Injury Patterns in Vehicle Crashes: The Significance of Occupant Seating Position

OBJECTIVES

 Investigating patterns among the outcomes of patients involved in motor vehicle accidents (MVAs) can provide information necessary to guide targeted interventions to improve road traffic safety. Our purpose is to identify any differences between passenger and driver injury severity and overall clinical course after MVAs.

METHODS

 We performed a retrospective review and analysis of 3,693 patients involved in MVAs from 2016 to 2021. We divided the data into two groups, drivers and passengers, and compared the Injury Severity Score (ISS), Revised Trauma Score (RTS) on admission, days in the Intensive Care Unit (ICU), length of hospital stay (LOS), post Emergency Department (ED) disposition, discharge (DC) disposition, and signs of life on arrival (SOLA) to the ED. We compared mean ISS, New Injury Severity Score (NISS), RTS, length in ICU and LOS using a student's T-test and SOLA, post-ED and DC disposition using Chi-square analysis.

RESULTS

 We did not find any statistically significant difference in ISS, RTS, days in ICU, LOS, or SOLA between the drivers and passengers. However, we did find a statistically significant difference in the post-ED (X2= 113.743, p=<0.0001) and DC disposition (X2=41.172, p=<0.0001) of drivers and passengers. After the ED and DC, more passengers were transferred to a higher level of care than expected, while the inverse was true for drivers. The number of drivers discharged to Skilled Nursing Facilities (SNFs) was also higher than expected, further contributing to the observed difference in DC disposition.  Conclusion: Our study found no statistically significant difference between driver and passenger injury severity, length of hospital stay, days in ICU, and SOLA after an MVA. The clinical courses of the two groups were found to be significantly different based on post-ED and DC disposition data. We identified limitations, such as a relatively small sample size and insufficient data on specific car seat locations for passengers, underscoring the need for a more nuanced exploration. Future research must broaden its scope to encompass diverse crash scenarios, vehicle design and safety technologies, seat belt dynamics, and age- and gender-specific vulnerabilities.

Pheochromocytoma-Induced Hypertension After Traumatic Brain Injury

A 23-year-old female presented to the emergency department (ED) after sustaining a motor vehicle accident and subsequent loss of consciousness. In the ED, the patient was hemodynamically stable and was appropriately discharged with a diagnosis of mild traumatic brain injury. The patient presented 10 days post-injury to the outpatient brain injury clinic with complaints of headache, anxiety, and dizziness, with an elevated blood pressure of 160/100 mmHg. Initial head imaging, drug screen, complete blood count, and complete metabolic panel were unremarkable, however, urine and plasma metanephrines were found to be elevated. Abdominal computed tomography imaging revealed a pheochromocytoma, and the patient was adequately treated with medication and adrenalectomy with complete resolution of symptoms. Existing literature has indicated that stress and physical trauma can contribute to the escalation of pheochromocytoma symptoms in previously asymptomatic individuals; here, the stress and trauma stemming from an automobile accident and mild traumatic brain injury may have precipitated the onset of pheochromocytoma symptoms in the patient. Symptoms of pheochromocytoma can align with those commonly observed after traumatic brain injury (TBI), encompassing headaches, anxiety, and dizziness. Our case demonstrates the need for clinicians to consider the presence of pheochromocytoma in a post-traumatic brain injury patient.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Unintentional Injuries Among Young Adolescents at a Level-One Trauma Center in Saudi Arabia: A Cross-Sectional Study

Background Unintentional injuries are the leading preventable cause of mortality across different demographics. This study aims to assess the prevalence, severity, contributing factors, and clinical outcomes of unintentional injuries among adolescent patients. Methods A retrospective study was conducted using the charts of patients admitted with unintentional injuries (motor vehicle accidents (MVA), falls, pedestrian injuries, burns, etc.) to the emergency department (ED) from January 2016 to December 2018 at a level-one trauma center in Riyadh, Saudi Arabia. A total of 721 patients' charts were reviewed, but only 52 patients were consecutively included as per the definition of an adolescent. All variables, including severity and outcome, were assessed. Results The overall prevalence of unintentional injuries was 7.2 per 100 adolescent patients. The most common cause of unintentional injury were MVAs, which were reported in 35 (71%), with head and neck region injuries among 38 (73%) patients. The overall mortality was noted at 10 per 52 (19%) patients. The mean Injury Severity Score (ISS) score was 17.81±12.76. The patients who stayed longer in the ED were not associated with pelvic and lower extremity injuries, with a p-value=0.008. The ISS was the significant predictor of mortality, with an odds ratio (OR) of 1.6, a confidence interval (CI) of 1.02-2.65, and a p-value=0.04. Conclusion MVAs were the main cause of unintentional injuries among adolescents. Future recommendation plans for adolescents should include stricter implementation of road traffic laws to control this early, preventable death among adolescents.

Sample size bias in the empirical assessment of the acute risks associated with daylight saving time transitions

The assessment of the acute impact of daylight saving time (DST) transitions is a question of great interest for an understanding of the benefits and inconveniences of a practice that is now under public scrutiny in Europe and America. Here, we report a thorough analysis of a record of 13 well-known research studies that reported increased risks associated with DST transitions in health issues - acute myocardial infarction, ischemic strokes and trauma admissions - and in societal issues - accidents, traffic accidents and fatal motor vehicle accidents. We found that five increase of the risks suffices to understand the reported increased risks associated with the spring transition. Reported values above this threshold are impacted by the sample size of the study. In the case of the autumn transition, no increase in the risks is found.

The Role of Emotional Dysregulation, Impulsivity Traits and Aggressive Behaviors in Adolescents Who Sustain Multiple Motor-Vehicle Crashes

Adolescents tend to experience multiple motor-vehicle crashes (MVCs). Recent literature has thoroughly explored the psychological consequences following an MVC, but prior psychological functioning, the ability to regulate one's emotions and tendencies to impulsivity and aggressive behaviors have been far less explored. This study aims to explore the emotional-behavioral functioning, measured with the Youth Self-Report (YSR); emotional dysregulation, measured with the Difficulties in Emotional Regulation Scale (DERS); impulsivity traits, measured with the Barratt Impulsiveness Scale (BIS-11); and the capacity to be mindful, measured with the Mindful Attention Awareness Scale (MAAS), in adolescents that have experienced one or more MVCs in a year. N = 295 adolescents who visited an emergency department for MVCs were divided in two groups based on the number of MVCs they had sustained over the course of a year. The adolescents in Group 1 sustained more than three MVCs, and adolescents in Group 2 sustained only one. Participants were assessed through self-report questionnaires. Adolescents showed difficulties in emotional regulation, impulsivity traits, aggressive behaviors and a low capacity to be mindful. These results may be useful in the creation of intervention and prevention programs focused on emotional awareness targets for adolescents.

Isolated vehicle rollover is not an independent predictor of trauma injury severity

OBJECTIVES

The objective of this study was to determine if vehicle rollover in a motor vehicle crash is an independent predictor of major injury.

METHODS

A retrospective cohort study of all patients injured in motor vehicle crashes presenting to a major trauma center between July 2012 and June 2016 was conducted. Crashes were classified into groups: non-rollover, isolated rollover (without other mechanisms of injury), or mixed-mechanism rollover (with other mechanisms of injury). Associations between rollover group, other covariates (entrapment, encapsulation, ejection, death on scene, high speed, seat belt usage, airbag deployment, trauma team activation), and major injury (injury severity score >15, major surgery, intensive care unit admission, or in-hospital death) were tested using binary logistic regression models. Vehicle rollover was categorized either as "present" or "absent" on 1 model or as either "none," "isolated," or "mixed mechanism" in the other.

RESULTS

In 2446 motor vehicle crashes, there were 423 rollovers (196 isolated, 227 mixed mechanisms). Compared with crashes without rollovers, the prevalence of patients with major injury was lower in crashes with isolated rollovers and higher in crashes with mixed-mechanism rollovers (13.8% vs 9.5% vs 27.5%, respectively; P < 0.001). Rollover (present vs absent) was not an independent predictor of major injury (odds ratio [OR], 1.10; 95% confidence interval [CI], 0.78-1.53). Patients in crashes with mixed-mechanism but not isolated rollovers had increased odds (OR, 2.04; 95% CI, 1.41-2.96) of major injury compared with patients from crashes without rollovers.

CONCLUSIONS

Patients from crashes with isolated vehicle rollovers may not need to be transported to a trauma center as they carry a lower risk of injury.

Vascular injury-related in-hospital mortality in Ontario between 1991 and 2009

OBJECTIVE

Trauma-related vascular injuries are major contributors to morbidity and mortality worldwide. We conducted a retrospective, population-based, cross-sectional study to examine temporal trends and factors associated with traumatic vascular injury-related in-hospital mortality in Ontario, Canada from 1991 to 2009.

METHODS

We obtained data on Ontario hospital admissions for traumatic vascular injury, including injury mechanism and body region; and patient age, sex, socioeconomic status, and residence from the Canadian Institute for Health Information Discharge Abstract Database and Registered Persons Database from fiscal years 1991 to 2009. We performed time series analysis of vascular injury-related in-hospital mortality rates and multivariable logistic regression analysis to identify significant mortality-associated factors.

RESULTS

The overall in-hospital mortality rate for trauma-related vascular injury was 5.5%. A slight but non-significant decline in mortality occurred over time. The likelihood of vascular injury-related in-hospital mortality was significantly higher for patients involved in transport-related accidents (odds ratio [OR[=2.21, 95% confidence interval [CI], 1.76-2.76), age ≥65 years (OR = 4.34, 95% CI, 2.25-8.38), or with thoracic (OR = 2.24, 95% CI, 1.56-3.20) or abdominal (OR = 2.45, 95% CI, 1.75-3.42) injuries.

CONCLUSIONS

In-hospital mortality from traumatic vascular injury in Ontario was low and stable from 1991 to 2009.

The Role of Obesity in Motor Vehicle Injuries and Fatalities in the Pediatric Population: A Systematic Review

PURPOSE

A systematic review done to evaluate obesity as a risk factor for injuries and mortality in motor vehicle accidents (MVAs) in the pediatric population, as there has not been a systematic review done in over 10 years. This study aims to update the literature regarding obesity as a risk factor for injuries in MVAs in the pediatric population.

MATERIALS AND METHODS

A systematic review was conducted according to the PRISMA guidelines with strict inclusion and exclusion criteria, resulting in the use of 3 total articles to analyze obesity as a risk factor for overall injury and mortality in the pediatric population.

RESULTS

Zaveri et al demonstrated a statistically significant, but weak, decrease in the odds of extremity injury in overweight patients ages 2 to 17 years old (odds ratio [OR] = 0.6, 95% confidence interval [CI] = 0.4-1.0, P ≤ 0.05). On the other hand, Pollack et al and Haricharan et al found an increase in extremity injury in the obese population, in ages 9 to 15 years (OR = 2.54, 95% CI = 1.15-5.59, P ≤ 0.05), and 10 to 17 years (Age 10-13: OR = 6.06, 95% CI = 2.23-16.44, P ≤ 0.05, Age 14-17 OR = 1.44, 95% CI = 1.04-2.00, P ≤ 0.05), respectively. Haricharan et al also found an increase in thoracic injuries in obese children, ages 2 to 13 and increased risk of head/face/neck injury in obese children ages 2 to 5 (OR = 3.67, 95% CI = 1.03-13.08, P ≤ 0.05), but a decreased risk of head injury in obese children ages 14 to 17 (OR = 0.33, 95% CI = 0.18-0.60, P ≤ 0.05).

CONCLUSIONS

There are sparse data that are conflicting, regarding the effect of obesity on extremity injuries in the pediatric population. Obesity is not protective against thoracic, head, or abdominal injuries. However, it was found to be a risk factor for trunk injuries in ages 2 to 13, as well as head/face/neck injuries for ages 2 to 5. Since the literature is so sparse, further research is warranted in these areas.

Assessing the Cushion Effect: A Systematic Review and Meta-Analysis of the Role of Obesity in Motor Vehicle Injuries and Fatalities

PURPOSE

A systematic review and meta-analysis were done to evaluate the effect of obesity in injury and mortality due to motor vehicle accidents.

MATERIALS & METHODS

The systematic review consisted of 20 studies meeting the inclusion criteria. The meta-analysis was conducted on these studies to analyze obesity as a risk factor for specific injuries, as well as overall injury and mortality compared to non-obese patients.

RESULTS

The data revealed that obesity was associated with increased lower extremity injuries (odds ratio [OR] = 1.44, 95% confidence interval [CI] = 1.19-1.69, P ≤ 0.05), neck injuries (OR = 3.38, 95% CI = 1.58-5.19, P ≤ 0.05), and overall mortality (OR = 1.51, 95% CI = 1.40-1.61, P ≤ 0.05). When stratified for obesity class with class I as BMI >30.1-34.9, class II BMI 35-39.9, and class III BMI >40, only class II (OR = 1.20, 95% CI = 1.15-1.24, P ≤ 0.05) and class III (OR = 1.49, 95% CI = 1.30-1.68, P ≤ 0.05) were associated with increased mortality risk. No significant differences were seen with head, upper extremity, thoracic, abdominal, or pelvic injuries.

CONCLUSION

Obesity is a risk factor in motor vehicle accidents for fatality and injury, specifically lower extremity and neck injuries.

Serious Transport Accidents in Tourette Syndrome or Chronic Tic Disorder

Background

It is unknown whether individuals with tic disorders are at increased risk for serious transport accidents.

Objectives

The aim of this study was to investigate the risk for injuries or death caused by transport and motor vehicle accidents in individuals with Tourette syndrome or chronic tic disorder.

Methods

This population‐based, sibling‐controlled cohort study included all individuals aged ≥18 years living in Sweden between 1997 and 2013 (N = 6,127,290). A total of 3449 individuals had a registered diagnosis of Tourette syndrome or chronic tic disorder in the Swedish National Patient Register. We also identified 2191 families with full siblings discordant for tic disorders. Cox proportional hazards regression modeling was used to estimate the risk for injuries or deaths as a result of transport accidents in individuals with a lifetime diagnosis of Tourette syndrome or chronic tic disorder compared with unexposed individuals and siblings.

Results

Individuals with tic disorders had a higher risk for transport injuries or death compared with the general population (adjusted hazard ratio, 1.50 [95% confidence interval: 1.33–1.69]) and their unaffected siblings (adjusted hazard ratio, 1.41 [95% confidence interval: 1.18–1.68]). The risks were similar across sexes. The exclusion of most psychiatric comorbidities did not alter the magnitude of the estimates. However, the risks were no longer significant after exclusion of individuals with comorbid attention deficit hyperactivity disorder.

Conclusions

The marginally increased risk for serious transport accidents in tic disorders is mainly driven by attention deficit hyperactivity disorder comorbidity. Improved detection and management of attention deficit hyperactivity disorder symptoms in this patient group are warranted. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

Are cardiac patients in Saudi Arabia provided adequate instructions when they should not drive?

Objective:

Driving capability can be significantly affected by different heath disorders; cardiovascular diseases (CVDs) should be considered when assessing patients for medical fitness to drive (MFTD). The aim of this study was to evaluate the awareness of Saudi patients about driving recommendations and to assess the incidence of motor vehicle accidents (MVAs) among cardiac patients.

Materials and Methods:

We conducted a cross-sectional survey-based study. Male patients diagnosed with CVDs and who were visiting outpatient departments were invited to complete a questionnaire regarding their awareness of driving recommendations. Patients’ demographics, clinical diagnosis, echocardiography parameters, and time-to-CVD diagnosis were all obtained from the patients’ medical records. Women were excluded because it was illegal for women to drive in Saudi Arabia during the study period.

Results:

In total, 800 men were included, with a mean age of 54 ± 12 years. Driving counseling had been provided to 241 participants (30%). Of these, 207 (25%) were advised not to drive for a period of between one week and six months. Five percent of the patients had a history of MVAs during the follow-up period of 6.2 ± 4 years. We found that the presence of a dyspnea ≥2, according to the New York Heart Association (NYHA), and a history of loss of consciousness (syncope/pre-syncope) were significantly associated with accidents (46% vs. 20%, P < 0.0001 and 41% vs. 10%, P < 0.0001, respectively).

Conclusion:

Patient–physician discussion about MFTD was only performed with 30% of the patients with CVDs in Saudi Arabia. Dyspnea NYHA class ≥2 or a prior history of syncope were significantly associated with the incidence of MVAs.

"Chance Takers Are Accident Makers": Are Patients With Epilepsy Really Taking a Chance When They Drive?

This review compiles scientific data about the real dangers faced by people with epilepsy (PWE) who drive. Those include risks of motor vehicle accidents (MVA) in PWE as compared with controls (individuals without epilepsy) and as compared with persons with other medical conditions that impact fitness to drive. Data regarding Accident rates as related to seizure free intervals (SFI), single vs. multiple seizure events, and/or antiseizure drug (ASD) taper and reintroduction are discussed. Variation in state, national, and international laws and guidance for non-commercial and commercial drivers is highlighted, along with some related reasons for driving restrictions. The review concludes by emphasizing the importance of physicians educating patients about local driving laws and about risks of ASD non-adherence. The need for a broader, multi-stakeholder re-examination of driving regulations for PWE is noted.

Predicting Overt Hepatic Encephalopathy for the Population With Cirrhosis

Hepatic encephalopathy (HE) is associated with poor quality of life, sharply increased mortality, repeated hospitalizations, falls, and motor vehicle accidents. HE manifests with a dynamic spectrum of severity. Overt HE is clinically obvious disorientation, even coma. Although multiple strategies are available to characterize early-stage HE, data are limited that validate these methods in predicting overt HE, many are impractical in clinical practice, and test cutoffs relevant to the average patient clinicians manage are lacking. To accurately and efficiently classify the risk of overt HE in the population with cirrhosis, novel strategies may be needed. Herein, we review the potential competing strategies for the prediction of overt HE. Conclusion: We propose refining diagnostic cutoffs for tests that are designed to define early HE, using overt HE as a gold standard and expanding prediction tools by using measures of components from the risk pathway for HE.

Citizens' Juries, Liquid Democracy and Legislative Reform of Australian Compulsory Insurance Schemes for Injury Compensation after Motor Vehicle Accidents

In 2017/2018 the Australian Capital Territory held its first citizens' jury to deliberate changes to the Territory's Compulsory Third Party (CTP) insurance scheme, for injury compensation after motor vehicle accidents. Such citizens' juries were designed to aid the transition to next-generation parliamentary processes (such as liquid democracy - citizen direct electronic voting on laws or individual transfer of their vote to respected politicians) by enabling a variety of key stakeholders and interests to be actively represented in the process of statutory development. In effect such a process is a democratic alternative to the current model of corporate lobbyists covertly influencing the legislative process. This column investigates how the citizens' jury chose one from four proposed CTP models. It then critiques how, following the jury's recommendation, the Australian Capital Territory Government introduced the Motor Accidents Injuries Bill 2018 (ACT). Once enacted, this is designed to create a "no-fault" expedited scheme, but on our analysis, at the cost of certain adverse outcomes. These include greatly reducing an injured person's entitlements to fair compensation, a "whole person impairment threshold" that limits entitlements to treatment and care, wage loss and compensation for pain and suffering, removing the right to compensation for gratuitous care, and giving the insurance companies unfettered power over the provision of entitlements.

Cortical surface area reduction in identification of subjects at high risk for post-traumatic stress disorder: A pilot study

OBJECTIVE

Victims of motor vehicle accidents often develop post-traumatic stress disorder, which causes significant social function loss. For the difficulty in treating post-traumatic stress disorder, identification of subjects at high risk for post-traumatic stress disorder is essential for providing possible intervention. This paper aims to examine the cortical structural traits related to susceptibility to post-traumatic stress disorder.

METHODS

To address this issue, we performed structural magnetic resonance imaging study in motor vehicle accident victims within 48 hours from the accidents. A total of 70 victims, available for both clinical and magnetic resonance imaging data, enrolled in our study. Upon completion of 6-month follow-up, 29 of them developed post-traumatic stress disorder, while 41 of them didn't. At baseline, voxelwise comparisons of cortical thickness, cortical area and cortical volume were conducted between post-traumatic stress disorder group and trauma control group.

RESULTS

As expected, several reduced cortical volume within frontal-temporal loop were observed in post-traumatic stress disorder. For cortical thickness, no between-group differences were observed. There were three clusters in left hemisphere and one cluster in right hemisphere showing decreased cortical area in post-traumatic stress disorder patients, compared with trauma controls. Peak voxels of the three clusters in left hemisphere were separately located in superior parietal cortex, insula and rostral anterior cingulate cortex.

CONCLUSION

The finding of reduced surface area of left insula and left rostral anterior cingulate cortex suggests that shrinked surface area in motor vehicle accident victims could act as potential biomarker of subjects at high risk for post-traumatic stress disorder.

Motor vehicle accident mortality by elderly drivers in the super-aging era: A nationwide hospital-based registry in Japan

Motor vehicle accidents (MVAs) are one of the major public health burdens worldwide. In particular, MVAs by elderly drivers have been significantly increasing in recent years in industrialized countries. This study aimed to assess the MVA characteristics and outcomes caused by elderly drivers in Japan.Japan Trauma Data Bank (JTDB) is a prospective, nationwide, hospital-based registry for trauma patients from 256 institutions in Japan. This study enrolled all MVA drivers older than the legal age for driving between 2004 and 2015. The included patients were divided into the following 3 groups: adults (aged ≤64 years), young-old (aged 65-74 years), and old-old (aged ≥75 years). The primary outcome was in-hospital mortality. The trend in the proportion of MVAs caused by the young-old or the old-old group was evaluated using the Cochran-Armitage trend test. To assess the association of the old-old group with in-hospital mortality, compared with the adult group, we used multivariable logistic regression analysis.During the study period, a total of 236,698 trauma patients were registered, and 39,691 patients (16.8%) were eligible for our analysis. The proportion of MVAs caused by elderly drivers aged ≥65 years significantly increased from 11.7% in 2004 to 23.8% in 2015 (P < .001). As for the primary outcome, unadjusted in-hospital mortality increased with age, but decreased year-by-year irrespective of the age group. In multivariable logistic regression analysis, in-hospital mortality was significantly higher in the old-old group than in the adult group [17.3% (584/3372) vs 8.0% (2556/31,985); adjusted odds ratio 4.80; 95% confidence interval 4.06-5.67].In the super-aging society of Japan, the proportion of MVAs by elderly drivers increased year-by-year, and the mortality rate was highest in those aged above 75 years.

The Self-perception of Text-message Dependency Scale (STDS): Psychometric update based on a United States sample

BACKGROUND

Some have suggested that text messaging is an addictive behavior. However, this characterization is uncertain, partly due to lack of well-validated measures of text messaging attitudes and behaviors. One standard instrument for measuring text messaging attitudes and behaviors is the Self-perception of Text-message Dependency Scale (STDS), though the psychometric properties of this scale have only been examined with a sample of Japanese youth.

OBJECTIVES

The primary objective of this study was to evaluate the STDS in the United States to determine its utility as a measure of text messaging dependence. We were interested in examining the factor structure and determining the extent to which this scale would correlate with two important outcome measures: motor vehicle accidents (MVAs) and moving violations.

METHODS

We analyzed data from 468 adults (age 18-74; 274 women) recruited via Amazon's Mechanical Turk (mTurk) service. Participants completed the STDS and provided information about their driving-related incidents in the past year.

RESULTS

First we performed a confirmatory factor analysis, which supported the instrument's original factor structure. Then we tested the relationship between scores on the STDS and two important variables, MVAs and moving violations. We found that the STDS significantly correlated with both MVAs and moving violations.

CONCLUSION

The present study confirms that the STDS is a potentially useful instrument for studying texting dependence in the United States and with adults of all ages. The instrument may be particularly useful in predicting motor vehicle outcomes.

Trends in pediatric liver transplant donors and deceased donor circumstance of death in the United States, 2002-2015

While much of the discussion regarding expanding the donor pool for pediatric liver transplantation has surrounded the use of technical variant grafts, little attention has been directed toward changes in the deceased donor population. The aim of this study was to investigate trends in the circumstance of the death of deceased donors used for pediatric liver transplantation. All pediatric liver transplant recipients transplanted between 2002 and 2015 were identified in the UNOS database and were categorized based on the donor circumstance of death. There was no significant correlation between year of transplantation and number of pediatric liver transplants performed, pediatric donors, split livers, or living donors. There was a significant downward trend in donors from motor vehicle fatalities and an upward trend in suicide, non-MVA, and death due to natural causes. There was also an upward trend in drowning, one of the most common mechanisms of death among non-MVA in 2015. While the number of donors who died in MVA has fallen, the number of deceased donors who died from suicide, natural causes, and non-MVA, especially drowning, has increased, maintaining the overall number of pediatric deceased donor livers transplanted.

Risk of Motor Vehicle Accidents Related to Sleepiness at the Wheel: A Systematic Review and Meta-Analysis

Study Objectives

Sleepiness at the wheel is widely believed to be a cause of motor vehicle accidents. Nevertheless, a systematic review of studies investigating this relationship has not yet been published. The objective of this study was to quantify the relationship between sleepiness at the wheel and motor vehicle accidents.

Methods

A systematic review was performed using Medline, Scopus, and ISI Web of Science. The outcome measure of interest was motor vehicle accident defined as involving four- or two-wheeled vehicles in road traffic, professional and nonprofessional drivers, with or without objective consequences. The exposure was sleepiness at the wheel defined as self-reported sleepiness at the wheel. Studies were included if they provided adjusted risk estimates of motor vehicle accidents related to sleepiness at the wheel. Risk estimates and 95% confidence intervals (95% CIs) were extracted and pooled as odds ratios (ORs) using a random-effect model. Heterogeneity was quantified using Q statistics and the I2 index. The potential causes of heterogeneity were investigated using meta-regressions.

Results

Ten cross-sectional studies (51,520 participants), six case-control studies (4904 participants), and one cohort study (13,674 participants) were included. Sleepiness at the wheel was associated with an increased risk of motor vehicle accidents (pooled OR 2.51 [95% CI 1.87; 3.39]). A significant heterogeneity was found between the individual risk estimates (Q = 93.21; I2 = 83%).

Conclusions

Sleepiness at the wheel increases the risk of motor vehicle accidents and should be considered when investigating fitness to drive. Further studies are required to explore the nature of this relationship.

Systematic review registration number

PROSPERO 2015 CRD42015024805.

Outcomes after Motor Vehicle Trauma: Transfers to Level I Trauma Centers Compared with Direct Admissions

BACKGROUND

The multilevel designation system given to U.S. trauma centers has proven useful in providing injury-level-appropriate care and guiding field triage. Despite the system, patients are often transferred to Level I trauma centers for higher-level care/specialized services.

OBJECTIVES

The objective of this study is to assess whether there is a difference in outcomes of patients transferred to Level I centers compared with direct admissions.

METHODS

The Nationwide Inpatient Sample was queried to identify patients involved in motor vehicle accidents, using International Classification of Diseases, Ninth Revision, Clinical Modification E-codes. Patients that were admitted to Level I trauma centers were identified using American College of Surgeons or American Trauma Society designations.

RESULTS

There were 343,868 patients that met inclusion criteria. Of these patients, 29.2% (100,297) were admitted to Level I trauma centers, 5.7% (5691) of which were identified as trauma transfers. The lead admitting diagnosis for transfers was pelvic fracture (11.5%). Caucasians were 2.62 times as likely to be transferred as African-Americans (confidence interval 2.32-2.97), and 3.71 times as likely as Hispanics (confidence interval 3.25-4.23). Despite transfer patients having higher adjusted severity scores and higher adjusted risk of mortality, there were no differences in mortality (p = 0.95).

CONCLUSIONS

Nationally, trauma transfers do not have an increase in mortality when compared with directly admitted patients, despite a higher adjusted severity of illness and higher adjusted risk of mortality.

Screening Commercial Vehicle Drivers for Obstructive Sleep Apnea: Tools, Barriers, and Recommendations

Obstructive sleep apnea (OSA) is a disorder characterized by a cessation of breathing during sleep, leading to poor sleep patterns and daytime somnolence. Daytime somnolence is of particular concern for commercial vehicle drivers, whose crash risk increases 50% with untreated OSA. The process of diagnosing and treating OSA in commercial drivers begins with effective and consistent screening. Therefore, the researchers screened drivers with both the STOP-Bang Questionnaire and the Obstructive Sleep Apnea Evaluation Worksheet (OSAEW) and compared the two tools. Drivers screening positive on the STOP-Bang Questionnaire, OSAEW, and both questionnaires were 28%, 23%, and 13%, respectively. Sleep study referrals were made for 50 drivers; 12 drivers were scheduled for sleep tests within 3 months. Health care provider referral rates for drivers screening at high risk (37%) and commercial driver monitoring rates (24%) were both low. Recommendations to improve OSA screening and testing practices include Federal Motor Carrier Safety Administration-mandated screening and referral guidelines, employee-facilitated sleep testing, and OSA awareness campaigns.

A Single-Center Review of Radiologically Diagnosed Maxillofacial Fractures: Etiology and Distribution

The etiology of fractures of the maxillofacial skeleton varies among studies, with motor vehicle accidents and assaults oftentimes the most common. The number of males outnumbers females throughout most studies. Fractures of the zygoma, orbit, and mandible are usually cited as most common fracture types. This study examines a single center's experience with regards to etiology and distribution of fractures. A retrospective review of all radiologically confirmed facial fractures in a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Patient demographics, etiology of injury, and location of fractures were collected. During this time period, 2,998 patients were identified as having sustained a fracture of the facial skeleton. The average age was 36.9 years, with a strong male predominance (81.5%). The most common etiologies of injury were assault (44.9%) and motor vehicle accidents (14.9%). Throughout the study period, the number of fractures as a result of assault remained relatively constant, whereas the number as a result of motor vehicle accidents decreased slightly. The most common fracture observed was of the orbit, followed by mandible, nasal bones, zygoma, and frontal sinus. Patients sustaining a fracture as a result of assault were more likely to have a mandible fracture. Patients in motor vehicle accidents were more likely to suffer fractures of the maxilla, orbit, and frontal sinus. Mandible fractures are more common in cases of assault. Motor vehicle accidents convey a large force, which, when directed at the craniofacial skeleton, can cause a variety of fracture patterns. The decreasing number of fractures as a result of motor vehicle accidents may represent improved safety devices such as airbags.

Child passengers and driver culpability in fatal crashes by driver gender

OBJECTIVE

Studies based on accident statistics generally suggest that the presence of a passenger reduces adult drivers' accident risk. However, passengers have been reported to be a source of distraction in a remarkable portion of distraction-related crashes. Although the effect of passengers on driving performance has been studied extensively, few studies have focused on how a child passenger affects the driver.  A child in a car is a potential distractor for parents, especially for mothers of small children, who often suffer from sleep deficit. The aim of this study was to examine how the presence of child passengers of different ages is associated with a higher driver culpability, which was expected due to child-related distraction and fatigue.

METHODS

The analysis was based on the comprehensive data of fatal crashes studied in-depth by multidisciplinary road accident investigation teams in Finland during 1988-2012. Teams determine the primary party who had the most crucial effect on the origin of the event. We define the primary party as culpable and the others involved as nonculpable drivers. The culpability rate was defined as the percentage of culpable drivers and rates were compared for drivers with a child/teen passenger aged 0-17 years (N = 348), with an adult passenger without children (N = 324), and when driving alone (N = 579), grouped by child age and driver gender.  Drivers with specific risk-related behavior (substantial speeding, driving when intoxicated, unbelted, or without a license) were excluded from the analyses, in order to make the drivers with and without children comparable. Only drivers 26-47 years old were included, representing parents with children 0-9 years of age.

RESULTS

Male drivers were less often culpable with 0- to 17-year-old passengers in the car than alone or with adults. This was not the case with female drivers. The gender difference in culpability was most marked with small children age 0-4 years. Female drivers' culpability rate with a 0- to 4-year-old child passenger was higher and male drivers' culpability rate was lower compared to drivers without passengers or with only adult passengers.

CONCLUSION

The results indicate that female drivers are at higher risk of crashes than male drivers when driving with small children. Further research is needed to replicate this finding and to determine causal mechanisms.

Potentially Driver-Impairing Medications: Risks and Strategies for Injury Prevention

Impaired driving is a major cause of motor vehicle accidents, injury, and fatality. Several classes of medication have been found to affect a driver's cognition, judgment, and reaction time and may put patients at increased risk for accidents and injury. This article will explore medications with side effects posing a potential threat to drivers, including anxiolytics, sedative hypnotics, antihistamines, and antidepressants, as well as describe potential strategies for mitigating or minimizing such risks.

Preliminary findings of a novel measure of driving behaviors in Veterans with comorbid TBI and PTSD

Veterans of the military operations in Iraq and Afghanistan are at an elevated risk of driving-related accidents and fatalities compared with civilians. Combat exposure, military driving training, risk-seeking, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD) are all factors associated with driving-related risk. However, few empirical studies have observed driving patterns in this population, and the influence of these contributing factors remains unclear. This study utilized a novel self-report measure to assess driving behaviors, subjective driving-related anxiety, and the emotional experiences of military Veterans who have returned to civilian driving. This questionnaire was completed by 23 combat Veterans diagnosed with comorbid TBI and PTSD and 10 nondisabled combat Veterans. Drivers with TBI and PTSD reported more frequent high-risk driving behaviors and higher levels of anxiety while driving in certain situations than nondisabled combat Veterans. These preliminary findings highlight the importance of studying on-the-road situations and cues that produce anxiety in Veterans, particularly those with TBI and PTSD. A greater understanding of driving-related anxiety is needed to inform targeted and effective interventions for unsafe driving in Veterans.

Trends in Socioeconomic Inequalities in Motor Vehicle Accident Deaths in the United States, 1995-2010

Motor vehicle accident (MVA) mortality has been declining overall, but little is known about trends by socioeconomic position. We examined trends in education-related inequalities in US MVA death rates from 1995 to 2010. We used mortality data from the National Center for Health Statistics and population estimates from the Current Population Survey, and we calculated vehicle- and person-miles traveled using data from the National Household Travel Survey. We used negative binomial regression to estimate crude and age-, sex-, and race-adjusted mortality rates among adults aged 25 years or more. We found larger mortality decreases among the more highly educated and some evidence of mortality increases among the least educated. Adjusted death rates were 15.3 per 100,000 population (95% confidence interval (CI): 10.7, 19.9) higher at the bottom of the education distribution than at the top of the education distribution in 1995, increasing to 17.9 per 100,000 population (95% CI: 14.8, 21.0) by 2010. In relative terms, adjusted death rates were 2.4 (95% CI: 1.7, 3.0) times higher at the bottom of the education distribution than at the top in 1995, increasing to 4.3 times higher (95% CI: 3.4, 5.3) by 2010. Inequality increases were larger in terms of vehicle-miles traveled. Although overall MVA death rates declined during this period, socioeconomic differences in MVA mortality have persisted or worsened over time.

Creative arts program as an intervention for PTSD: a randomized clinical trial with motor vehicle accident survivors

The aim of this study is to determine whether the creative arts program (HA) is effective in preventing the onset of Posttraumatic stress disorder (PTSD). PTSD develops in 10-20% of motor vehicle accident survivors (MVAs). MVAs in the initial months after the accident were randomly assigned to receive 8-week HA intervention (n = 26) or wait the list (WL, n = 26). The arts program consisted of writing and drawing. PTSD severity was assessed at 2, 6, and 12 months post injury with a clinical interview (Clinician-Administered PTSD Scale, CAPS) and self-report instrument (Impact of Event Scale-Revised, IES-R). Secondary outcomes were post-traumatic growth (PTG), depression and anxiety symptoms. Repeated measures analysis of variance indicated that both HA and WL group exhibited a significant effect of time (P < 0.01) on CAPS, but no significant group differences over time. There were no group differences on depression or anxiety over time. Pessimists did not benefit more from attending the HA than they did from attending the WL. Our results fail to support the hypothesis that the creative arts program is effect in avoiding MVA-related PTSD symptoms. But it only seems to be a short-term, rather than a long-term effect.

Child passenger deaths involving alcohol-impaired drivers

BACKGROUND AND OBJECTIVE

Approximately 1 in 5 child passenger deaths in the United States involves an alcohol-impaired driver, most commonly the child's own driver. The objective of this study was to document recent trends and state-specific rates of these deaths.

METHODS

A descriptive analysis of 2001-2010 Fatality Analysis Reporting System data for child passengers aged <15 years killed in alcohol-impaired driving crashes. Driver impairment was defined as a blood alcohol concentration of ≥0.08 g/dL.

RESULTS

During 2001-2010, 2344 children <15 years were killed in crashes involving at least 1 alcohol-impaired driver. Of these children, 1515 (65%) were riding with an impaired driver. Annual deaths among children riding with an alcohol-impaired driver decreased by 41% over the decade. Among the 37 states included in the state-level analysis, Texas (272) and California (135) had the most children killed while riding with an impaired driver and South Dakota (0.98) and New Mexico (0.86) had the highest annualized child passenger death rates (per 100 000 children). Most (61%) child passengers of impaired drivers were unrestrained at the time of the crash. One-third of the impaired drivers did not have a valid driver's license.

CONCLUSIONS

Alcohol-impaired driving remains a substantial threat to the safety of child passengers in the United States, and typically involves children being driven by impaired drivers. This risk varies meaningfully among states. To make further progress, states and communities could consider increased use of effective interventions and efforts aimed specifically at protecting child passengers from impaired drivers.

Randomized controlled trial of a brief dyadic cognitive-behavioral intervention designed to prevent PTSD

BACKGROUND

There is a dearth of effective interventions to prevent the development of post-traumatic stress disorder (PTSD).

METHOD

We evaluated the efficacy of a brief dyadic two-session cognitive-behavioral intervention through a controlled trial involving trauma-exposed individuals recruited at the hospital's emergency room. Participants were randomly assigned to either the dyadic intervention group (n=37) or to a waiting list (assessment only) group (n=37).

RESULTS

In an intent-to-treat analysis, a time-by-group interaction was found, whereby the treated participants had less PTSD symptoms at the post-treatment but not at the pre-treatment compared to controls. Controlling for the improvement observed in the control participants, the intervention yielded a net effect size of d=0.39.

CONCLUSIONS

A brief, early, and effective intervention can be provided by nurses or social workers in hospital settings, at a fairly low cost to individuals presenting to the emergency room as the result of trauma exposure.

Factors contributing to anxious driving behavior: the role of stress history and accident severity

Although fear and travel avoidance among anxious drivers are well documented, relatively little is known about the behavior of anxious individuals who continue to drive. Previous research has identified three broad domains of anxious driving behavior: exaggerated safety/caution behaviors, anxiety-based performance deficits, and hostile/aggressive driving behaviors. In an effort to explicate factors associated with the development of anxious driving behavior, associations with objective accident severity, accident-related distress, and life stress history were explored among individuals reporting accident involvement (N=317). Interactive effects of accident distress and self-reported stress history were noted across all three domains of anxious driving behavior. Examination of these effects indicates unique associations between accident distress and anxious behavior only in those reporting more severe life stress. Consistent with contemporary models of anxiety, these data suggest stress history may serve as a general vulnerability factor for development of anxious driving behavior following accident involvement.

The Driving Behavior Survey: scale construction and validation

Although long recognized in the clinical literature, problematic behavior characteristic of anxious drivers has received little empirical attention. The current research details development of a measure of anxious driving behavior conducted across three studies. Factor analytic techniques identified three dimensions of maladaptive behaviors across three college samples: anxiety-based performance deficits, exaggerated safety/caution behavior, and anxiety-related hostile/aggressive behavior. Performance deficits evidenced convergent associations with perceived driving skill and were broadly related to driving fear. Safety/caution behaviors demonstrated convergence with overt travel avoidance, although this relationship was inconsistent across studies. Safety/caution scores were associated specifically with accident- and social-related driving fears. Hostile/aggressive behaviors evidenced convergent relationships with driving anger and were associated specifically with accident-related fear. Internal consistencies were adequate, although some test-retest reliabilities were marginal in the unselected college sample. These data provide preliminary evidence for utility of the measure for both research and clinical practice.

Young adults, mortality, and employment

OBJECTIVE

This study assessed the relationship between employment status and mortality over a 2-year period among a nationally representative sample of young adults aged 18 to 24 years (n = 121,478, representing more than 21 million US young adults).

METHODS

By using data from the 1986-2000 National Health Interview Survey and its public-use mortality follow-up through 2002, mortality after 2-year follow-up (for each individual) was regressed on employment status at baseline, controlling for gender, race, education, season, and survey design.

RESULTS

Having been employed was associated with significantly lower risks of all-cause, homicide, and "other-cause" mortality (adjusted odds ratios range: 0.51 to 0.60).

CONCLUSION

Working appears to be a factor that may prevent premature mortality among young adults; increasing unemployment may result in increased mortality risks among young adults in the future.

Physical and psychosocial functioning following motor vehicle trauma: relationships with chronic pain, posttraumatic stress, and medication use

Chronic pain and PTSD are known to hold substantial comorbidity following traumatic injury. Although pharmacological agents have been examined in the treatment of pain and PTSD individually, little is known regarding the relationship of medication use with functioning in patients with comorbid conditions. This research examined the relationships of pain, PTSD, and medication use across physical and psychosocial functioning in patients with chronic pain following motor vehicle injury (N=234). Separate analyses were conducted for opioids, SSRIs, and sedative/anxiolytics, respectively. Several relevant effects were noted: (1) Pain evidenced strong associations with reduced functioning across both physical and psychosocial domains, (2) Opioid use held interactive relationships with PTSD across both functioning domains. Specifically, opioids were associated with greater physical impairment in patients without comorbid PTSD. Opioids also were related to greater psychosocial impairment in patients without PTSD while PTSD was associated with greater impairment in patients not using opioids, (3) Opioid use evidenced a marginal interaction with pain on psychosocial functioning. Opioids were associated with greater psychosocial impairment among patients with high-pain, and high-pain was associated with greater impairment among opioid users, (4) SSRIs held a marginal interaction with PTSD such that PTSD was related to poorer psychosocial functioning only among individuals not using an SSRI, and (5) Anxiolytic use evidenced a marginal interaction with PTSD on physical functioning although no between-group differences were noted. These data suggest that PTSD symptomology may be an important consideration in determining treatment modality for patients experiencing pain subsequent to traumatic injury.

Understanding the interpersonal impact of trauma: contributions of PTSD and depression

To build on the growing literature on interpersonal relationships among individuals with PTSD, this study examined the separate influences of PTSD symptoms and depression on functioning with friends, romantic partners, and family. To examine the influence of measurement, both interviewer-rated assessment of interpersonal functioning and self-reported assessment of perceived social support were included. The sample included 109 community members who sought help for mental health problems in the aftermath of a serious motor vehicle accident. Building on previous research, hierarchical regression models were used to examine the impact of re-experiencing, avoidance, emotional numbing, and hyperarousal on relationship functioning, followed by depression. Results suggest that assessment modality makes a difference in understanding factors contributing to interpersonal strain. When assessed by an interviewer, depression seems to play a larger role in interpersonal strain, relative to PTSD symptoms. When assessed via self-reported perceived social support, weaker associations were observed, which highlighted the role of emotional numbing. Results are discussed in light of the possible role that PTSD comorbidity with depression plays in interpersonal functioning following a traumatic event, with implications for future research.

Understanding the relationship between PTSD and social support: the role of negative network orientation

Network orientation is conceptualized as an individual's attitudes and expectations regarding the usefulness of support networks in coping with stress. The present research examined the potential for network orientation to explicate the well documented association between post-traumatic stress disorder (PTSD) and attenuated social support. Data collected from survivors of serious motor vehicle trauma (N=458) were used to test the hypothesis that severity of PTSD would hold a significant indirect relationship with social support through negative network orientation. Childhood victimization and elapsed time from the accident were examined as potential moderators of this indirect relationship. Consistent with hypotheses, path analyses demonstrated a significant indirect relationship between PTSD and social support through negative network orientation. Specifically, this indirect effect was the result of a direct association between PTSD severity and negative network orientation and an inverse association between negative network orientation and social support. This pattern of relationships was invariant across mode of PTSD assessment (interview vs. self-report). No moderation effects were noted. These data suggest that network orientation may be an important factor in understanding interface of interpersonal processes and post-trauma pathology.

[Smoking and nonfatal traffic accidents]

OBJECTIVE

To investigate the possible associations between smoking and nonfatal traffic accidents, and to evaluate the possible influence of other factors on traffic accidents.

DESIGN

Cross-sectional study of associations.Setting. Eight health centers in the city of Zaragoza.

PARTICIPANTS

1214 drivers between 25 and 65 years of age, who visited the health center during the months of July to September 2001, and who drove on at least 2 days of the week. MAIN MEASURES. We recorded data on sex, age, marital status, level of education, profession, diseases, use of prescription and nonprescription drugs, drinking, smoking, illegal drug use, accidents and traffic infractions.

RESULTS

We found accidents to be most common among unmarried men between 25 and 29 years of age. There were no significant differences in accident rates between drinkers and nondrinkers. The accident rate was 50% higher in smokers than in nonsmokers (OR, 2.22; 95% CI, 1.49%-3.09%), and there were no significant differences between smokers who smoked while driving and those who refrained from smoking while driving. CONCLUSIONS. The prevalence of accidents is highest in unmarried men younger than 45 years of age. In statistical terms, smokers have twice as many accidents as nonsmokers. The absence of significant differences between smokers who do and do not smoke while driving suggests that smoking increases the risk of being involved in traffic accidents regardless of whether drivers refrain from smoking at the wheel.

Adolescent and young adult mortality by cause: age, gender, and country, 1955 to 1994

PURPOSE

To compare mortality rates from motor vehicle accidents (MVA), homicide, and suicide across countries, age groups, and time.

METHODS

The World Health Organization Mortality Database was used to construct age- and gender-specific rates in 26 countries for individuals aged 15 to 34 years during the period 1955 to 1994. The rates were adjusted for differences among countries in the age-and-gender distributions of their populations. Cause-specific rates were compared by country, 4-year age groups, 8-year time blocks, and male/female ratios.

RESULTS

The proportion of deaths in 15-34-year-olds owing to MVA, homicide, and suicide increased from 26% to 43% over the 40-year study period. Mortality rates differ by country more than time block, peak at ages 15-29 years, and are higher in males than females. Compared to the United States, 24 countries had lower homicide rates and 23 had lower MVA-death rates.

CONCLUSIONS

Despite declining rates of death from other causes, the rates of adolescent and young adult death from MVA, homicide, and suicide remain high in countries throughout the world. The proportion of deaths attributable to these causes increased steadily during the latter half of the 20th century. Fatal risk behaviors begin to increase during adolescence but do not peak until age 30 years, suggesting that the target population for prevention extends well beyond the teenage years.

"... As my own brothers..."

The author describes the aftermath of a serious motor vehicle accident in which her husband, a family practitioner, sustained a life-threatening brain injury just over two years ago. The period of rehabilitation was long and painful for everyone involved, and made the more distressing by lack of a rehabilitative program for profoundly injured physicians who wish to return to practice. The author argues strongly that it is the obligation of the medical profession to implement the promises of the Hippocratic Oath by developing such a protocol.