BACKGROUND: To improve reinjury prevention strategies targeting hazardous drinking, we determined its predictors and longitudinal course in the year after injury.
METHODS: This was a prospective study of 101 randomly selected hospitalized trauma patients who before injury represented the full range of substance abuse, from severe to none. We hypothesized that clinical data obtained routinely by trauma centers would predict hazardous drinking during the postinjury year.
FINDINGS: Drug and alcohol use dropped markedly 1 month after injury but returned to preinjury levels by 4 months. Forty-one percent of the sample drank hazardously before injury, and 55% drank hazardously after. From before to after injury, 20% of patients worsened their hazardous drinking status, and only 6% of patients improved it. Three clinical predictors of hazardous drinking during the year were identified: any positive blood alcohol concentration > 0 at admission (odds ratio [OR], 9.18; 95% confidence interval [CI], 2.51-33.56), any days > 0 of using nonprescription drugs of abuse in the month before injury (OR, 6.63; 95% CI, 1.76-25.04), and suffering an intentional injury (OR, 5.1; 95% CI, 1.38-18.77).
DISCUSSION: Efforts to reduce hazardous drinking after injury should target patients with this risk profile and focus on the 1- to 4-month period after injury hospitalization.
According to the Centers for Disease Control (2002), each year nearly 150,000 Americans die from injuries, making injury the leading cause of death among children and young adults and a significant problem for Americans of all ages. Nonfatal injuries account for approximately 114 million physician office visits and 25% of all emergency department examinations. It is estimated that one in four Americans will suffer a potentially preventable injury serious enough to require medical attention (Shienfield Gorin & Arnold, 1998). As injury-prevention advocates, we must address this public health problem with a multidimensional approach that includes the three Es: education, engineering, and enforcement. Professionals from many disciplines, including nurses, physicians, health educators, school teachers, social workers, police officers, fire fighters, emergency medical technicians, and coaches, must have accurate information to educate. Education in injury prevention must be a collaborative approach. These injury-prevention leaders must stay informed and knowledgeable of this ever-changing science. This article highlights common injuries, preventive strategies, and resources for injury-prevention information. This information will assist the healthcare provider in finding accurate sources of information concerning injury prevention (Shienfield Gorin & Arnold, 1998).
The authors have reviewed studies of human health effects that resulted from exposure to methyl isocyanate gas that leaked from the Union Carbide plant in Bhopal, India, in 1984. The studies were conducted during both the early and late recovery periods. Major organs exposed were the eyes, respiratory tract, and skin. Although mortality was initially high, it declined over time, but remained elevated among the most severely exposed population. Studies conducted during the early recovery period focused primarily on ocular and respiratory systems. Major findings included acute irritant effects on the eyes and respiratory tract. In follow-up studies, investigators observed persistent irritant effects, including ocular lesions and respiratory impairment. Studies conducted during the late recovery period focused on various systemic health endpoints. Significant neurological, reproductive, neurobehavioral, and psychological effects were also observed. Early and late recovery period studies suffered from several clinical and epidemiological limitations, including study design, bias, and exposure classification. The authors herein recommend long-term monitoring of the affected community and use of appropriate methods of investigation that include well-designed cohort studies, case-control studies for rare conditions, characterization of personal exposure, and accident analysis to determine the possible components of the gas cloud.
Biomechanics of fall arrest using the upper extremity: age differences.
- Kim KJ, Ashton-Miller JA. Clin Biomech 2003; 18(4): 311-318.
Correspondence: Kyu-Jung Kim, Department of Mechanical Engineering, University of Wisconsin--Milwaukee, 3200 N Cramer Street, 1239 EMS, 53211, Milwaukee, WI, USA; (email: kimk2@uwm.edu).
BACKGROUND: The role of the upper extremity is not well defined despite its primary usage as a local shock absorber during fall impact.
OBJECTIVES: This study tried to isolate critical biomechanical factors in fall arrests using the upper extremity during simulated forward falls. This study also attempted to find the differences in those factors between young and old age groups.
METHODS: Comparative study in which two age groups underwent motion analysis. Ten healthy older males (mean age, 66.4 years) and 10 young males (mean age, 24.1 years) volunteered to perform self-initiated and cable-released falls at selected falling distances, while the joint motion and impact forces at the hand were recorded.
FINDINGS: Significant age differences were demonstrated in joint kinematics and impact force parameters at close distances. Excessive reflexive responses of the upper extremity in cable-released falls for the older adults resulted in 10-15 times higher peak impact forces and 2-3 times shorter body braking time than in self-initiated falls.
DISCUSSION: Pre-impact activities of the upper extremity predispose the post-impact response during fall arrests. Suppressing excessive pre-impact reflexive activation of the arms could efficiently decrease the risk of fall-related injuries, which calls for securing sufficient arm movement time. Any fall prevention strategy that can increase arm movement time would be effective against injuries of the upper extremity during falling in the older adults. The findings will help to understand underlying mechanisms of fall arrest using the upper extremity for prevention of fall-related fractures.
BACKGROUND: Falls are frequent occupational accidents, and are responsible for a significant amount of lost working time and, more importantly, for a high mortality. The factors involved in falling mechanisms can be of external or individual origin, the latter being less well identified.
OBJECTIVE: To assess the relations between certain individual characteristics and occupational accidents due to imbalance.
METHODS: A total of 427 male employees, who had been victims of at least one occupational accident with sick leave due to imbalance (cases) and 427 controls were recruited among the employees of a large French railway company. A standardized questionnaire on life conditions and professional factors, and a description of the accidents was filled in by an occupational physician for each subject.
FINDINGS: Some job categories were more affected by a specific release mechanism of work related falls. Certain individual characteristics such as smoking, alcohol consumption, inactivity, sleep disorders, and request for a job change were correlated with the occurrence of occupational accidents. Sick leaves of eight days or over were more frequent in older and overweight injured workers. Some lesions were linked with the specific fall released mechanisms.
DISCUSSION: Individual characteristics can increase the risk of occupational accidents, especially falling. This study identified subjects most at risk on whom prevention related to working conditions and falls could be focused.
Posttraumatic stress disorder (PTSD) in the workplace: a descriptive study of workers experiencing PTSD resulting from work injury.
- MacDonald HA, Colotla V, Flamer S, Karlinsky H. J Occup Rehabil 2003; 13(2): 63-77.
Correspondence: Harry Karlinsky, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, CANADA; (email: harryk@telus.net).
In view of the relatively understudied status of work-related posttraumatic stress disorder (PTSD), this study retrospectively examined 44 workers whose claims were accepted for workers' compensation benefits in the absence of significant coexisting physical injuries. The majority of workers (82%) directly experienced the traumatic event while the rest witnessed the event. Over half (54%) of those directly experiencing the event were involved in armed robberies, whereas 38% were physically or verbally assaulted in nonrobbery situations. Almost half of the workers were assigned a coexisting mood or anxiety diagnosis. Psychoactive medication was prescribed to 66% of workers, and 93% of all workers received some form of psychological/psychiatric treatment. Twenty-three percent of the group received vocational rehabilitation assistance and only 43% returned to their previous job with the accident employer. Findings suggest that work-related PTSD is both complex and disabling and merits further investigation.
Dying for work: The magnitude of US mortality from selected causes of death associated with occupation.
- Steenland K, Burnett C, Lalich N, Ward E, Hurrell J. Am J Ind Med 2003; 43(5): 461-482.
Correspondence: Kyle Steenland, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA; (email: nsteenl@sph.emory.edu).
BACKGROUND: Deaths due to occupational disease and injury place a heavy burden on society in terms of economic costs and human suffering.
METHODS: We estimate the annual deaths due to selected diseases for which an occupational association is reasonably well established and quantifiable, by calculation of attributable fractions (AFs), with full documentation; the deaths due to occupational injury are then added to derive an estimated number of annual deaths due to occupation.
FINDINGS: Using 1997 US mortality data, the estimated annual burden of occupational disease mortality resulting from selected respiratory diseases, cancers, cardiovascular disease, chronic renal failure, and hepatitis is 49,000, with a range from 26,000 to 72,000. The Bureau of Labor Statistics estimates there are about 6,200 work-related injury deaths annually. Adding disease and injury data, we estimate that there are a total of 55,200 US deaths annually resulting from occupational disease or injury (range 32,200-78,200).
DISCUSSION: Our estimate is in the range reported by previous investigators, although we have restricted ourselves more than others to only those diseases with well-established occupational etiology, biasing our estimates conservatively. The underlying assumptions and data used to generate the estimates are well documented, so our estimates may be updated as new data emerges on occupational risks and exposed populations, providing an advantage over previous studies. We estimate that occupational deaths are the 8th leading cause of death in the US, after diabetes (64,751) but ahead of suicide (30,575), and greater than the annual number of motor vehicle deaths per year (43,501).
Shift work and occupational medicine: an overview.
Correspondence: Giovanni Costa, Department of Medicine and Public Health, University of Verona, Servizio di Sorveglianza Sanitaria, Strada Le Grazie 8, 37134 Verona, ITALY; (email: giovanni.costa@univr.it).
In modern society, more and more people work during 'non-standard' working hours, including shift and night work, which are recognized risk factors for health, safety and social well-being. Suitable preventive and protective measures are required to mitigate the adverse effects and ensure that the worker can cope satisfactorily. These are based mainly on the organization of shift schedules according to ergonomic criteria and on specific medical surveillance. Occupational medicine has to consider very carefully the several factors (psycho-physiological, pathological and social) that can influence tolerance and/or maladaptation.
Correspondence: Kathleen Braden, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA; (email: Kathleen.Braden@umassmed.edu).
OBJECTIVE: To determine differences between hospitalized injured children who had preinjury cognitive impairments (IMPs) and children who had no preinjury cognitive conditions (NO).
DESIGN: Comparative analysis, excluding fatalities, of patients with IMP (n = 371) with patients with NO (n = 58 745), aged from 0 to 19 years.
MAIN OUTCOME MEASURES: Demographics, injury characteristics, injury nature and severity, use of resources, disability, and disposition at discharge from acute care. Data Source Medical records of children injured between January 1, 1989, and December 31, 1998, submitted to the National Pediatric Trauma Registry, Boston, Mass.
FINDINGS: Compared with children with NO, children with IMPs were more likely to be boys (72.5% vs 64.3%), to be older (53.1% vs 40.0%, aged 10-19 years), to be victims of child abuse (5.9% vs 1.6%), and to be individuals with self-inflicted injuries (2.2% vs 0.1%). They were more likely to be injured as pedestrians (19.9% vs 13.8%), less likely to be injured in sport activities (2.7% vs 6.9%), and less likely to sustain a penetrating injury (3.8% vs 8.3%). They were more likely to sustain injuries to multiple body regions (57.4% vs 43.7%) and the head (62.0% vs 45.1%), and to be severely injured. They were more likely to be admitted to the intensive care unit (52.6% vs 25.2), and their mean length of stay was twice as long (9.9 vs 4.8 days). They were also more likely to develop impairments from the current injury (46.6% vs 41.0%) and more likely to be discharged to a rehabilitation facility (11.1% vs 2.3%). The IMPs became worse in 75 children.
DISCUSSION: Preinjury cognitive impairments in a pediatric population had a significant effect on the causes, nature, severity of injury, and outcomes. Targeted prevention programs should consider the characteristics of this population.
Correspondence: Suzanne Brannan, Department of Ophthalmology, Birmingham and Midlands Eye Center, City Hospital, Dudley Road, Birmingham B18 7QU, UK; (email: suzanne@brannan43.fsnet.co.uk)
BACKGROUND: There has been considerable interest in the development of intervention programs aimed at reducing the risk of falls. The primary objective was to ascertain whether cataract surgery reduced the risk of falls in elderly patients with age related cataract.
METHODS: 97 patients scheduled for cataract surgery were enrolled in this prospective clinical study. The patients were assessed for established risk factors for falls preoperatively and postoperatively. Patients were issued with a diary to record any falls and phoned at 2 monthly intervals during the 6 month preoperative and postoperative periods.
FINDINGS: Of the 84 patients who completed the study, 31 recorded falls during the preoperative period (37%). This group showed a statistically significant reduction in the number of fallers in the postoperative period (n = 6, p<0.001)
DISCUSSION: These results suggest that cataract surgery is an effective intervention to reduce the risk of falls in elderly patients with cataract related visual impairment.
The effect of texture relief on perception of slant from texture.
Texture can be an effective source of information for perception of slant and curvature. A computational assumption required for some texture cues is that texture must be flat along a surface. There are many textures which violate this assumption, and have some sort of texture relief: variations perpendicular to the surface. Some examples include grass, which has vertical elements, or scattered rocks, which are volumetric elements with 3-D shapes. Previous studies of perception of slant from texture have not addressed the case of textures with relief. The experiments reported here test judgments of slant for textures with various types of relief, including textures composed of bumps, columns, and oriented elements. The presence of texture relief was found to affect judgments, indicating that perception of slant from texture is not robust to violations of the flat-texture assumption. For bumps and oriented elements, slant was underestimated relative to matching flat textures, while for columns textures, which had visible flat top faces, perceived slant was equal or greater than for flat textures. The differences can be explained by the way different types of texture relief affect the amount of optical compression in the projected image, which would be consistent with results from previous experiments using cue conflicts in flat textures. These results provide further evidence that compression contributes to perception of slant from texture.
Estimating time to contact and impact velocity when catching an accelerating object with the hand.
Correspondence: Patrice Senot, Laboratoire de Physiologie de la Perception et de l'Action, Centre National de la Recherche Scientifique-College de France, Paris, FRANCE; (email: patrice.senot@college-de-france.fr)
To catch a moving object with the hand requires precise coordination between visual information about the target's motion and the muscle activity necessary to prepare for the impact. A key question remains open as to if and how a human observer uses velocity and acceleration information when controlling muscles in anticipation of impact. Participants were asked to catch the moving end of a swinging counterweighted pendulum, and resulting muscle activities in the arm were measured. The authors also simulated muscle activities that would be produced according to different tuning strategies. By comparing data with simulations, the authors provide evidence that human observers use online information about velocity but not acceleration when preparing for impact.
Utility of the international classification of diseases injury severity score: detecting preventable deaths and comparing the performance of emergency medical centers.
OBJECTIVE: The purpose of this study was to assess the ability of the International Classification of Diseases-based Injury Severity Score (ICISS) to detect preventable deaths, and to compare the performance of trauma care facilities.
METHODS: For 2 years, from 1997 to 1998, 131 trauma deaths and 1,087 blunt trauma inpatients from 6 emergency medical centers (EMCs) in Korea were reviewed. Trauma deaths were reviewed and the preventability of those deaths was judged by two professional panels. For both trauma deaths and trauma inpatients, the survival probability of each trauma patient was assessed using the ICISS full model. The degree of agreement in the preventability of trauma death between survival probability on the basis of the ICISS and judgment rendered by professional panels was determined, and the correlation between the W-score and the preventable death rate in each EMC was also assessed.
RESULTS: The overall agreement rate between ICISS survival probability and preventable deaths judged by professional panels was 66.4% (kappa statistic, 0.36), and the positive predictive value of the ICISS in detecting preventable trauma deaths was 54.1% and the negative predictive value was 84.8%. The Spearman correlation coefficient between the W-score and the preventable death rate by each EMC was -0.77 (p = 0.07).
DISCUSSION: The degree of agreement in the preventability of trauma death derived from the ICISS with a professional judgment on preventability was similar to that derived from the Trauma and Injury Severity Score. The W-scores of EMCs correlated well with their preventable death rates, with marginal statistical significance. This study has demonstrated that the ICISS is useful in detecting preventable deaths and in comparing the performance of trauma care facilities.
The prognostic significance of a system for classifying mechanical injuries of the eye (globe) in open-globe injuries.
- Pieramici DJ, Eong KG, Sternberg P Jr, Marsh MJ. J Trauma 2003; 54(4): 750-754.
Correspondence: Dante J. Pieramici, California Retina Consultants, 515 East Micheltorena, Suite C, Santa Barbara, CA 93103, USA; (email: dpieramici@yahoo.com.).
OBJECTIVE: The aim of this study was to determine the prognostic significance of a previously published system for classifying mechanical injuries of the eye (globe) in open-globe injuries.
METHODS: The medical records of 150 patients with open-globe injuries identified from an established institutional database were retrospectively reviewed to classify all injuries at presentation by the four specific variables of the classification system: type of injury, defined by the mechanism of injury; grade of injury, defined by visual acuity in the injured eye at initial examination; pupil, defined as the presence or absence of a relative afferent pupillary defect in the injured eye; and zone of injury, defined by the location of the eye-wall opening. Final visual outcomes for these injuries were also recorded. Logistic regression models were used to analyze the data and to determine whether relationships existed between the specific classification variables and final visual acuity in the injured eyes.
FINDINGS: All four classification variables were significant predictors of visual outcome. When adjusted for the other variables, grade and pupil were the most significant predictors of final visual acuity.
DISCUSSION: This system for classifying mechanical injuries of the eye appears to be prognostic for visual outcomes in open-globe injuries. In particular, the measurement of visual acuity and testing for a relative afferent pupillary defect at the initial examination should be performed in all injured eyes because of their relative prognostic significance.
In 1998, India was the only country in the world where fire (burns) was classified among the 15 leading causes of death. High mortality in young married women from burns has already become an alarming and contentious medical problem in rural India. The incidence of burn mortality by age, sex,residence, marital status; manner and reasons have been reported only infrequently from the rural parts of India. From a total of 4042 medicolegal deaths reported at an Apex medical center of a rural health district, over a period of 5 years 1997-2001, 942 deaths (23.3%) were due to burns; with mortality rate of 15.1 per year per 100,000 population. Of all burn death cases, 80.8% were females, 82.4% married ones, 71.9% belonged to the young age group of 21-40 years and 75.0% came from the rural parts of the district. Out of all burn deaths, 50.7% were accidental, 47.8% suicidal and 1.5% were homicidal in manner. In all female suicides, burns was the commonest method adopted by over 60% females. Torture by in-laws (32.1%) was the commonest reason for committing suicide by burns in married women. The present study has tried to identify the high-risk group and reasons for high burn mortality in this rural area. Religious and sociocultural reasons prevalent in the area are discussed, which play the determinant role in such a high mortality rate in burns in rural India. Further studies in India into psychodynamics of sociocultural, religious and family life are advised.
A dog rabies vaccination campaign in rural Africa: impact on the incidence of dog rabies and human dog-bite injuries.
Cleaveland S, Kaare M, Tiringa P, Mlengeya T, Barrat J. Vaccine 2003; 21(17-18): 1974-1982.
Correspondence: Sarah Cleaveland, Centre for Tropical Veterinary Medicine, University of Edinburgh, Easter Bush, Roslin, EH25 9RG, Midlothian, UK; (email:sarah.cleaveland@ed.ac.uk).
Despite the availability of safe and effective rabies vaccines, the incidence of dog rabies has been increasing throughout much of sub-Saharan Africa. Here we describe a vaccination strategy that has resulted in successful control of rabies in a rural dog population of Northwestern Tanzania. From October 1996 to February 2001, four central-point dog vaccination campaigns were conducted in villages within Serengeti District with a mean interval between campaigns of 338, 319 and 456 days. Vaccination coverage of the dog population was estimated from household questionnaires as 64.5, 61.1, 70.6 and 73.7% following each of the four campaigns, respectively. The incidence of dog rabies declined significantly in Serengeti District falling by 70% after the first campaign and by 97% after the second campaign. Over the same period, the incidence of dog rabies did not differ significantly in unvaccinated control villages of Musoma District. The incidence of human bite injuries from suspected rabid dogs declined significantly in Serengeti District after dog vaccination but not in adjacent unvaccinated districts. Vaccination of 60-70% of dogs has been sufficient to control dog rabies in this area and to significantly reduce demand for human post-exposure rabies treatment. Dog-bite injuries can provide a valuable and accessible source of data for surveillance in countries where case incidence data are difficult to obtain.
Burn patients in Portugal: analysis of 14,797 cases during 1993-1999.
- Natividade da Silva P, Amarante J, Costa-Ferreira A, Silva A, Reis J. Burns 2003; 29(3): 265-269.
Correspondence: P. Natividade da Silva, Service of Plastic and Reconstructive Surgery, Hospital de Sao Joao, Oporto Medical School, Oporto, PORTUGAL; (email: unavailable).
The incidence and cause of burns in Portugal are unknown. The present study seeks to collect these data as a basis for future studies in prevention and development of treatment regimes. The data used in this work was obtained from the registries existing in The Direccao Geral de Saude (General Health Administration) and relates to burn patients admitted to 91 Portuguese hospitals-that serve all the territory-during the period of 1993-1999. All patients selected had at least one diagnosis of burn (ICD-9: 94.###) among all the diagnoses motivating an admission. A total of 14797 burn patients were obtained. Among all the patients admitted to hospitals, 8731 (59.0%) were male and 6066 (41.0%) were female, with a male/female ratio of 1.44:1. The mean length of in-hospital stay was 15.5+/-21.0 days. Throughout this period, 553 (3.7%) patients died in Portuguese hospitals as a result of burn injury. There were no significant differences in the number of deaths in each year, P=0.45, in contrast to the decrease of burn mortality rates reported in other studies. It is likely that the reason for this situation is the lack of investment in the last years in this area and the delay in opening new Burn Centers.
Mortality rates among 5,321 patients with burns admitted to a burn unit in China: 1980-1998.
A retrospective study was conducted on 5,321 burn patients hospitalized in a burn center in Jinzhou, China during the period 1980-1998. Of the 5,321 patients, 57.8% were between 15 and 44 years old and 3.4% were >/=60 years old. Ninety-six percent had burns covering less than half of body surface area and 31.7% had only full thickness skin burn. The number of patients in the 1990s was three times that of the 1980s. Overall mortality rate was 0.86%. LA(50) for total body burn area (TBSA) and only full thickness skin burn (FTSB) was 94 and 87%, respectively. The high survival rate, may relate primarily to the low percentages of older patients and of patients with severe burns. Inhalation injuries, infection and MOD are the main causes of deaths in our patients and would be key targets to improve clinical care and in future study.
Correspondence: Dirk M. Dhossche, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA; (email: ddhossche@psychiatry.umsmed.edu).
BACKGROUND: Systematic studies of consecutive suicides show that risk for suicide concentrates heavily in people with psychiatric illness, particularly depressive disorders and substance abuse. It is generally assumed that suicide is preventable although there is currently no conclusive evidence for efficacy of any preventive action, including use of psychotropic prescription medications. The low base-rate of suicide and ethical concerns of studying suicidal people in controlled trials of medications or psychotherapy are the two most important obstacles for progress in suicide research. No prevention suicide program currently includes routine toxicological monitoring of suicide or other violent death. The use of toxicological monitoring in suicide was examined in this study.
METHODS: Review of the literature on toxicological studies of suicide, in particular of a study done in consecutive suicides in Mobile County, Alabama, between 1990-1998.
FINDINGS: Toxicological studies in suicides support that there is undertreatment of depressive disorders in people who are at risk for suicide and that substance abuse is an important risk factor. Higher detection rates of antidepressants in recent suicide samples may indicate higher treatment rates of depression.
DISCUSSION: Surveillance of psychoactive substances among suicides may be a novel and practical way to assess efficacy of selected medical interventions aimed at reducing the number of suicides. Use of toxicological monitoring in suicide should be explored in future studies.
Occupant- and collision-related risk factors for blunt thoracic aorta injury.
- McGwin G Jr, Metzger J, Moran SG, Rue LW 3rd. J Trauma 2003; 54(4): 655-662.
Correspondence: Gerald McGwin, Center for Injury Sciences, 120 Kracke Building, 1922 7th Avenue South, University of Alabama at Birmingham, Birmingham, AL 35294-0016, USA; (email:gerald.mcgwin@ccc.uab.edu).
BACKGROUND: Blunt thoracic aortic injury (BAI) is a rare and highly lethal injury. We sought to identify occupant and collision characteristics associated with motor vehicle collision (MVC)-related BAI.
METHODS: The 1995 to 2000 National Automotive Sampling System data files were used. The National Automotive Sampling System is a national probability sample of passenger vehicles involved in police-reported tow-away MVCs. The risk of BAI was calculated according to specific occupant (e.g.,age, seat belt use) and collision (e.g., delta-V [estimated change in velocity], vehicular intrusion) characteristics. The association between BAI and these characteristics was calculated using risk ratios (RRs) and associated 95% confidence intervals (CIs).
FINDINGS: Specific occupant and collision characteristics demonstrated independent association with BAI. Occupant characteristics included age >/= 60 (RR, 3.6; 95% CI, 2.5-5.2), seat belt use (RR, 0.3; 95% CI, 0.2-0.5), and being a front-seat occupant (RR, 3.1; 95% CI, 1.5-6.3). Frontal and near-side MVCs were associated with an increased risk (RR, 3.1; 95% CI, 1.9-5.1; and RR, 4.3; 95% CI, 2.6-7.2, respectively) relative to other collision types. Collisions with a delta-V >/= 40 km/h (RR, 3.8; 95% CI, 2.6-5.6)or that produce extensive vehicle crush (>/= 40 cm) (RR, 4.1; 95% CI, 2.7-6.3) or intrusion (>/=15 cm) (RR, 5.0; 95% CI, 3.5-7.3) also increase the risk of BAI.
DISCUSSION: The risk factors for BAI identified in this study support generally accepted etiologic mechanisms for this injury.
"Born to be wild". The effect of the repeal of Florida's mandatory motorcycle helmet-use law on serious injury and fatality rates.
In response to political pressure, the state of Florida repealed its mandatory motorcycle helmet-use law for all operators and passengers older than the age of 21, effective July 1, 2000. Using monthly data and a multiple time-series design, the authors assessed the effect of this law change on serious injury and fatality rates for motorcycle riders aged 21 and older. Controls for serious injury and fatality rates for motorcycle riders younger than 21 years of age were included in the analyses. Maximum-likelihood results showed that the repeal of the mandatory helmet-use law in Florida had little observable effect on serious injuries or on fatalities that resulted from motorcycle crashes. Policy implications of these findings are discussed, and explanations are given as to why the repeal of the mandatory motorcycle helmet-use law in Florida was inconsequential.
Correspondence: Patricia F. Waller, Center for Transportation Safety, Texas Transportation Institute, 1779 Crawford Dairy Road, Chapel Hill, NC 27516, USA; (email: pwaller@umich.edu).
This paper discusses the early research that lead to graduated driver licensing, some of the educational principals on which it is based, obstacles to its acceptance, and some of the early efforts in the U.S. and elsewhere.
EARLY RESEARCH: The research underlying the concept of graduated driver licensing was a 1971 North Carolina study that identified the overrepresentation of young drivers in crashes at night and when another young person was the right front passenger.
EDUCATIONAL PRINCIPALS: Efforts to reduce the risk to young novice drivers applied what was known about learning. The concepts included distributed learning (i.e., over time) and progressing from simple to complex skills.
A PROPOSAL: The proposed graduated licensing system based on learning principals included (a) initial experience under low risk conditions, (b) extended supervised practice, (c) gradual move to more complex conditions, and (d) harsher penalties for deliberate risk-taking.
OBSTACLES: There were several most common objections raised against graduated licensing. Raising the licensing age decreased mobility. Some young drivers were 'good' drivers. Enforcement is difficult. Fear of parental objections. Parents are not driver educators and some young people do not have an available parent. Administrative costs are too high.
ACCEPTANCE: Driver educators were the first to see the benefits of a graduated system in the 1970s and 1980s. Toronto nearly adopted a graduated system in 1976. New Zealand was the first to adopt a graduated licensing system in 1984. Michigan in 1997 was the first state to require parental certification of extended supervised driving practice.
The evolution and effectiveness of graduated licensing.
Correspondence: Herb M. Simpson, Traffic Injury Research Foundation, Suite 200, 171 Nepean Street, Ottawa, Ontario, CANADA K2P OB4; (email: herbs@trafficinjuryresearch.com).
This paper traces the history of graduated licensing, starting about the point in time when Pat Waller's paper on the genesis of the concept ends, and examines the extent to which graduated licensing has produced reductions in collisions. It concludes with some general observations about future research needs, anticipating several of the papers that follow.
The evolution of graduated licensing is chronicled, beginning with the early and largely unsuccessful efforts to introduce it in the United States in the late 1970s, through the pioneering efforts in New Zealand, which resulted in the first truly graduated system in 1987, to Canada where the program was introduced 7 years later, to the United States where it has flourished in more recent years.
This 25-year history lesson hopefully creates an appreciation for the somewhat torturous journey that graduated licensing has experienced in achieving acceptance among the public and policy-makers-a journey that is not yet over, as subsequent papers in the symposium will show. The proliferation of graduated licensing in recent years is a mixed blessing-the wider adoption of graduated licensing has been a very positive development, but the programs that have evolved are anything but homogeneous in structure or content. Although this is often necessary for various reasons, it is worrisome that some programs are graduated licensing in name only. This suggests that future efforts to promote graduated licensing must emphasize adherence to the fundamental risk reduction and multistage principles on which the concept is based.
The paper also considers the extent to which graduated licensing achieves its objective of reducing collisions among those covered by the program. Understandably, most jurisdictions would not introduce graduated licensing until it was shown to be effective and this, to some extent, slowed the process of implementation. The obvious irony is that it could not be shown to be effective until it was introduced. Fortunately, as history demonstrates, some jurisdictions were prepared to try the system based on its very sound empirical rationale. And, their confidence has been rewarded. A growing body of research, which shows that graduated licensing has been associated with significant and substantial reductions in collisions, is briefly described.
The paper concludes with some general observations designed to anticipate the papers that follow. First, it outlines questions that still remain unanswered about graduated licensing-why or how it works, with whom it works, and what features are most effective. Precise and unambiguous answers to these questions are essential for the design of a system that maximizes the potential for reducing collisions, injuries, and deaths. Second, it signals a note of caution on the limits of graduated licensing-it is important to recognize just how effective and beneficial this program is; it is equally important to recognize that it is not the sole panacea for the problem of collisions involving new drivers.
Correspondence: Daniel R. Mayhew, Traffic Injury Research Foundation, Suite 200, 171 Nepean Street, Ottawa, ON, CANADA K2P 0B4; (email: danm@trafficinjuryresearch.com).
OBJECTIVE: This paper considers the role and value of an extended learner's period in a graduated licensing system.
METHOD: Review and synthesis of the literature.
FINDINGS: The learner's permit allows beginners to practice under supervision before attempting the road test for a driver's license. A learner's permit stage was an integral part of the "provisional" (graduated) licensing model initially formulated by NHTSA in the mid-1970s. Almost all Canadian provinces and U.S. states now have graduated licensing (GDL) programs that typically include an extended period of supervised driving. Most parents and teens favor the learner stage, and consistent with the intent of GDL, most learners are practicing and gaining driving experience under low-risk conditions.
DISCUSSION: Research shows that very few learners crash while under supervision and that an extended learner stage has safety benefits. Further research is needed on the safety benefits of an extended learner stage and on its optimal features.
Correspondence: David F. Preusser, Preusser Research Group, Incorporated, 7100 Main Street, Trumbull, CT 06611, USA; (email: preussergroup@earthlink.net).
The Provisional or Intermediate license is the central phase in a comprehensive Graduated Licensing System. Young drivers qualify for a Provisional license by completing their Learners phase, reaching a specified age, and passing a road test. Provisional license holders are allowed to drive unsupervised subject to various restrictions. Typical restrictions include prohibitions against night driving, passengers and alcohol. The goal is to limit teen exposure to risky driving situations during their first few months of licensure, a time when their crash rates are extremely high. States with such restrictions have been shown to have lower teen crash rates than states without. Parents indicate strong support both for Graduated Licensing Systems and for the specific restrictions.
The provisional license: nighttime and passenger restrictions--a literature review.
- Lin ML, Fearn KT. J Safety Res 2003; 34(1): 51-61.
Correspondence: Mei-Li Lin, National Safety Council, Itasca, IL, USA; (email: unavailable).
BACKGROUND: Due to inexperience and inadequate driving skills, the road is a very risky place for young and beginning drivers, yet such experience and skills can only be built by increased driving and exposure to risks on the road. Graduated driver licensing (GDL) allows beginning drivers to get their initial driving experience under less risky conditions and gradually eases them into more complex driving situations.
OBJECTIVES: This paper reviews the literature exploring two key features of the intermediate licensing phase of GDL, nighttime driving restrictions and passenger restrictions.
METHOD: Literature review.
FINDINGS: Nighttime driving restrictions have been shown to effectively reduce the number and rate of crash involvements on the part of teenage drivers. Data suggest that having passengers in the car increases the likelihood of a fatal injury in young drivers and that this risk increases with the number of passengers. Young drivers were more likely to cause a crash when accompanied by their peers.
DISCUSSION: Nighttime driving and passenger restrictions are effective in decreasing injuries among teenage drivers and their passengers, especially in the context of a full GDL system. Several research questions remain to be answered in order to fully refine and optimize the impact of these provisional measures.
Graduated driver licensing in the United States: evaluation results from the early programs.
Correspondence: Jean T. Shope, Transportation Research Institute, University of Michigan, 2901 Baxter Road, Ann Arbor, MI 48109-2105, USA; (email: jshope@umich.edu).
BACKGROUND: Seventeen states enacted graduated driver licensing (GDL) programs that were implemented from 1996 through 1999 and for which evaluations are of interest.
METHODS: We received evaluation results reported for six states for which data were available. Summarizing results is difficult in other than the most global terms because of differences in pre-GDL programs, differences in GDL programs, and differences in evaluation methodology.
FINDINGS: All states identified some crash reduction among teen drivers following GDL implementation. This positive effect was observed across different geographic regions, and with different GDL programs. Simple counts are down-fewer teens are experiencing crashes and becoming injured. After calculating crash rates to adjust for changes over time in populations or licensed drivers, reductions generally were still found. Population-adjusted risks of injury/fatal crash involvement of 16-year-old drivers in Florida and Michigan were reduced by 11% and 24%, respectively. Population-adjusted risks of any crash involvement of 16-year-old drivers in Michigan and North Carolina were reduced by 25% and 27%, respectively. Reductions in night (restricted hours) crash risk were impressive in Florida, Michigan, and North Carolina. A comparison state design was only possible in the Florida evaluation, and results showed greater crash reductions under GDL. Change-point analyses of Michigan's crash data trends over time provided additional support of GDL's effectiveness in reducing crashes.
DISCUSSION: Taken as a whole, and including the preliminary findings from California, Ohio, and Pennsylvania, these reports demonstrate the early effectiveness of GDL in reducing the crash risk of teen drivers. The impact of these studies and others to come will guide future research, practice, and policy.
Other high-risk factors for young drivers--how graduated licensing does, doesn't, or could address them.
Correspondence: Susan A. Ferguson, Insurance Institute for Highway Safety, 1005 North Glebe Road, Arlington, VA 22201, USA; (email: sferguson@iihs.org).
BACKGROUND: Young drivers, particularly those who are newly licensed, have a very high crash risk. This paper examines the risk factors underlying their high crash rates and assesses the extent to which existing graduated licensing programs address these risks and whether improvements to these programs should be considered.
METHODS: Review and synthesis of the literature.
FINDINGS: The elevated risk among young drivers of being in an injury crash is the result of a number of factors found alone or in combination, such as risky driving, alcohol use, seat belt nonuse, driver distraction, fatigue, and vehicle choice. Nighttime and passenger restrictions, adopted widely in the United States, work by keeping drivers out of hazardous situations rather than by addressing risk factors directly. However, the risk factors remain in play in driving situations not specifically restricted by law. Although other graduated licensing components adopted around the world - more stringent exit tests (i.e., you need to pass a test to move to the next stage), hazard perception tests, and restrictions on speed, vehicle power, and roadway access-make sense based on the identified risk factors, they are not yet supported by research. Should research findings warrant it, consideration should be given to providing guidance to parents about how to keep their beginning drivers safe, including information on vehicle choice.
DISCUSSION: Researchers should continue to monitor and to evaluate innovative approaches to reduce the crash risk of young drivers. The effectiveness of new approaches should be established before adoption on a wider scale takes place.
Enhancing the effectiveness of graduated driver licensing legislation.
- Foss R, Goodwin A. J Safety Res 2003; 34(1): 79-84.
Correspondence: Robert Foss , Highway Safety Research Center, University of North Carolina, 730 Airport Road, CB 3430, Chapel Hill, NC 27599-3430, USA; (email: rob_foss@unc.edu).
BACKGROUND: Many states have enacted graduated driver licensing (GDL) systems in an effort to reduce the very high crash rates of young beginning drivers. This article addresses how to achieve the maximum benefit from GDL by ensuring compliance with protective restrictions.
ENHANCING GDL THROUGH SYSTEM STRUCTURE: The major crash reductions due to GDL systems result from the protective restrictions during the initial two levels, which isolate novice drivers from the highest risk driving situations. Accordingly, GDL systems should include protective restrictions that adequately control the greatest dangers facing young drivers: multiple teen passengers and night driving before midnight.
ENCOURAGING COMPLIANCE THROUGH SYSTEM STRUCTURE: Including protective restrictions that are supported by parents and teens will encourage compliance. Furthermore, linking a teen's advancement through GDL to demonstrated responsible driving will likely encourage compliance more than threatening punishment for violations.
ENCOURAGING COMPLIANCE THROUGH ENFORCEMENT: Parents are in a prime position to enforce most GDL restrictions, but there is some evidence they do not enforce those restrictions that they consider too extreme. Little is currently known about the involvement of law enforcement in GDL systems, but there is potential for high visibility law enforcement activities to encourage compliance with restrictions.
DISCUSSION: There is a need for better designed GDL systems in many states; more research is needed to examine compliance with restrictions and to evaluate enforcement efforts by parents and law enforcement.
Graduated Driver Licensing (GDL) inserts between the leaner permit and full licensure an intermediate or "provisional" license that allows novices to drive unsupervised but subject to provisions intended to reduce the risks that accompany entry into highway traffic. Introduction of GDL has been followed by lowered accident rates, resulting from both limiting exposure of novices to unsafe situations and by helping them to deal with them more safely. Sources of safer driving include extended learning, early intervention, contingent advancement, and multistage instruction. To extend the learning process, most GDL systems lengthen the duration of the learner phase and require a specified level of adult-supervised driving. Results indicate that extended learning can reduce accidents substantially if well structured and highly controlled. Early intervention with novice traffic violators have shown both a general deterrent effect upon novice violators facing suspension and a specific effect upon those who have experienced it. Making advancement to full licensure contingent upon a violation-free record when driving on the provisional license has also evidenced a reduction in accidents and violations during that phase of licensure. Multistage instruction attempts development of advanced skills only after novices have had a chance to master more basic skills. Although this element of GDL has yet to be evaluated, research indicates crash reduction is possible in situations where it does not increase exposure to risk. While the various elements of GDL have demonstrated potential benefit in enhancing the safety of novice drivers, considerable improvement in the nature and enforcement of GDL requirements is needed to realize that potential.
How well do parents manage young driver crash risks?
Correspondence: Bruce G. Simons-Morton, Prevention Research Branch, Division of Epidemiology, Statistics, and Prevention Research, National Institute of Child Health and Human Development, 6100 Executive Boulevard, 7B05, Bethesda, MD 20892-7510, USA; (email: mortonb@mail.nih.gov).
(Published by National Safety Council and Elsevier Science)
Motor vehicle crashes are extremely high among young drivers during at least the first year of licensure. Crash risks decline with increased experience, but the more newly licensed teenagers drive, the greater their risk exposure. Hence, the dilemma facing policy makers and parents is how to provide young drivers with driving experience without unduly increasing their crash risk. Graduated driver licensing policies serve to delay licensure and then limit exposure to the highest risk conditions after licensure, allowing young drivers to gain experience only under less risky driving conditions. A similar strategy is needed to guide parents. Parents do not appear to appreciate just how risky driving is for novice drivers and tend to exert less control over their teenage children's driving than might be expected. Recent research has demonstrated that simple motivational strategies can persuade parents to adopt driving agreements and impose greater restrictions on early teen driving.
Graduated driver licensing: the New Zealand experience.
- Begg D, Stephenson S. J Safety Res 2003; 34(1): 99-105.
Correspondence: Dorothy Begg, Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, P.O. Box 913, Dunedin, NEW ZEALAND; (email: dorothy.begg@ipru.otago.ac.nz).
BACKGROUND: In New Zealand, on 1 August 1987, a three-stage graduated driver licensing (GDL) system that applied to all new drivers aged 15-24 years was introduced. The essential elements of GDL were a 6-month learner license (supervised driving) and an 18-month restricted license stage (with restrictions on night driving and carrying passengers). A blood alcohol limit of 0.03 mg% applied at both stages.
EVALUATION STUDIES: Early studies indicated that young people were reasonably accepting of the restrictions, with the passenger restriction being the least acceptable. Problems of compliance with the restricted license driving restrictions were reported. Evaluations of the impact of the graduated driver licensing (GDL) on serious traffic-related injury showed that up until 1991-1992, an 8% reduction could be attributed to GDL. At this time, it was considered that reduced exposure was the main reason for this reduction. However, the number of fatalities and hospital admissions among young people continued to decline, as did the population rate and the rate per number of licensed drivers among the young driver age group. A further evaluation study showed that drivers with a restricted license had a smaller proportion of crashes at night, and with passengers, compared with drivers licensed before GDL.
FINDINGS: These results suggested that GDL restrictions had contributed to the reduction in crashes among young people and that it was not simply a case of reduced exposure to risk. An update of the most recent crash statistics indicated that, compared with older age groups, the fatal and serious injury crash rate among young people has remained substantially below the pre-GDL level. This suggests that the impact of GDL has not diminished over time.
What we know, what we don't know, and what we need to know about graduated driver licensing.
- Hedlund J, Shults RA, Compton R. J Safety Res 2003; 34(1): 107-115.
Correspondence: James Hedlund, Highway Safety North, 110 Homestead Road, Ithaca, NY 14850-6216, USA; (email: jhedlund@sprynet.com).
On November 5-7, 2002, the Symposium on Graduated Driver Licensing in Chatham, MA, brought together 75 researchers and practitioners from the United States, Canada, Australia, and New Zealand to document the current science of graduated driver licensing (GDL) and to outline research needs. Participants reviewed 12 background papers and discussed the papers in depth. The symposium's background papers are published in this issue of the Journal of Safety Research. This paper summarizes and provides a quick reference to information from the symposium papers and participant discussions. It cites the 12 symposium papers, which in turn provide more information and cite original sources. Issues and recommendations not followed by a citation were raised in the symposium discussions. This paper is divided into seven sections. The first six sections summarize information from the symposium papers and discussions. The sections are: (1) The need for graduated driver licensing; (2) Effectiveness of GDL as implemented; (3) The learner's permit phase; (4) The provisional license phase; (5) The roles of teens, parents, and public agencies; and (6) Enacting and implementing GDL. In each of these six sections, research needs are classified as either high priority (important for designing and implementing effective GDL programs) or lower priority (useful but not critical for GDL at this time).The final section summarizes the discussion of research issues and priorities from the symposium's closing session. This section has three topics: general research, issues involving parents, and issues involving graduated licensing legislation and implementation. It presents participants' collective views on both broad priorities and specific issues. In providing a concise summary of presentations and discussions from the symposium, this paper necessarily omits some information and points of discussion. The views and judgments expressed are the authors' best attempt to capture the symposium's consensus, but they do not necessarily represent the views of the authors, their organizations, or any other individual symposium participant. In particular, they are not necessarily endorsed by the symposium's sponsors: General Motors, the National Highway Traffic Safety Administration, the National Safety Council, and Nationwide.
Graduated licensing for teens: why everybody's doing it.
- Branche C, Williams AF, Feldman D. J Law Med Ethics 2002; 30(3 Suppl): 146-149.
Correspondence: Christine Branche, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; (email: crb3@cdc.gov)
While the United States traditionally has allowed quick and easy paths to full-privilege licensure of drivers at an early age, graduated licensing is becoming increasingly popular. The graduated licensing system phases in unrestricted driving by allowing beginners to get their initial behind-the-wheel experiences under conditions that reduce the risk of collision. As of June 2002, 35 states and the District of Columbia had enacted some sort of graduated licensing law. Recent evaluations of graduated licensing systems in four states have found reductions in crashes among 16-year-old drivers ranging from 11 to 33 percent. Yet, not all states have such laws, and many of the graduated licensing systems in use lack important provisions, such as nighttime driving and passenger restrictions. This article reviews the rules, restrictions, and provisions of the graduated licensing model; discusses evaluations of graduated licensing systems; identifies and analyzes variations in graduated licensing approaches across states; assesses the successes and failures of early graduated licensing laws, using New Mexico as an example; and discusses the potential of these systems to prevent injuries.
Correspondence: L F Duque, School of Public Health, University of Antioquia, Diagonal 29D no 9Sur-90, Number 1007, Medell�n, COLOMBIA; (email: lfduque@epm.net.co).
OBJECTIVES: To establish the prevalence and distribution of witnesses, victims, and perpetrators of different types of violence in the general population and the proportion of victims consulting health services or reporting the incident to authorities.
METHODS: Cross sectional survey of a random sample of 3007 inhabitants between the ages of 15 and 60 in the city of Bogota, Colombia, in 1997, based on a face to face interview.
FINDINGS: Age adjusted past year prevalence of witnesses, victims, and perpetrators of physical aggression was 61%, 27%, and 27%, respectively, while lifetime prevalence of witnesses, victims, and perpetrators of assault with a weapon in this population reached 70%, 55%, and 5.8%. Between 11% and 67% of the victims consulted a health service and less than 32% reported the incident to an authority. Those involved in most types of physical violence tended to be young, male, from lower middle social classes, with some degree of secondary education, and single or divorced.
DISCUSSION: Prevalence of witnesses and victims of violence in this sample appears to be high, while perpetrators constitute a small proportion. Violence is not equally distributed throughout the population suggesting the possibility of identifying a population at higher risk for the development of intervention programs.
