19, CI 95 = 3.5, 107). Legislators who considered restrictions on individual freedoms an "extremely" important decision criterion were 43 times (CI 95 = 7, 267) more likely to vote "no." In the logistic model only extreme importance assigned to individual freedoms (beta = 3.7; OR = .025; p = 0.002) and policy effectiveness (beta = +3.1; OR = 22; p = 0.01) predicted "vote." The logistic model correctly predicted 90% of legislators' votes., Conclusions: In this study the strongest predictors of voting behavior were concern for individual freedoms, perceived constituents' support and attention paid to policy effectiveness. Those seeking to persuade legislators to vote for mandatory safety belt laws must pay attention to attitudes and values in addition to scientific facts.

We observed 55 inpatients with "do-not-resuscitate" (DNR) orders to determine what happened to their DNR status after hospital discharge. All were admitted to the medical service of a Department of Veterans Affairs hospital. Of the 55 patients, 16 died in the hospital, 10 were discharged to inpatient hospice units, and 1 was transferred to an acute care hospital. An additional 19 patients were discharged to nursing homes. The other 9 patients (16% of the total) survived their hospital stays; 6 successful contacts were made with patients' spouses. In 1 case the spouse thought a DNR order was no longer desirable. In the other 5 cases the spouse said the DNR status was "probably" or "definitely" still warranted, but only 1 spouse had a written DNR order at home. We contacted 9 of the 14 house officers who had cared for the patients in hospital. Only 2 had ever written a DNR order after hospital discharge. Two house officers said they routinely discussed with family members a patient's expected dying process at home. Unwanted resuscitation is as undesirable at home as in the hospital. Physicians should discuss future resuscitation procedures with patients who have DNR orders at the time of hospital discharge. Physicians, paramedic service directors, and policymakers also should develop protocols and standardized home DNR orders so that paramedics can honor the wishes of patients in the prehospital setting.

Objective: To determine the incidence of acute mountain sickness in a general population of visitors to moderate elevations, the characteristics associated with it, and its effect on physical activity., Design: A cross-sectional study., Setting: Resort communities located at 6300 to 9700 feet elevation in the Rocky Mountains of Colorado., Participants: Convenience sample of 3158 adult travelers, 16 to 87 years old (mean age [+/- SD], 43.8 +/- 11.8 years)., Results: Twenty-five percent of the travelers to moderate elevations developed acute mountain sickness, which occurred in 65% of travelers within the first 12 hours of arrival. Fifty-six percent of those with symptoms reduced their physical activity. The odds favoring acute mountain sickness were 3.5 times as large for visitors whose permanent residence was below 3000 feet elevation as for those whose residence was above 3000 feet; 2.8 times as large for visitors with previous symptoms of acute mountain sickness; and twice as large in travelers younger than 60 years. Women, obese persons, those in poor or average physical condition, and those with underlying lung disease also had a higher occurrence of acute mountain sickness (P < 0.05)., Conclusions: Acute mountain sickness occurs in 25% of visitors to moderate altitudes and affects activity in most symptomatic visitors. Persons who are younger, less physically fit, live at sea level, have a history of acute mountain sickness, or have underlying lung problems more often develop these symptoms.

Study Objectives: To determine whether moderately to severely ill patients with acute pyelonephritis can be treated successfully on an outpatient basis, and whether any aspect of history, physical examination, or initial laboratory data predicts failure of outpatient therapy and the need for hospitalization., Design: Retrospective chart review of all patients with a diagnosis of acute pyelonephritis seen during a three-year period., Setting: Emergency department observation unit of an urban teaching hospital serving residents of the city and county of Denver., Type of Participants: Women between the ages of 15 and 50 with symptoms, physical examination, and initial laboratory data consistent with a diagnosis of pyelonephritis., Interventions: Patients received IV antibiotics, rehydration, analgesics, and antiemetics in an observation unit for up to 12 hours, when they were either admitted to the hospital or discharged home on oral antibiotics., Measurements and Main Results: Sixty-three of 87 patients (72%) with acute pyelonephritis were managed successfully as outpatients, nine (22%) were hospitalized directly from the observation unit because they were considered to be too ill to go home, and five (6%) returned with persistent symptoms after ED therapy and were hospitalized. No clinical or laboratory variable predicted success or failure of ED observation unit therapy at the time of initial presentation., Conclusion: In selected patients, the observation unit may be used to initiate therapy for acute pyelonephritis. Those with an adequate clinical response to initial treatment may be discharged on oral antibiotic therapy with appropriate follow-up.