What determines the success of states in reducing alcohol related crash fatalities? A longitudinal analysis of alcohol related crashes in the U.S. from 1985 to 2019.

In the United States, nearly 28 people die in alcohol-related motor vehicle crashes every day (1 fatality every 52 min). Over decades, states have enacted multiple laws to reduce such fatalities. From 1982 to 2019, the proportion of drivers in fatal crashes with a blood alcohol concentration (BAC) above 0.01 g/dl declined from 41% to 22%. States vary in terms of their success in reducing alcohol-related crash fatalities. The purpose of this study was to examine factors associated with changes in fatalities related to alcohol-impaired driving at the state level. We created a panel dataset of 50 states from 1985 to 2019 by merging different data sources and used fixed-effect linear regression models to analyze the data. Our two outcome variables were the ratio of drivers in fatal crashes with BAC ≥ 0.01 g/dl to those with BAC = 0.00, and the ratio of those with BAC ≥ 0.08 g/dl to those with BAC < 0.08 g/dl. Our independent variables included four laws (0.08 g/dl BAC per se law, administrative license revocation law, minimum legal drinking age law, and zero tolerance law), number of arrests due to impaired driving, alcohol consumption per capita, unemployment rate, and vehicle miles traveled. We found that the 0.08 g/dl per se law was significantly associated with lower alcohol-related crash fatalities while alcohol consumption per capita was significantly and positively associated with crash-related fatalities. Arrests due to driving under the influence (DUI) and crash fatalities were nonlinearly correlated. In addition, interaction of DUI arrests and two laws (0.08 g/dl BAC per se law, and zero tolerance) were significantly associated with lower crash-related fatalities. Our findings suggest that states which have more restrictive laws and enforce them are more likely to significantly reduce alcohol-related crash fatalities.

Trajectories and Outcomes of Adolescents that Ride With an Impaired Driver/Drive While Impaired.

Introduction: For young drivers, independent transportation has been noted to offer them opportunities that can be beneficial as they enter early adulthood. However, those that choose to engage in riding with an impaired driver (RWI) and drive while impaired (DWI) over time can face negative consequences reducing such opportunities. This study examined the prospective association of identified longitudinal trajectory classes among adolescents that RWI and DWI with their later health, education, and employment in emerging adulthood. Methods: We analyzed all seven annual assessments (Waves, W1-W7) of the NEXT Generation Health Study, a nationally representative longitudinal study starting with 10th grade (2009-2010 school year). Using all seven waves, trajectory classes were identified by latent class analysis with RWI (last 12 months) and DWI (last 30 days) dichotomized as ≥once = 1 vs. none = 0. Results: Four RWI trajectories and four DWI trajectories were identified: abstainer, escalator, decliner, and persister. For RWI and DWI trajectories respectively, 45.0% (N=647) and 76.2% (N=1,657) were abstainers, 15.6% (N=226) and 14.2% (N=337) were escalators, 25.0% (N=352) and 5.4% (N=99) were decliners, and 14.4% (N=197) and 3.8% (N=83) persisters. RWI trajectories were associated with W7 health status (χ2=13,20, p<.01) and education attainment (χ2=18.37, p<.01). Adolescent RWI abstainers reported better later health status than RWI escalators, decliners, and persisters; and decliners reported less favorable later education attainment than abstainers, escalators, and persisters. DWI trajectories showed no association with health status, education attainment, or employment. Conclusions: Our findings suggest the importance of later health outcomes of adolescent RWI. The mixed findings point to the need for more detailed understanding of contextual and time-dependent trajectory outcomes among adolescents engaging in RWI and DWI.

Mapping the complex causal mechanisms of drinking and driving behaviors among adolescents and young adults.

BACKGROUND: The proportion of motor vehicle crash fatalities involving alcohol-impaired drivers declined substantially between 1982 and 1997, but progress stopped after 1997. The systemic complexity of alcohol-impaired driving contributes to the persistence of this problem. This study aims to identify and map key feedback mechanisms that affect alcohol-impaired driving among adolescents and young adults in the U.S. METHODS: We apply the system dynamics approach to the problem of alcohol-impaired driving and bring a feedback perspective for understanding drivers and inhibitors of the problem. The causal loop diagram (i.e., map of dynamic hypotheses about the structure of the system producing observed behaviors over time) developed in this study is based on the output of two group model building sessions conducted with multidisciplinary subject-matter experts bolstered with extensive literature review. RESULTS: The causal loop diagram depicts diverse influences on youth impaired driving including parents, peers, policies, law enforcement, and the alcohol industry. Embedded in these feedback loops are the physical flow of youth between the categories of abstainers, drinkers who do not drive after drinking, and drinkers who drive after drinking. We identify key inertial factors, discuss how delay and feedback processes affect observed behaviors over time, and suggest strategies to reduce youth impaired driving. CONCLUSION: This review presents the first causal loop diagram of alcohol-impaired driving among adolescents and it is a vital first step toward quantitative simulation modeling of the problem. Through continued research, this model could provide a powerful tool for understanding the systemic complexity of impaired driving among adolescents, and identifying effective prevention practices and policies to reduce youth impaired driving.

Riding with an impaired driver and driving while impaired among adolescents: Longitudinal trajectories and their characteristics.

PURPOSE: The purpose of this study was to identify and characterize trajectory classes of adolescents who ride with an impaired driver (RWI) and drive while impaired (DWI). METHODS: We analyzed all 7 annual assessments (Waves W1-W7) of the NEXT Generation Health Study, a nationally representative longitudinal study starting with 10th grade (2009-2010 school year). Using all 7 waves, latent class analysis was used to identify trajectory classes with dichotomized RWI (last 12 months) and DWI (last 30 days; once or more = 1 vs. none = 0). Covariates were race/ethnicity, sex, parent education, urbanicity, and family affluence. RESULTS: Four RWI trajectories and 4 DWI trajectories were identified: abstainer, escalator, decliner, and persister. For RWI and DWI trajectories respectively, 45.0% (n = 647) and 76.2% (n = 1,657) were abstainers, 15.6% (n = 226) and 14.2% (n = 337) were escalators, 25.0% (n = 352) and 5.4% (n = 99) were decliners, and 14.4% (n = 197) and 3.8% (n = 83) persisters. Race/ethnicity (χ2 = 23.93, P = .004) was significantly associated with the RWI trajectory classes. Race/ethnicity (χ2 = 20.55, P = .02), sex (χ2 = 13.89, P = .003), parent highest education (χ2 = 12.49, P = .05), urbanicity (χ2 = 9.66, P = .02), and family affluence (χ2 = 12.88, P = .05) were significantly associated with DWI trajectory classes. CONCLUSIONS: Among adolescents transitioning into emerging adulthood, race/ethnicity is a common factor associated with RWI and DWI longitudinal trajectories. Our results suggest that adolescent RWI and DWI are complex behaviors warranting further detailed investigation of the respective trajectory classes. Our study findings can inform the tailoring of prevention and intervention efforts aimed at preventing illness/injury and preserving future opportunities for adolescents to thrive in emerging adulthood.

Why substitute decision makers provide or decline consent for ICU research studies: a questionnaire study.

PURPOSE: Consent for research participation in the intensive care unit (ICU) is often obtained from a substitute decision maker (SDM). In this study we explored SDMs' reasons for declining or providing consent for research studies for critically ill adult family members. METHODS: Two questionnaires were developed, one directed at SDMs who agreed to have their relative participate in a research study (AGREE group), and another for SDMs who declined participation (DECLINE group). The questionnaires explored SDMs' opinions about research in general, timing of research approach, the informed consent process, and reasons for agreeing or declining participation. RESULTS: Ninety-six SDMs completed the questionnaire (68 AGREE, 27 DECLINE). There were no differences between AGREE and DECLINE groups with respect to SDM demographics, perceived severity of illness of the patient, or the research study approach. The most common reasons for providing consent were potential for research to help others (91%), research is important for medical progress (88%), and trust in the medical team (87%). The most common reasons for declining consent were SDM was too anxious to consider research (67%), fear that patient would receive experimental treatment (37%), and concern about risks of the study (33%). CONCLUSIONS: SDMs who agree to have a relative participate in an ICU research study are motivated by the potential benefit to the patient and altruism. SDMs who decline research participation, while not generally opposed to research, are fearful of study-related harm or discomfort for the patient, and are too anxious to consider a research study at that time.

Diet, fluid, or supplements for secondary prevention of nephrolithiasis: a systematic review and meta-analysis of randomized trials.

CONTEXT: Although numerous trials have evaluated efficacy of diet, fluid, or supplement interventions for secondary prevention of nephrolithiasis, few are included in previous systematic reviews or referenced in recent nephrolithiasis management guidelines. OBJECTIVE: To determine efficacy and safety of diet, fluid, or supplement interventions for secondary prevention of nephrolithiasis. EVIDENCE ACQUISITION: Systematic review and meta-analysis of trials published January 1950 to March 2008. Sources included Medline and bibliographies of retrieved articles. Eligible trials included adults with a history of nephrolithiasis; compared diet, fluids, or supplements with control; compared relevant outcomes between randomized groups (eg, stone recurrence); had > or = 3 mo follow-up; and were published in the English language. Data were extracted on participant and trial characteristics, including study methodologic quality. EVIDENCE SYNTHESIS: Eight trials were eligible (n=1855 participants). Study quality was mixed. In two trials, water intake > 2 l/d or fluids to achieve urine output > 2.5 l/d reduced stone recurrence (relative risk: 0.39; 95% confidence interval: 0.19-0.80). In one trial, fewer high soft drink consumers assigned to reduced soft drink intake had renal colic than controls (34% vs 41%, p=0.023). Content and results of multicomponent dietary interventions were heterogeneous; in one trial, fewer participants assigned increased dietary calcium, low animal protein, and low sodium had stone recurrence versus controls (20% vs 38%, p=0.03), while in another trial, more participants assigned diets that included low animal protein, high fruit and fiber, and low purine had recurrent stones than controls (30% vs 4%, p=0.004). No trials examined the independent effect of altering dietary calcium, sodium, animal protein, fruit and fiber, purine, oxalate, or potassium. Two trials showed no benefit of supplements over control treatment. Adverse event reporting was poor. CONCLUSIONS: High fluid intake decreased risk of recurrent nephrolithiasis. Reduced soft drink intake lowered risk in patients with high baseline soft drink consumption. Data for other dietary interventions were inconclusive, although limited data suggest possible benefit from dietary calcium.

A randomized trial of daily awakening in critically ill patients managed with a sedation protocol: a pilot trial.

OBJECTIVE: Protocolized sedation (PS) and daily sedative interruption (DI) in critically ill patients have both been shown to shorten the durations of mechanical ventilation (MV) and intensive care unit (ICU) stay. Our objective was to determine the safety and feasibility of a randomized trial to determine whether adults managed with both PS + DI have a shorter duration of MV than patients managed with PS alone. DESIGN: Prospective randomized, concealed, unblinded, multicenter, pilot trial. SETTING: Three university-affiliated medical-surgical ICUs. PATIENTS: Sixty-five adults anticipated to require MV >48 hrs and receiving sedative/analgesic infusions. INTERVENTIONS: Patients were randomized to PS alone, or PS + DI. PS was implemented by bedside nurses; sedatives/analgesics were titrated to achieve Sedation Agitation Score (SAS) 3-4. The PS + DI group also had infusions interrupted daily until the patients awoke. MEASUREMENTS AND MAIN RESULTS: Diagnosis, age [mean +/- SD] (53 +/- 18.3 vs. 62.1 +/- 16.7 yrs) and Acute Physiology and Chronic Health Evaluation II (27.7 +/- 8.4 vs. 26.6 +/- 8.4) were similar in the PS and PS + DI groups, respectively. The median duration of MV in the PS and PS + DI groups was 8.0 vs. 10.5 days, and ICU stay was 10.0 vs. 13.0 days, respectively. The SAS was within target range (3-4) in 59% of 9,611 measurements, and within an acceptable range (2-5) in 86% of measurements. Self-assessed nursing and respiratory therapist workload was low in the majority of the cohort. Adverse events were similar in both groups. Patient recruitment was slower than projected (1.5 patients/mo). CONCLUSION: This pilot trial comparing PS vs. PS + DI confirmed the safety and acceptability of the sedation protocol and DI, and guided important modifications to the protocol, thus enhancing the feasibility of a future multicenter trial. This trial was not designed to detect small but significant differences in clinically important outcomes.

High-frequency oscillatory ventilation in adults: the Toronto experience.

STUDY OBJECTIVES: To review the clinical experience with high-frequency oscillatory ventilation (HFOV) in three medical-surgical ICUs in Toronto, ON, Canada, and to describe patient characteristics, HFOV strategies, and outcomes. DESIGN AND PATIENTS: Retrospective chart review of all patients treated with HFOV at three academic university-affiliated ICUs since 1998. The data extracted included patient demographics, etiology of respiratory failure, ventilator settings, and gas exchange and cardiovascular data from baseline to 72 h of treatment, as well as at the transition from HFOV to conventional ventilation (CV). Heart rate and BP were recorded at regular intervals in all patients, and hemodynamic data were recorded in 32 patients who had pulmonary artery catheters in place. Cointerventions and ICU mortality were also recorded. MEASUREMENTS AND RESULTS: A total of 156 adults (67 women and 89 men; mean [+/- SD] age, 48 +/- 18 years; mean acute physiology and chronic health evaluation [APACHE] II score, 23.8 +/- 7.5) with severe ARDS (ie, mean Pao(2)/fraction of inspired oxygen [Fio(2)] ratio, 91 +/- 48 mm Hg; mean oxygenation index [OI], 31 +/- 14) who had received CV for a duration of 5.6 +/- 7.6 days underwent 171 trials of HFOV. HFOV was discontinued within 4 h in 19 patients (12%) because of difficulties with oxygenation, ventilation, or hemodynamics. Pao(2)/Fio(2) ratios and OI ([Fio(2) x mean airway pressure x 100]/Pao(2)) improved significantly with the application of HFOV, and this benefit persisted for the 72-h study duration. Significant changes in hemodynamics following HFOV initiation included an increase in central venous pressure and a reduction in cardiac output (throughout the 72 h), and an increase in pulmonary artery occlusion pressure (at 3 and 6 h). Patients were treated with HFOV for 5.1 +/- 6.3 days. The 30-day mortality rate was 61.7%. Pneumothorax occurred in 21.8% of patients, 43.6% of patients were treated with inhaled nitric oxide, and 37.2% of patients were treated with steroids. Independent predictors of mortality on multivariate analysis were older age, higher APACHE II score, lower pH at the initiation of HFOV, and a greater number of days receiving CV prior to HFOV. CONCLUSIONS: HFOV has beneficial effects on Pao(2)/Fio(2) ratios and OI, and may be an effective rescue therapy for adults with severe oxygenation failure. The early institution of HFOV may be advantageous.

Temporal change, reproducibility, and interobserver variability in pressure-volume curves in adults with acute lung injury and acute respiratory distress syndrome.

OBJECTIVES: To assess the reproducibility of the static pressure-volume curve of the respiratory system by using a "mini-syringe" technique; to assess the temporal change in upper (UIP) and lower inflection points (LIP) measured from pressure-volume curves of the respiratory system; to assess the inter- and intraobserver variability in detection of the UIP and LIP in patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); and to compare the syringe and multiple occlusion techniques for determining LIP and UIP. DESIGN: Prospective observational study. SETTING: Academic medical-surgical critical care unit. PATIENTS: Consecutive patients with ALI or ARDS. INTERVENTIONS: Static inspiratory pressure-volume curves of the respiratory system were determined twice on day 1 of diagnosis of ALI/ARDS and then once daily for up to 6 days by using the syringe technique. Pressure-volume curves were determined from zero positive end-expiratory pressure. At each time point, three separate measurements of the pressure-volume curve were made to determine reproducibility. A 100-mL graduated syringe was used to inflate patients' lungs with 50- to 100-mL increments up to an airway pressure of 45 cm H2O or a total volume of 2 L; each volume step was maintained for 2-3 secs until a plateau airway pressure was recorded. On day 1, the static pressure-volume curve also was determined by using the multiple occlusion technique. In a random and blinded sequence, the pressure-volume curves were examined visually by three critical care physicians on three different occasions, to determine the intra- and interobserver variability in visual detection of the LIP and UIP. Observers were given objective instructions to visually identify LIP and UIP. MEASUREMENTS AND MAIN RESULTS: Eleven patients were enrolled, with a total of 134 pressure-volume curves generated. LIP and UIP could be detected in 90-94% and 61-68% of curves, respectively. When the three successive pressure-volume curves were compared, both the LIP and UIP were within 3 cm H2O in >65% of curves. The index of reliability (intraclass correlation coefficient) in LIP and UIP was 0.92 and 0.89 for interobserver variability and 0.90 and 0.88 for intraobserver variability. Daily variability was as high as 7 cm H2O for LIP and 5 cm H2O for UIP. When pressure-volume curves obtained by using the multiple occlusion and syringe techniques were compared, LIP was within 2 cm H2O, and UIP was within 4 cm H2O with the two techniques. CONCLUSIONS: The static pressure-volume curve of the respiratory system is reasonably reproducible, thus avoiding the need for multiple measurements at a single time. We found excellent interobserver and intraobserver correlation in manual identification of the LIP and UIP. Both LIP and UIP show appreciable daily variability in patients with ALI/ARDS. The multiple occlusion and syringe techniques generate similar values for LIP and UIP.

Acute oxygenation response to inhaled nitric oxide when combined with high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.

OBJECTIVE: To prospectively evaluate the oxygenation effect of inhaled nitric oxide (INO) delivered during high-frequency oscillatory ventilation in adult patients with the acute respiratory distress syndrome and oxygenation failure. DESIGN Prospective, clinical study. SETTING: Intensive care unit of a university teaching hospital. PATIENTS: A total of 23 adults (14 women, 9 men, 44.9 +/- 17.5 yrs, Acute Physiology and Chronic Health Evaluation II score of 28.6 +/- 7.1) with acute respiratory distress syndrome (lung injury score, 3.5 +/- 0.4) with Fio2 of > or = 0.6 and mean airway pressure of >or=28 cm H2O. INTERVENTIONS: INO was initiated at a dose of 5 ppm, and subsequently titrated according to a protocol, to determine the dose (5, 10, or 20 ppm) resulting in the greatest increase in Pao2/Fio2. Blood gas measurements were obtained 10-15 mins after initiation or any increase in INO dosage to assess the effect on Pao2/Fio2. MEASUREMENTS AND MAIN RESULTS: Arterial blood gases and ventilator settings were recorded at four time points: during conventional ventilation just before initiating high-frequency oscillatory ventilation, during high-frequency oscillatory ventilation just before initiating INO, after 30 mins on the optimal dose of INO, and 8-12 hrs after starting INO. Oxygenation index ([Fio2 x mean airway pressure x 100]/Pao2) and Pao2/Fio2 ratios were calculated at the same time intervals. At 30 mins after INO initiation, 83% of patients had a significant increase in blood oxygen tension, defined as > or = 20% increase in Pao2/Fio2. The mean change in Pao2/Fio2 at 30 mins was 38%. In these 19 patients, Pao2/Fio2 was highest at 20 ppm in four patients, at 10 ppm in eight patients, and at 5 ppm in seven patients. Compared with baseline measurements, Pao2/Fio2 improved significantly at both 30 mins (112 +/- 59 vs. 75 +/- 32, p=.01) and 8-12 hrs after INO initiation (146 +/- 52 vs. 75 +/- 32, p<.0001). In addition, oxygenation index was reduced at 8-12 hrs compared with baseline measurements (26 +/- 13 vs. 40 +/- 17, p=.08). CONCLUSIONS: INO delivered at doses of 5 to 20 ppm during high-frequency oscillatory ventilation increases Pao2/Fio2 and may be a safe and effective rescue therapy for patients with severe oxygenation failure.

Safety of pressure-volume curve measurement in acute lung injury and ARDS using a syringe technique.

STUDY OBJECTIVES: To assess the safety of frequent pressure-volume (PV) curve measurement in patients with acute lung injury (ALI)/ARDS. DESIGN: Prospective observational study. SETTING: Academic medical-surgical critical care unit. PATIENTS: Consecutive patients with ALI or ARDS. INTERVENTIONS: Static inspiratory PV curves of the respiratory system were determined twice on day 1, then once daily for up to 6 days using a syringe. At each time point, three separate measurements of the PV curve were made. A 100-mL graduated syringe was used to inflate patients' lungs with 50- to 100-mL increments up to an airway pressure of 45 cm H(2)O or a total volume of 2 L; each volume step was maintained for 2 to 3 s until a plateau airway pressure was recorded. Outcome measures were mean arterial BP, heart rate (HR), and oxyhemoglobin saturation (SpO(2)) prior to and immediately after PV curve measurement. There were a priori criteria for procedure discontinuation if poorly tolerated. MEASUREMENTS AND RESULTS: Eleven patients were enrolled with a total of 134 PV curves generated. SpO(2) was 93 +/- 4% (mean +/- SD) before and fell to a nadir of 89 +/- 5% during PV curve measurement (p < 0.001), but increased to 97 +/- 4% immediately afterwards (p < 0.001, before vs after). HR rose from 106 +/- 22 to 108 +/- 22 beats/min immediately after the maneuver (p < 0.001). Mean arterial BP was 93 +/- 15 mm Hg before and 100 +/- 17 mm Hg immediately afterwards (p < 0.001). During PV curve measurement, systolic BP in one patient fell to 64 mm Hg from 113 mm Hg; in another patient, SpO(2) dropped to 79% from 89%. Both changes were transient. The study was discontinued in one patient because of inability to tolerate zero positive end-expiratory pressure; in another patient, the study was discontinued because of the development of subcutaneous emphysema. CONCLUSIONS: PV curve measurement by syringe technique is well tolerated in most patients. Nonetheless, the maneuver may cause significant changes in oxygenation and/or hemodynamics, necessitating close monitoring.