Repeated hospital admission for intentional poisonings among older adults - a Swedish national register-based study.

BACKGROUND: Poisoning injuries is an increasing concern among older people, and so is the repetition of intentional poisonings. To date, few studies have documented the pattern and individual risk factors for repeated poisonings. This national study aims to shed light on the burden, pattern, and health-related risk factors of repeated intentional poisoning leading to hospitalization or death among older Swedish adults (50 years and older), with a focus on the year following a first event. METHODS: We conducted a nationwide register-based cohort study of people aged 50-100, hospitalized for intentional poisoning (ICD10: X60-69) during 2006-2016 (n = 15,219) and re-hospitalized by poisoning of any intent within a year (n = 1710), i.e., up to the end of 2017. We considered in turn, the distribution of the second poisoning in 30-day intervals stratified by intent; poisoning lethality within a month and a year; and the sex-specific association between health conditions and being re-hospitalized for intentional poisoning within one year as compared to being hospitalized only once using logistic regression (odds ratios (OR) with 95% confidence intervals (95% CI)). RESULTS: Following an intentional poisoning, re-hospitalization within a year was predominantly for a new intentional poisoning (89.7%) and occurred most typically within a month (median 4 days). Death within 30 days occurred in similar proportion for the first and second poisoning (2.3% vs. 2.1% respectively). Among both men and women, comorbidity of psychiatric illness was strongly associated with re-hospitalization for intentional poisoning (adjusted ORs = 1.70; 95% CI = 1.45-2.01 and 1.89 (95% CI = 1.60-2.19) respectively). CONCLUSION: Most re-hospitalizations within a year after intentional poisoning are also for intentional poisoning and occur most typically within days. Re-hospitalization is associated with several conditions that are characteristic of poor mental health and there are more similarities than differences between men and women in that respect.

Trends in intentional and unintentional poisonings among older adults - A national register-based study in Sweden.

BACKGROUND: Among older people intentional poisoning outnumber unintentional ones. While there are indications that time trends differ by poisoning intent, studies are scarce. We assessed how the annual prevalence of intentional and unintentional poisoning changed over time, overall and by demographic groups. METHODS: We conducted a national open cohort study of individuals aged 50-100 years, resident in Sweden during 2005-2016. Individuals were followed up in population-based registers for their demographic and health attributes from 2006-2016. Annual prevalence of hospitalization and death by poisoning intent (unintentional vs. intentional or undetermined; ICD-10 definitions) were compiled for the categories of four demographic attributes (age, sex, marital status, and birth cohort "baby boomers"). The time trends were assessed by multinomial logistic regression with year as an independent variable. RESULTS: The annual overall prevalence of hospitalization and death by intentional poisonings consistently exceeded that of unintentional poisonings. There was a significant downward trend in intentional poisonings but not in unintentional ones. This difference in trends also applied when considering men and women separately, married and unmarried people, the young-old individuals (but not the older- or oldest-old ones), and the baby boomers and non-baby boomers. The largest demographic differences within intent were found between married and unmarried people, and the smallest one between men and women. CONCLUSION: As expected, the annual prevalence of intentional poisonings considerably exceed that of unintentional ones among Swedish older people. The recent trends reveal a significant reduction of intentional poisonings, consistent across a range of demographic attributes. The scope for action regarding this preventable cause of mortality and morbidity remains considerable.

Social position and geriatric syndromes among Swedish older people: a population-based study.

BACKGROUND: Older people with a low social position are at higher risk of poor health outcomes compared to those with a higher social position. Whether lower social position also increases the risk of geriatric syndromes (GSs) remains to be determined. This study investigates the association of social position with GSs among older community-dwellers. METHODS: Three consecutive population-based health surveys in 2006, 2010 and 2014 among older community-dwellers (age 65-84 years) in Stockholm County were combined (n = 17,612) and linked with Swedish administrative registry information. Social position was assessed using registry information (i.e. education, country of origin and civil status) and by self-reports (i.e. type of housing and financial stress). GSs were assessed by self-reports of the following conditions: insomnia, urinary incontinence, functional decline, falls, depressive disorder, hearing or vision problems. Binomial logistic regression analyses were used to estimate the association between social position and GSs after adjusting for age, sex, health status, health behavior and social stress. RESULTS: The prevalence of GSs was 70.0%, but varied across GSs and ranged from 1.9% for depression to 39.1% for insomnia. Living in rented accommodation, being born outside the Nordic countries, being widowed or divorced were associated with GS presence. Financial stress was most strongly associated with GSs (adjusted odds ratio, 2.59; 95% CI, 2.13-3.15). CONCLUSION: GSs are highly prevalent among older Swedish community-dwellers with wide variations across syndromes and strong association with all measures of social position, most strikingly that of experiencing financial stress.

Number of medications and adverse drug events by unintentional poisoning among older adults in consideration of inappropriate drug use: a Swedish population-based matched case-control study.

PURPOSE: This national, population-based study aims to determine the association between the number of prescribed medications and adverse drug events (ADE) by unintentional poisoning and examine this risk when known indicators of inappropriate drug use (IDU) are accounted for. METHODS: We employed a matched case-control design among people living in Sweden who were 50 years and older. Cases experiencing an ADE by unintentional poisoning resulting in hospitalization or death (n = 5336) were extracted from the National Health and Death Registers from January 2006 to December 2009. Four controls per case matched by age, sex and residential area were randomly selected among those without an ADE (n = 21,344). Prescribed medications dispensed during the 4-month period prior to the ADE were identified via the Swedish Prescribed Drug Register and coded according to the number of different dispensed medications (NDDM) (0 to 10 medications) and IDU indicators (one single-drug, and three drug-combinations). Conditional logistic regression was used. RESULTS: Each of the IDU indicators was significantly associated with very high risks of ADE. For NDDM, we found a lower but graded positive association from two to ten or more medications (adjusted OR, 1.5; 95% CI, 1.2-1.8). Exclusion of IDU from the NDDM decreased the risk of ADE, but the effects remained significant for three or more medications (adjusted OR excl. IDU, 1.5; 95% CI, 1.2-2.0). CONCLUSION: At population level, the number of different dispensed medications starting from three or more remains associated with ADE even after adjusting for known IDUs. Clinicians and patients need to be made aware of the increased likelihood of serious ADE, not only in case of documented inappropriate medications but also in the case of an increasing number of medications.

Injurious falls and subsequent adverse drug events among elderly - a Swedish population-based matched case-control study.

BACKGROUND: Fall injuries are stressful and painful and they have a range of serious consequences for older people. While there is some clinical evidence of unintentional poisoning by medication following a severe fall injuries, population-based studies on that association are lacking. This is investigated in the current study, in which attention is also paid to different clinical conditions of the injured patients. METHODS: We conducted a matched case-control study of Swedish residents 60 years and older from various Swedish population-based registers. Cases defined as adverse drug events (ADE) by unintentional poisoning leading to hospitalization or death were extracted from the National Patient Register (NPR) and the Cause of Death Register from January 2006 to December 2009 (n = 4418). To each case, four controls were matched by sex, age and residential area. Information on injurious falls leading to hospitalization six months prior to the date of hospital admission or death from ADE by unintentional poisoning, and corresponding date for the controls, was extracted from the NPR. Data on clinical conditions, such as dispensed medications, comorbidity and previous fall injuries were also extracted from the Swedish Prescribed Drug Register (SPDR) and NPR. Effect estimates were calculated using conditional logistic regression and presented as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: We found a three-fold increased risk of unintentional poisoning by medication in the six-month period after an injurious fall (OR 3.03; 95% CI, 2.54-3.74), with the most pronounced increase 1-3 weeks immediately after (OR, 7.66; 95% CI, 4.86-12.1). In that time window, from among those hospitalized for a fall (n = 92), those who sustained an unintentional poisoning (n = 60) tended to be in poorer health condition and receive more prescribed medications than those who did not, although this was not statistically significant. Age stratified analyses revealed a higher risk of poisoning among the younger (aged 60-79 years) than older elderly (80+ years). CONCLUSION: Medication-related poisoning leading to hospitalization or death can be an ADE subsequent to an episode of hospitalization for a fall-related injury. Poisoning is more likely to occur closer to the injurious event and among the younger elderly. It cannot be ruled out that some of those falls are themselves ADE and early signs of greater vulnerability among certain patients.

Housing, income inequality and child injury mortality in Europe: a cross-sectional study.

BACKGROUND: Child poverty rates are compared throughout Europe to monitor how countries are caring for their children. Child poverty reduction measures need to consider the importance of safe living environments for all children. In this study we investigate how European country-level economic disparity and housing conditions relate to one another, and whether they differentially correlate with child injury mortality. METHODS: We used an ecological, cross-sectional study design of 26 European countries of which 20 high-income and 6 upper-middle-income. Compositional characteristics of the home and its surroundings were extracted from the 2006 European Union Income Social Inclusion and Living Conditions Database (n = 203,000). Mortality data of children aged 1-14 years were derived from the World Health Organization Mortality Database. The main outcome measure was age standardized cause-specific injury mortality rates analysed by income inequality and housing and neighbourhood conditions. RESULTS: Nine measures of housing and neighbourhood conditions highly differentiating European households at country level were clustered into three dimensions, labelled respectively housing, neighbourhood and economic household strain. Income inequality significantly and positively correlated with housing strain (r = 0.62, P = 0.001) and household economic strain (r = 0.42, P = 0.009) but not significantly with neighbourhood strain (r = 0.34, P = 0.087). Child injury mortality rates correlated strongly with both country-level income inequality and housing strain, with very small age-specific differences. CONCLUSIONS: In the European context housing, neighbourhood and household economic strains worsened with increasing levels of income inequality. Child injury mortality rates are strongly and positively associated with both income inequality and housing strain, suggesting that housing material conditions could play a role in the association between income inequality and child health.

Dos and don'ts for mHealth-based clinical support among clinicians in South Africa: Results from a 1-day workshop.

Digital technologies continue to penetrate the South African (SA) healthcare sector at an increasing rate. Clinician-to-clinician diagnostic and management assistance through mHealth is expanding rapidly, reducing professional isolation and unnecessary referrals, and promoting better patient outcomes and more equitable healthcare systems. However, the widespread uptake of mHealth use raises ethical concerns around patient autonomy and safety, and guidance for healthcare workers around the ethical use of mHealth is needed. This article presents the results of a multi-stakeholder workshop at which the 'dos and don'ts' pertaining to mHealth ethics in the SA context were formulated and aligned to seven basic recommendations derived from the literature and previous multi-stakeholder, multi-country meetings.

Acute and usual drinking among emergency trauma patients: a study on alcohol consumption and injury patterns.

OBJECTIVE: To investigate the relationship between usual and acute alcohol consumption among injured patients and, when combined, how they covary with other injury attributes. METHODS: Data from a randomised sample of 486 injured patients interviewed in an emergency department (Lausanne University Hospital, Switzerland) were analysed using the chi(2) test for independence and cluster analysis. RESULTS: Acute alcohol consumption (24.7%) was associated with usual drinking and particularly with high volumes of consumption. Six injury clusters were identified. Over-representations of acute consumption were found in a cluster typical of injuries sustained through interpersonal violence and in another formed by miscellaneous circumstances. A third cluster, typical of sports injuries, was linked to a group of frequent heavy episodic drinkers (without acute consumption). CONCLUSIONS: Among injured patients, acute alcohol consumption is common and associated with usual drinking. Acute and/or usual consumption form part of some, but not all, injury clusters.

Demographic and circumstantial accounts of burn mortality in Cape Town, South Africa, 2001-2004: an observational register based study.

BACKGROUND: Burns are a persisting public health problem in low- and middle-income countries; however, epidemiologic data for these settings is scarce. South Africa is no exception although there is an emerging knowledge base, especially for paediatric burns. The current study describes the epidemiology of burn mortality across the lifespan in Cape Town (2.9 million inhabitants in 2001), one of the six South African metropolitan centres. METHODS: The distribution of burn mortality across socio-demographic groups and also their circumstances of occurrence were investigated using four year (2001 to 2004) surveillance data from the National Injury Mortality Surveillance System (n = 1024 cases). RESULTS: Burn mortality occurred at a rate of 7.9 per 100,000 person-years (95% CI: 7.3-8.3). Males sustained fatal rates 2.2 times more than that for females (p < 0.001), with rates significantly higher in the 25 to 38 and 39 to 50 age groups than at other ages (p < 0.001). The greatest difference between male and female deaths was observed in the 25 to 38 year age group, when almost three male deaths occurred for every female one. The vast majority of fatal burns were registered as accidental and occurred in the home, either over the cold and wet months or during recreational periods over weekends and across the year. Alcohol intoxication was reported for the majority of those adults whose alcohol blood levels were tested (i.e. 52.6% of cases aged 16+ years). CONCLUSION: Besides paediatric burns, the high prevalence and circumstances of occurrence of burns among middle age men are a source of concern. There are reasons to believe that this over-representation is a reflection of detrimental living conditions, life-style and poor socio-economic status. It is recommended that there be greater prioritisation of prevention activities that involve the control or management of kerosene heat sources, the provision of alternatives to flammable housing materials, and the implementation of strategies to reduce harmful drinking practices.

Injury incidence, healthcare consumption and avenues for prevention: a household survey on injury in rural Twiserkan, Iran.

OBJECTIVES: To assess the incidence rates of injuries of various levels of severity, and to document people's healthcare-seeking behaviours in case of injury and their views regarding the potential contribution of various actors for injury control and prevention. STUDY DESIGN: Community-based household survey in the Twiserkan district, Iran. METHODS: A questionnaire-based interview survey was undertaken over a 3-week period in June 2006, and a cluster sample of households (n=759) was visited by 10 pre-trained field workers. Denominator data were obtained from the Twiserkan district health centre. Gender- and age-specific injury distribution data were compiled by mechanism of injury. RESULTS: The overall estimated annual incidence rate of injuries was 91/1000 person-years (10 for hospitalization and 81 for other medical attendance). Traffic and falls were the most common mechanisms of injury (n=22 and 19, respectively); traffic injuries were more common among men and falls injuries were more common among women. Both mechanisms of injury were more common among adults (aged > or =16 years). Most people with severe injuries and nearly half of those people with moderate injuries initially sought care at hospital, whereas all people with minor injuries initially presented at their local health house. Common suggestions for injury prevention included engineering changes (authorities), safety education (local health workers) and increased cooperation (citizens). CONCLUSIONS: In the rural area studied, the incidence of injuries is high. Injuries affecting children and males are more severe, and many of these are related to traffic and falls. The rural healthcare system appears to be accessible to people for trauma care. A range of context-relevant injury counter-measures were proposed by injured and non-injured laypeople.

Targeting ethical considerations tied to image-based mobile health diagnostic support specific to clinicians in low-resource settings: the Brocher proposition.

Background: mHealth applications assist workflow, help move towards equitable access to care, and facilitate care delivery. They have great potential to impact care in low-resource countries, but have significant ethical concerns pertaining to patient autonomy, safety, and justice. Objective: To achieve consensus among stakeholders on how to address concerns pertaining to autonomy, safety, and justice among mHealth developers and users in low-resource settings, in particular for the application of image-based consultation for diagnostic support. Methods: A consensus approach was taken during a three-day workshop using a purposive sample of global mHealth stakeholders (n = 27) professionally and geographically spread. Throughout a series of introductory talks, group brainstorming, plenary reviews, and synthesis by the moderators, lists of actions were generated that address the concerns engendered by mHealth applications on autonomy, justice and safety, taking into account the development, implementation, and scale-up phases of an mHealth application lifecycle. Results: Several types of actions were recommended; key ones among them included building in risk mitigation measures from the development stage, establishing inclusive consultation processes, using open sources platform whenever possible, training all clinical users, and bearing in mind that the gold standard of care is face-to-face consultation with the patient. Recommendations of patient, community and health system participation and of governance were identified as cutting across the mHealth lifecycle. Conclusion: Priorities agreed-upon at the meeting echo those put forward concerning other domains and locations of application of mHealth. Those more forcefully articulated are the need to adopt and maintain participatory processes as well as promoting self-governance. They are expected to cut across the mHealth lifecycle and are prerequisites to the safeguard of autonomy, safety and justice.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research.

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research.

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

Using online databases to find journal articles on injury prevention and safety promotion research: key journals and the databases that index them.

OBJECTIVES: (1) To determine the trends of the number of journals that publish injury prevention and safety promotion (IPSP) articles and the number of articles published each year from 1900 through 2006; (2) to determine the coverage of key IPSP journals in widely used literature databases. METHODS: Journals were identified through a structured procedure that included hand-searching selected classification categories of two major listings of periodicals that publish four or more IPSP-relevant articles per year. Article relevance was assessed using the inclusion criteria for SafetyLit (a database of scholarly literature selected for its relevance to the IPSP field). Each identified journal was hand-searched from its first issue, and IPSP-relevant articles were added to the SafetyLit archive database. A MySQL database was used to perform basic queries and statistical summary analyses for journals published 1900-2006. The number of IPSP journals and journal articles was plotted for these years to identify publication trends. The publication year range of each IPSP journal was compared with the coverage, if any, of the journals in each of the five databases. RESULTS: Of the 17 839 journals assessed, 597 met the threshold for inclusion in this study. This amounts to thousands of IPSP-related articles published each year: 6100 in 2006. Only 160 (26.8%) of the journals are included in all five databases, and none have all publication years included in all of the databases. CONCLUSIONS: Some key IPSP journals are completely excluded from some of the databases. Thus, a search in a single database may miss key information from one of the many disciplines that publish IPSP-relevant information.

Opinions about potential causes and triggers of intimate partner violence against women: a population-based study among married men from Kermanshah city, Iran.

This cross-sectional study forms part of a community-based social diagnosis in an Iranian city where different community members were approached regarding their opinions about what can cause and trigger intimate partner violence against women (IPVAW). The study deals with the opinions of married men and looks for patterns of opinions and how those patterns relate to individual socio-demographic characteristics. It also discusses opinions expressed concerning the consequences of IPVAW. A workplace-based convenient sample of men from Kermanshah city filled in a standardised, self-administered questionnaire (n = 480, response rate 93%). By means of cluster analysis, four patterns of answers emerged: (1) regarding most items proposed as potential causes or triggers (33.3% of respondents); (2) not regarding them as potential causes or triggers (18.9%); (3) being ambivalent about their role (20.3%); (4) having mixed opinions but mainly not regarding them as potential causes and triggers (27.4%). Being less educated and a blue-collar worker were prominent attributes of those men inclined not to agree with the potential role played in IPVAW by the items proposed (class 2). Moreover, individual ethnicity and perpetration of non-physical violence against one's spouse had very little association with the patterns observed.

Car crash and injury among young drivers: contribution of social, circumstantial and car attributes.

The objective of the study was to assess the independent contribution of individual, car and circumstantial features in severe and fatal car crashes involving young drivers. A prospective longitudinal, register-based cohort study was conducted at national level (in Sweden), in which people born in the years 1970-1972 (n = 334070) were followed up for the period 1988-2000 (aged 16-18 years in 1988) for their first two-car crashes leading to severe or fatal injury. Ten variables descriptive of the driver (sociodemographics), the car (safety level) and the crash have been analysed using multiple logistic regressions for male and female drivers separately, compiling crude and adjusted odds ratios with 95% CI. When controlling for other features, none of the variables descriptive of male and female drivers' socio-demographic characteristics impacts significantly on the odds of being severely injured or dying in a car-to-car crash. After adjustment, significant excess risks are observed for speed limits higher than the lowest one, type of crash other than rear end collision and road and light conditions other than favourable (dry and daylight), for both male and female drivers. For males only, cars from all car safety levels have significantly higher odds than those from the safest category. Among male and female young drivers, class differences in the risk of being severely injured in a traffic injury are substantial. Yet, despite this imbalance, crash characteristics (for males and females) and safety level of the vehicle driven (for males) remain the most determinant factors of crash severity. Understanding the social patterning of road traffic injuries is a challenge for public health and it seems that qualitative and quantitative differences in crash exposure offer part of the explanation. Young drivers from all social groups need, however, to be sensitized to the risk factors.

Determination of suicide in South Africa: medical practitioner perspectives.

Decisional processes underlying the determination of a suicide in the largest injury surveillance system currently available in South Africa are assessed through face-to-face semi-structured interviews with 32 medical practitioners involved in the system. Focus is placed on their current work circumstances and practices, and views of operational and empirical criteria proposed by US experts. Common themes and discrepancies in opinions emerged regarding the quality of the data currently available for suicide determinations, and regarding the importance and difficulty in assessing the US-developed criteria in South Africa. A truly standard approach is unlikely without considerable changes to the medico-legal system.

Assessing guidelines for burn referrals in a resource-constrained setting: Demographic and clinical factors associated with inter-facility transfer.

AIM: The aim was to assess demographic and clinical factors associated with inter-facility referrals for patients with burns in a resource-constrained setting. METHODS: This was a cross-sectional case review of patients presenting with a burn at the trauma unit at the Red Cross War Memorial Children's Hospital (RXH) in Cape Town, South Africa. RESULTS: Six hundred and eleven-(71%) children were referred to the burns or the intensive care unit and 253 children were treated and discharged from the trauma unit. Of those admitted as inpatients 94% fulfilled at least one of the criteria for referral and 80% of those treated and discharged fulfilled the criteria for referral. CONCLUSIONS: Almost three out of four children evaluated at the trauma unit were referred to the burns unit for further management. However, a large number of patients were treated and discharged from the trauma unit despite being eligible for referral.

The neighbourhood socio-demographic context of teenage girls' deliberate self-harm.

This study investigates whether living area characteristics relate to the commission of self-inflicted injuries and to psychiatric consultation among teenage girls. An ecological study was conducted at the parish level. Seven descriptors of the population's sociodemographic composition were selected and psychiatric health care seeking and hospitalization for deliberate self-harm (DSH) among girls aged 12-19 years were considered (years 1999-2003). For each parish characteristic, three levels of concentration were determined and health outcomes were compared between levels using rate ratios (RR). Acute psychiatric consultation was strongly associated with all parish characteristics, particularly with the concentration of female-headed households. For hospitalization for DSH, RR were significantly higher in parishes with higher concentrations of female-headed poor families, social welfare recipients and low-income people. Teenage girls' acute psychiatric consultations more than their rate of DSH injuries are affected by parish compositional characteristics. The contextual, family-related and individual mechanisms lying behind this deserve further investigation. This may have implications for prevention strategies and for the allocation of care.

First car-to-car crashes involving young adult drivers: main patterns and their relation to car and driver characteristics.

The primary objective of the study was to examine the relationship between patterns in car-to-car crashes involving young drivers and car and driver characteristics and the research design was a national register-based prospective cohort study. Individual records in a cohort born 1970-1972 are linked to road-traffic-crash data (1988-2000). Subjects' first police-registered two-car crash leading to severe or fatal injury (n = 4875) are identified. Typical crash patterns are highlighted and associations between pattern and both car and individual socio-demographic characteristics are tested. Four crash patterns are highlighted. Male drivers and those with lower educational attainment are over-represented in all patterns. Pattern-based risk levels vary considerably according to car safety level and driver's age at time of injury and socio-economic status. Crash patterns might be considered in young adult driver education systems, bearing in mind the consistent higher risks of male drivers and of drivers with lower educational attainment.