Age, crash type and the changing patterns of cycling fatalities in Australia between 1991 and 2022.

BACKGROUND: Australia has made significant efforts in recent years to promote cycling. METHODS: Trends in cyclist fatalities in Australia between 1991 and 2022, particularly in those aged 60 years and over, were examined using Poisson regression modelling. RESULTS: Overall, cyclist fatalities decreased by 1.1% annually. However, while there was an annual decline of 2.5% in those aged <60 years, fatalities in the 60+ age group increased by 3.3% annually. Mortality rates also showed an annual decrease of 3.5% for cyclists aged <60 years but remained almost stable in the 60+ age group over the study period. Single vehicle fatalities increased markedly, particularly among the 60+ age group (4.4% annually). DISCUSSION: The observed increase in 60+ fatalities is due to the ageing of the population rather than a rise in cycling popularity as previously thought. The rise in single vehicle fatalities is likely to be related to the increase in the availability and use of dedicated cycling infrastructure.

Acculturation and risk of traffic crashes in young Asian-born Australian drivers.

The study examines changes over time in crash risk differences between young Australian drivers born in Asia and those born in Australia.Data from the 2003 baseline survey of the DRIVE cohort of 20 806 young drivers aged 17-24 years were linked to police, hospital and death data up until 2016. The association between country of birth and crash was investigated using flexible parametric survival models adjusted for confounders.Six months after baseline, the crash risk in Asian-born drivers was less than half that of their Australian-born counterparts (mean HR, MHR 0.41; 95% CI 0.29 to 0.57), only to increase steadily over time to resemble that of Australian-born drivers 13 years later (MHR 0.94; 95% CI 0.66 to 1.36).This is likely to be associated with acculturation and the adoption by young Asian-born Australian drivers of driving behaviour patterns akin to those born locally. This needs to be considered in future road safety campaigns.

The incidence of falls after first and second eye cataract surgery: a longitudinal cohort study.

OBJECTIVE: To compare fall incidence, and visual acuity and refractive status, before surgery and after first and second eye cataract surgery. DESIGN, SETTING: Prospective observational study in eight tertiary referral ophthalmology clinics in public hospitals in Sydney, Melbourne, and Perth. PARTICIPANTS: People aged 65 years or more referred for bilateral age-related cataract surgery during 2013-16, followed for maximum of 24 months after study entry or until six months after second eye surgery, whichever was shorter. MAIN OUTCOME MEASURES: Primary outcome: age- and sex-adjusted incidence of falls. SECONDARY OUTCOMES: visual acuity and refractive error. RESULTS: The mean age of the 409 included participants was 75.4 years (SD, 5.4 years); 220 were women (54%). Age- and sex-adjusted fall incidence prior to surgery was 1.17 (95% CI, 0.95-1.43) per year, 0.81 (95% CI, 0.63-1.04) per year after first eye surgery, and 0.41 (95% CI, 0.29-0.57) per year after second eye surgery. For the 118 participants who underwent second eye surgery and participated in all follow-up visits, age- and sex-adjusted incidence before (0.80 [95% CI, 0.55-1.15] falls per year) and after first eye surgery (0.81 [95% CI, 0.57-1.15] falls per year) was similar, but was lower after second eye surgery (0.32 [95% CI 0.21-0.50] falls per year). Mean habitual binocular visual acuity (logMAR) was 0.32 (SD, 0.21) before surgery, 0.15 (SD, 0.17) after first eye surgery, and 0.07 (SD, 0.15) after second eye surgery. CONCLUSIONS: First eye surgery substantially improves vision in older people with cataract, but second eye surgery is required to minimise fall incidence. Timely cataract surgery for both eyes not only optimises vision in older people with cataract, but also reduces their risk of injury from falls.

Driving offences and risk of subsequent crash in novice drivers: the DRIVE cohort study 12-year follow-up.

BACKGROUND: Penalties are a key component to improve road user safety, but previous studies suggested that they might not be successful in reducing crashing in offending drivers. However, these studies were not able to consider important crash risk factors in the analysis that might confound the results. Using data from a large prospective cohort study of young drivers in New South Wales, Australia, we explored if novice drivers with driving offences have a higher rates of car crash and if these differences are explained by established crash risk factors. METHODS: We used data from a 2003/2004 Australian survey of young drivers, linked to police reported offence and crash data, hospital data and deaths data up to 2016. We used Poisson regression models adjusted for confounders to estimate the association between driving offences during 2003-2006 with car crash during 2007-2016. RESULTS: The study cohort comprised 20 781 young drivers of whom 7860 drivers (37.8%) had at least one driving offence and 2487 (12.0%) were involved in at least one crash. After adjusting for confounders in the regression model, drivers with three or more driving offences had 2.25 (95% CI 1.98 to 2.57), 2.87 (95% CI 1.60 to 5.17) and 3.28 (95% CI 2.28 to 4.72) times higher rates of any crash, crashes that resulted in hospital admission or death and single vehicle crashes compared with drivers with no driving offences. CONCLUSION: Measures that successfully mitigate the underlying risk factors for both, crashes and offences, have the potential to improve road safety.

Risky youth to risky adults: Sustained increased risk of crash in the DRIVE study 13 years on.

The objective of this study was to investigate if drivers who exhibit risky driving behaviours during youth (aged 17-24 years) have an increased risk of car crash up to 13 years later. We used data from the DRIVE study, a 2003/04 survey of 20,806 young novice drivers in New South Wales, Australia. The data were linked with police crash, hospital and deaths data up to 2016. We analysed differences in crash associated with 13 items of risky driving behaviours using negative binominal regression models adjusted for driver demographics, driving exposure and known crash risk factors. The items were summarised in one index and grouped into quintiles for the analysis. After adjusting for confounding, drivers of the third (RR 1.16, 95% CI 1.05-1.30), fourth (RR1.22, 95% CI1.09-1.36) and fifth quintile (RR 1.36, 95% CI 1.21-1.53) had higher crash rates compared to the lowest risk-takers. Drivers with the highest scores on the risky driving measure had higher rates of crash related hospital admission or death (RR 1.92, 95% CI 1.13-3.27), crashes in wet conditions (RR 1.35,95% CI 1.05-1.73), crashes in darkness (RR 1.55, 95% CI 1.25-1.93) and head-on crashes (RR 2.14, 95% CI 1.07-4.28), compared with drivers with the lowest scores. Novice adolescent drivers who reported high levels of risky driving when they first obtained a driver licence remained at increased risk of crash well into adulthood. Measures that successfully reduce early risky driving, have the potential to substantially reduce road crashes and transport related injuries and deaths over the lifespan.

Burden of injury along the development spectrum: associations between the Socio-demographic Index and disability-adjusted life year estimates from the Global Burden of Disease Study 2017.

BACKGROUND: The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates. METHODS: Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm-the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate. RESULTS: For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced. CONCLUSIONS: The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.

Crash characteristics of on-road single-bicycle crashes: an under-recognised problem.

Compared with crashes with motor vehicles, single-bicycle crashes are an under-recognised contributor to cycling injury and the aetiology is poorly understood. Using an in-depth crash investigation technique, this study describes the crash characteristics and patient outcomes of a sample of cyclists admitted to hospital following on-road bicycle crashes. Enrolled cyclists completed a structured interview, and injury details and patient outcomes were extracted from trauma registries. Single-bicycle crashes (n=62) accounted for 48% of on-road crashes and commonly involved experienced cyclists. Common single-bicycle crash types included loss-of-control events, interactions with tram tracks, striking potholes or objects or resulting from mechanical issues with the bicycle. To address single-bicycle crashes, targeted countermeasures are required for each of these specific crash types.

Towards valid 'serious non-fatal injury' indicators for international comparisons based on probability of admission estimates.

BACKGROUND: Governments wish to compare their performance in preventing serious injury. International comparisons based on hospital inpatient records are typically contaminated by variations in health services utilisation. To reduce these effects, a serious injury case definition has been proposed based on diagnoses with a high probability of inpatient admission (PrA). The aim of this paper was to identify diagnoses with estimated high PrA for selected developed countries. METHODS: The study population was injured persons of all ages who attended emergency department (ED) for their injury in regions of Canada, Denmark, Greece, Spain and the USA. International Classification of Diseases (ICD)-9 or ICD-10 4-digit/character injury diagnosis-specific ED attendance and inpatient admission counts were provided, based on a common protocol. Diagnosis-specific and region-specific PrAs with 95% CIs were calculated. RESULTS: The results confirmed that femoral fractures have high PrA across all countries studied. Strong evidence for high PrA also exists for fracture of base of skull with cerebral laceration and contusion; intracranial haemorrhage; open fracture of radius, ulna, tibia and fibula; pneumohaemothorax and injury to the liver and spleen. Slightly weaker evidence exists for cerebellar or brain stem laceration; closed fracture of the tibia and fibula; open and closed fracture of the ankle; haemothorax and injury to the heart and lung. CONCLUSIONS: Using a large study size, we identified injury diagnoses with high estimated PrAs. These diagnoses can be used as the basis for more valid international comparisons of life-threatening injury, based on hospital discharge data, for countries with well-developed healthcare and data collection systems.

Recent trends in cyclist fatalities in Australia.

The study examines trends in bicycling fatalities reported to the Australian police between 1991 and 2013. Trends were estimated using Poisson regression modelling. Overall, cycling fatalities decreased by 1.9% annually between 1991 and 2013. However, while deaths following multivehicle crashes decreased at a rate of 2.9% per annum (95% CI -4.0% to -1.8%), deaths from single vehicle crashes increased by 5.8% per annum (95% CI 4.1% to 7.5%). Over the study period, the average age of cyclists who died in single vehicle crashes (45.3 years, 95% CI 41.5 to 49.1) was significantly higher than cyclists who died in multivehicle crashes (36.2 years, 95% CI 34.7 to 37.7). The average age of deceased cyclists increased significantly for both types of crashes. The observed increase in single vehicle crashes need to be closely monitored in Australia and internationally. In-depth studies are needed to investigate the circumstances of fatal single bicycle crashes in order to develop appropriate countermeasures.

Describing and comparing the characteristics of injured bicyclists and other injured road users: a prospective cohort study.

BACKGROUND: We aimed to establish the frequency and characteristics (e.g. socioeconomic, pre-injury, and crash-related parameters) of injured bicyclists and other injured road users. METHODS: 748 participants aged ≥17 years who had sustained a minor or non-catastrophic injury in a land-transport crash, were interviewed after presenting to a metro hospital emergency department in New South Wales, Australia. A telephone-administered questionnaire obtained information on socio-economic, pre-injury health, and crash-related characteristics. These factors were then compared between injured bicyclists and other road users (car driver/passengers, motorcyclists/pillion and pedestrians/skateboarders). Cycling injury severity was characterized by three metrics (sustaining multiple injuries; hospital admission for ≥12 h; and sustaining a head/neck and/or facial injury). RESULTS: In this cohort of people with injuries, 238 (32 %) were bicyclists. Frequency of cycling injuries were significantly different between age-groups among men (p = 0.0002), and were more common in men aged 45-59. Bicyclists were more likely to be aged 45-59, married, have university/tertiary qualifications and have a professional occupation compared to other road users (all p <0.0001). Bicyclists compared to participants involved in other types of land transport crashes were more likely to self-report excellent general health (p = 0.01), and were less likely to report a great/overwhelming perceived danger of death or 15.0 % versus 23-41 %; p <0.0001). Frequency of upper extremity and lower extremity injuries in bicyclists were 81.9 % and 60.5 %, respectively. Explanatory variables significantly associated with injury severity metrics were age, education level, paid work status and perceived danger of death/disability in the crash. CONCLUSIONS: Minor cycling injuries were a relatively common cause of mild-moderate injury presentations to metro emergency departments. A wide spectrum of socio-demographic-, pre-injury-, and crash-related characteristics were related to cycling injuries.

Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success. METHODS: We generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030. FINDINGS: We estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone. INTERPRETATION: Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030. FUNDING: Bill & Melinda Gates Foundation, US Agency for International Development.

The role of sleepiness, sleep disorders, and the work environment on heavy-vehicle crashes in 2 Australian states.

Heavy-vehicle driving involves a challenging work environment and a high crash rate. We investigated the associations of sleepiness, sleep disorders, and work environment (including truck characteristics) with the risk of crashing between 2008 and 2011 in the Australian states of New South Wales and Western Australia. We conducted a case-control study of 530 heavy-vehicle drivers who had recently crashed and 517 heavy-vehicle drivers who had not. Drivers' crash histories, truck details, driving schedules, payment rates, sleep patterns, and measures of health were collected. Subjects wore a nasal flow monitor for 1 night to assess for obstructive sleep apnea. Driving schedules that included the period between midnight and 5:59 am were associated with increased likelihood of crashing (odds ratio = 3.42, 95% confidence interval: 2.04, 5.74), as were having an empty load (odds ratio = 2.61, 95% confidence interval: 1.72, 3.97) and being a less experienced driver (odds ratio = 3.25, 95% confidence interval: 2.37, 4.46). Not taking regular breaks and the lack of vehicle safety devices were also associated with increased crash risk. Despite the high prevalence of obstructive sleep apnea, it was not associated with the risk of a heavy-vehicle nonfatal, nonsevere crash. Scheduling of driving to avoid midnight-to-dawn driving and the use of more frequent rest breaks are likely to reduce the risk of heavy-vehicle nonfatal, nonsevere crashes by 2-3 times.

Falls in Older people with Cataract, a longitudinal evalUation of impact and riSk: the FOCUS study protocol.

BACKGROUND: Falls result in >$1 billion in treatment, disability, lost output and mortality each year in Australia and people with cataract are at increased risk. Previous research is inconclusive; one large Australian study using linked hospital data found no protective effect of cataract surgery. We aim to examine the impact of cataract-related vision impairment on falls risk and the additional effects of delays in access to surgery, refractive management (type of spectacles and changes to spectacle prescription) and the resulting level of function, particularly binocular function which can impact balance. METHOD/DESIGN: A prospective, 24-month cohort study is planned involving over 700 patients aged 70 years or older with bilateral cataract presenting for surgery at five public hospital eye clinics in Sydney, Melbourne and Perth, Australia. The primary outcomes will be self-reported falls and falls requiring medical care, assessed objectively using administrative data sets. Secondary outcomes include community participation, quality of life, mood and depressive symptoms. McNemar's test will be used to evaluate differences in falls rate before, after first eye and after second eye cataract surgery. Generalised Estimating Equations linear regression analysis will be undertaken to examine factors associated with falls risk and the secondary outcomes. DISCUSSION: With limited resources to further shorten public waiting lists, there is a need to better understand an individuals' risk of fall injury or other negative consequences while waiting for surgery. The findings of this project will inform the development of strategies to reduce falls risk in the many older people with cataract.

Factors influencing social and health outcomes after motor vehicle crash injury: an inception cohort study protocol.

BACKGROUND: There is growing evidence that health and social outcomes following motor vehicle crash injury are related to cognitive and emotional responses of the injured individual, as well as relationships between the injured individual and the compensation systems with which they interact. As most of this evidence comes from other states in Australia or overseas, investigation is therefore warranted to identify the key determinants of health and social outcomes following injury in the context of the New South Wales motor accident insurance scheme. METHODS/DESIGN: In this inception cohort study, 2400 participants, aged 17 years or more, injured in a motor vehicle crash in New South Wales will be identified though hospital emergency departments, general and physiotherapy practitioners, police records and a government insurance regulator database. Participants will be initially contacted through mail. Baseline interviews will be conducted by telephone within 28 days of the injury and participants will be followed up with interviews at 6, 12 and 24 months post-injury. Health insurance and pharmaceutical prescription data will also be collected. DISCUSSION: The study results will report short and long term health and social outcomes in the study sample. Identification of factors associated with health and social outcomes following injury, including related compensation factors will provide evidence for improved service delivery, post-injury management, and inform policy development and reforms. TRIAL REGISTRATION: Australia New Zealand Clinical trial registry identification number--ACTRN12613000889752. Available at: ANZCTR Registered FISH Study.

The impact of alcohol intoxication in patients admitted due to assault at an Australian major trauma centre: a trauma registry study from 1999 to 2009.

OBJECTIVE: To examine the long term trend in assault admissions at an inner city major trauma centre and determine the association between clinical evidence of alcohol intoxication and major trauma due to assault. METHODS: Adult trauma patients admitted due to assault between 1999 and 2009 were identified through the hospital based trauma registry at an inner city major trauma centre in Sydney. Demographic data, incident details, clinical evidence of alcohol intoxication, injury severity scores and injury related outcomes were collected. Population based incidences were calculated and outcomes compared between intoxicated and non-intoxicated patients. Major trauma was defined as a composite outcome of severe injury (injury severity score>15), intensive care admission or in-hospital mortality. RESULTS: There were 2380 patients analysed. Clinical evidence of alcohol intoxication was documented in 12% (287/2380) of cases. There was a marked peak in incidence of hospital admissions due to assault which occurred between 2000 and 2002. Overall, the rate of hospital admissions due to assault decreased during the study period (incident rate ratios 0.94, 95% CI 0.90 to 0.99, p<0.001). The odds of major trauma were three times higher in patients with clinical evidence of intoxication compared to those that did not (adjusted OR 2.9, 95% CI 2.1 to 4.0, p<0.001). CONCLUSIONS: There was a peak in hospital admissions due to inner city assault around 2000-2002 associated with an overall decline in hospital admissions at this trauma centre over 10 years. Clinical evidence of alcohol intoxication in patients admitted for assault appears to be associated with more severe injury, including severe head injury.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.

BACKGROUND: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. METHODS: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. FINDINGS: In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. INTERPRETATION: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. FUNDING: Bill & Melinda Gates Foundation.

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.

BACKGROUND: Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs). METHODS: Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis. FINDINGS: Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350,000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient -0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa. INTERPRETATION: Rates of YLDs per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world. FUNDING: Bill & Melinda Gates Foundation.

Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.

BACKGROUND: Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time. METHODS: We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights. FINDINGS: Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions. INTERPRETATION: Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results. FUNDING: Bill & Melinda Gates Foundation.

Single- versus multi-vehicle bicycle road crashes in Victoria, Australia.

The aim of the study is to compare trends, circumstances and outcomes of single- versus multi-vehicle bicycle on-road crashes in Victoria, Australia, through the analysis of police records and hospital admissions between January 2004 and December 2008. The results show that over 80% of on-road single-vehicle bicycle crashes occurred as a result of the cyclist losing control of the bicycle with the remainder involving collisions with objects. Compared with multi-vehicle crashes, single-vehicle crashes were more likely to occur in the dark, in wet conditions and in rural areas. Over half of the cyclists hospitalised as result of on-road crashes were injured in single-vehicle crashes and this proportion seems to be increasing over time. Single-vehicle crashes were associated with hospitalised injuries as severe as those resulting from multivehicle crashes. The findings highlight the significant burden of serious injury associated with single-vehicle bicycle road crashes. Further research is needed to investigate in greater detail the risk factors of these crashes and the effectiveness of countermeasures to reduce their burden.

A randomized trial to evaluate the effectiveness of an individual, education-based safe transport program for drivers aged 75 years and older.

BACKGROUND: There are concerns over safety of older drivers due to increased crash involvement and vulnerability to injury. However, loss of driving privileges can dramatically reduce independence and quality of life for older members of the community. The aim of this trial is to examine the effectiveness of a safe transport program for drivers aged 75 years and older at reducing driving exposure but maintaining mobility. METHODS AND DESIGN: A randomised trial will be conducted, involving 380 drivers aged 75 years and older, resident in urban and semi-rural areas of North-West Sydney. The intervention is an education program based on the Knowledge Enhances Your Safety (KEYS) program, adapted for the Australian context. Driving experience will be measured objectively using an in-vehicle monitoring device which includes a global positioning system (GPS) to assess driving exposure and an accelerometer to detect rapid deceleration events. Participation will be assessed using the Keele Assessment of Participation (KAP). Data will be analysed on an intention-to-treat basis; the primary outcomes include driving exposure, rapid deceleration events and scores for KAP. Secondary outcomes include self-reported measures of driving, socialisation, uptake of alternative forms of transport, depressive symptoms and mood. A detailed process evaluation will be conducted, including examination of the delivery of the program and uptake of alternative forms of transport. A subgroup analysis is planned for drivers with reduced function as characterized by established cut-off scores on the Drivesafe assessment tool. DISCUSSION: This randomised trial is powered to provide an objective assessment of the efficacy of an individually tailored education and alternative transportation program to promote safety of older drivers but maintain mobility. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000543886.