Trajectories of health-related quality of life following road trauma: Latent growth mixture modeling across a 12-month cohort study.

INTRODUCTION: Health-related quality of life (HRQoL) should be considered when evaluating the burden of road trauma (RT) injuries. This study aimed to identify distinct HRQoL trajectories following minor to severe RT injury and determine characteristics of trajectory membership. METHODS: This prospective inception cohort study recruited 1480 RT survivors from three emergency departments in British Columbia, Canada (July 2018 - March 2020). HRQoL outcome was measured with the Short Form 12 survey (SF-12) and the 5-level version of the EuroQol instrument (EQ-5D-5L) at baseline (pre-injury) and at 2, 4, 6, and 12 months post-injury. Potential predictors of outcome trajectory included sociodemographic, psychological, medical, crash, and injury factors collected at baseline. We used a latent growth mixture model to identify distinct recovery trajectories and multinomial logistic regression to determine predictors of trajectory membership. RESULTS: Three distinct HRQoL trajectories were identified for SF-12 subscales and EQ-5D-5L measures: Low/Moderate-Stable, High-Large decline, and High-Slight decline. Participants in the Low/Moderate-Stable trajectory had persistent low to moderate HRQoL before and after the injury. Those in the High-Large decline trajectory had good pre-injury HRQoL followed by persistently decreased HRQoL afterwards. The High-Slight decline trajectory was characterized by good pre-injury HRQoL and only a slight decline afterwards. Participants in the Low/Moderate-Stable and High-Large decline trajectories were considered at risk of permanently poor HRQoL following RT injury given their low HRQoL over a long period of time. Characteristics that placed participants in the Low/Moderate-Stable trajectory were older age, female gender, poor pre-injury health (medical comorbidity, prescribed medication use, complaints in the injured body area(s)), pre-injury somatic symptoms, pain catastrophizing or psychological distress, injury severity (ISS) and injury pain. Patients with head injury were less likely to be in the Low/Moderate-Stable trajectory. Risk factors for membership in the High-Large decline trajectory included older age (for physical HRQoL), younger age (for mental HRQoL), female gender, living alone, pre-injury psychological distress, ISS, injury pain, no expectations for a fast recovery, as well as head injuries, spine/back injuries or lower extremity injuries. CONCLUSIONS: This study highlighted the heterogeneity of HRQoL trajectories following RT injury and the importance of considering differences between characteristics of survivors. In addition to injury type and severity, outcome is related to demographic factors, pre-injury health and pre-injury psychological factors.

Health-related quality of life in the year following road trauma: Longitudinal analysis using piecewise latent curve modeling.

BACKGROUND: Road trauma (RT) survivors have reduced health-related quality of life (HRQoL). We identified phases and predictors of HRQoL change following RT injury. METHODS: In a prospective cohort study of 1480 Canadian RT survivors aged 16 to 103 years (July 2018 - March 2020), physical component (PCS) and mental component (MCS) summary scores from the SF-12v2 were measured pre-injury and 2, 4, 6, and 12 months post-injury and their trajectories were analyzed with piecewise latent growth curve modeling. Potential predictors of HRQoL changes included sociodemographic, psychological, medical, and trauma-related factors. RESULTS: PCS and MCS scores worsened from pre-injury to 2-months (phase 1) and then improved (phase 2), but never regained baseline values. Older age, somatic symptoms and pain catastrophizing were associated with lower preinjury PCS and MCS scores. Psychological distress was associated with lower preinjury MCS scores and higher preinjury PCS scores. Phase 1 PCS scores decreased most in females, participants with fewer pre-injury somatic symptoms and those without expectations for fast recovery. Phase 1 MCS decreases were associated with younger age, female sex, living alone, lower psychological distress, lack of expectation for fast recovery and higher injury pain. In phase 2, MCS improved most in participants not using recreational drugs; PCS improved most in participants with higher education and longer recovery expectations. LIMITATIONS: There may be recall bias with reporting pre-injury HRQoL. Selection bias is possible. CONCLUSIONS: Many factors influence HRQoL following RT. These findings may inform measures to minimize HRQoL reduction following RT and speed up subsequent recovery.

Off-road vehicle crashes: dangers of alcohol and drug impairment.

BACKGROUND: Impaired driving is a public health issue, yet little is known concerning the prevalence of substance use in drivers involved in off-road vehicle crashes. The goal of the present study was to describe the demographics and prevalence of alcohol and drug use in drivers of off-road vehicle crashes. METHODS: In this observational substudy, we collected clinical and toxicological data on all moderately or severely injured off-road vehicle drivers who had blood samples obtained within 6 h of the crash. Clinical data were extracted from patients' medical charts and toxicology analyses were performed for blood alcohol, cannabinoids, recreational drugs, and impairing medications. RESULTS: Thirty-three injured drivers met the inclusion criteria. The mean age was 37.6 ± 13.4 years and 79% were male. Blood alcohol was detected in 58% of drivers and 42% of these were above the legal limit. Tetrahydrocannabinol was positive in 12% of drivers, and 18% were positive for recreational drugs. Opiates were detected in 21% of drivers. Overall, 85% were positive for at least one substance and 39% tested positive for multiple substances. CONCLUSION: This study presents the first evidence of alcohol and drug use in off-road vehicle drivers after cannabis legalization in Canada. Our results show that over half of drivers in off-road vehicle crashes test positive for alcohol and 30% tested positive for THC, cocaine, or amphetamines. Opiates are also commonly detected in off-road vehicle drivers. Emergency department (ED) visits resulting from drug driving of off-road vehicles serve as an opportunity for screening, initiating treatment, and connecting patients to interventions for substance use disorders.

ABSTRAIT: CONTEXTE: La conduite avec facultés affaiblies est un problème de santé publique, mais on sait peu de choses sur la prévalence de la toxicomanie chez les conducteurs impliqués dans des accidents de la route. L'objectif de la présente étude était de décrire la démographie et la prévalence de la consommation d'alcool et de drogues chez les conducteurs de véhicules hors route. MéTHODES: Dans le cadre de cette sous-étude observationnelle, nous avons recueilli des données cliniques et toxicologiques sur tous les conducteurs de véhicules hors route ayant subi des blessures modérées ou graves qui avaient reçu des échantillons de sang dans les 6 heures suivant l'accident. Les données cliniques ont été extraites des dossiers médicaux des patients et des analyses toxicologiques ont été effectuées pour l'alcool dans le sang, les cannabinoïdes, les drogues récréatives et les médicaments pour les facultés affaiblies. RéSULTATS: Trente-trois conducteurs blessés répondaient aux critères d'inclusion. L'âge moyen était de 37,6 13,4 ans et 79 % étaient des hommes. L'alcool dans le sang a été détecté chez 58 % des conducteurs et 42 % d'entre eux dépassaient la limite légale. Le tétrahydrocannabinol était positif chez 12 % des conducteurs et 18 % étaient positifs aux drogues récréatives. Des opiacés ont été détectés chez 21 % des conducteurs. Dans l'ensemble, 85 % étaient positifs pour au moins une substance et 39 % étaient positifs pour plusieurs substances. CONCLUSION: Cette étude présente les premières preuves de la consommation d'alcool et de drogues chez les conducteurs de véhicules hors route après la légalisation du cannabis au Canada. Nos résultats montrent que plus de la moitié des conducteurs de véhicules hors route ont un résultat positif au test de dépistage de l'alcool et 30 % ont un résultat positif au test de dépistage du THC, de la cocaïne ou des amphétamines. Les opiacés sont également couramment détectés chez les conducteurs de véhicules hors route. Les visites aux services d'urgence (SU) découlant de la conduite de véhicules hors route avec facultés affaiblies par la drogue constituent une occasion de dépistage, d'amorcer un traitement et de mettre les patients en contact avec des interventions pour les troubles liés à la consommation de substances.

Syncope While Driving and the Risk of a Subsequent Motor Vehicle Crash.

STUDY OBJECTIVE: Syncope that occurs while driving can result in a motor vehicle crash. Whether individuals with a prior syncope-related crash exhibit an exceptional risk of subsequent crash remains uncertain. METHODS: We performed a population-based retrospective observational study of patients diagnosed with 'syncope and collapse' at any of 6 emergency departments in British Columbia, Canada (2010 to 2015). Data were obtained from chart abstraction, administrative health records, insurance claims and police crash reports. We compared crash-free survival among individuals with crash-associated syncope (a crash and an emergency visit for syncope on the same date) to that among controls with syncope alone (no crash on date of emergency visit for syncope). RESULTS: In the year following their index emergency visit, 13 of 63 drivers with crash-associated syncope and 852 of 9,160 controls with syncope alone experienced a subsequent crash as a driver (crash risk 21% versus 9%). After accounting for censoring and potential confounders, crash-associated syncope was not associated with a significant increase in the risk of subsequent crash (adjusted hazard ratio [aHR] 1.38, 95% confidence interval [CI] 0.78 to 2.47). Individuals with crash-associated syncope were 31-fold more likely to have physician driving advice documented during their index visit (prevalence ratio 31.0, 95% CI, 21.3 to 45.1). In the subgroup without documented driving advice, crash-associated syncope was associated with a significant increase in subsequent crash risk (aHR 1.88, 95% CI 1.06 to 3.36). CONCLUSIONS: Crash risk after crash-associated syncope appears similar to crash risk after syncope alone.

Syncope and Traffic Crash: A Population-Based Case-Crossover Analysis.

BACKGROUND: Among individuals with recent syncope, recurrence of syncope while driving might incapacitate a driver and cause a motor vehicle crash. Current driving restrictions assume that some forms of syncope transiently increase crash risk. We evaluated whether syncope is associated with a transient increase in crash risk. METHODS: We performed a case-crossover analysis of linked administrative health and driving data from British Columbia, Canada (2010 to 2015). We included licensed drivers who visited an emergency department with "syncope and collapse" and who were involved as a driver in an eligible motor vehicle crash, both within the study interval. Using conditional logistic regression, we compared the rate of emergency visits for syncope in the 28 days before crash (the "pre-crash interval") with the rate of emergency visits for syncope in 3 self-matched 28-day control intervals (ending 6, 12, and 18 months before the crash). RESULTS: Among eligible crash-involved drivers, 47 of 3026 pre-crash intervals and 112 of 9078 control intervals had emergency visits for syncope, indicating syncope was not significantly associated with subsequent crash (1.6% vs 1.2%; adjusted odds ratio [OR], 1.27; 95% confidence interval [CI], 0.90-1.79; P = 0.18). There was no significant association between syncope and crash in subgroups at higher risk for adverse outcomes after syncope (eg, age > 65 years, cardiovascular disease, cardiac syncope). CONCLUSIONS: In the context of prevailing modifications of driving behaviour after syncope, an emergency department visit for syncope did not transiently increase the risk of subsequent traffic collision. Overall crash risks after syncope appear to be adequately addressed by current driving restrictions.

Circumstances and outcome of active transportation injuries: protocol of a British Columbian inception cohort study.

INTRODUCTION: Active transport (AT) is promoted by urban planners and health officials for its environmental, economic and societal benefits and its uptake is increasing. Unfortunately, AT users can be injured or killed due to falls or collisions. Active transport injury (ATI) prevention efforts are hindered by limited research on the circumstances, associated infrastructure, injury pattern, severity and outcome of ATI events. This study seeks to address these knowledge gaps by identifying built environment features associated with injury and risk factors for a poor outcome following ATI. METHODS AND ANALYSIS: This prospective observational study will recruit an inception cohort of 2000 ATI survivors, including pedestrians, cyclists and micromobility users aged 16 years and older who arrive at a participating emergency department within 48 hours of sustaining an ATI. Baseline interviews capture demographic and socioeconomic information, pre-injury health and functional status, as well as circumstances of the injury event and recovery expectations. Follow-up interviews at 2, 4, 6 and 12 months postinjury (key stages of recovery) use standardised health-related quality of life tools to determine physical and mental health outcomes, functional recovery and healthcare resource use and lost productivity costs. ETHICS AND DISSEMINATION: The Active Transportation Injury Circumstances and Outcome Study is approved by our institutional research ethics board and the research ethics boards of all participating sites. This study aims to provide healthcare providers with knowledge of risk factors for poor outcome following ATI with the goal of improving patient management. Additionally, this study will provide insight into the circumstances of ATI events including built environment features and how those circumstances relate to recovery outcomes. This information can be used to inform city engineers and planners, policymakers and public health officials to plan roadway design and injury prevention policy.

Did implementation of no-fault auto-insurance in British Columbia, Canada, impact return to work following road trauma? Protocol for a before-after survival analysis.

INTRODUCTION: Road trauma (RT) is a major public health problem that often results in prolonged absenteeism from work. Limited evidence suggests that recovery after RT is associated with automobile insurance compensation schemes. In May 2021, British Columbia, Canada switched from fault-based to no-fault auto-insurance coverage. This manuscript presents the protocol for a planned evaluation of that natural experiment: We will evaluate the impact of changing automobile insurance schemes on return to work following RT. METHODS AND ANALYSIS: The evaluation will use a before-after design to analyse auto-insurance claims (1 April 2019 to 30 April 2024) in order to compare recovery of claimants with non-catastrophic injuries who filed claims under the no-fault insurance scheme to that of those who filed claims under the previous system. Claimants will be followed from date of injury until they return to work or have been followed for 6 months (right-censored). We will perform sensitivity analyses to examine the robustness of our findings. First, we will exclude injuries that occurred during the COVID-19 provincial State of Emergency. Second, we will use propensity score methods rather than conventional covariate adjustment to address potential imbalance between characteristics of claimants pre-change and post-change. Finally, as the implementation effect may have a heterogeneous association with time off work, we will use quantile regression with right-censoring at 6 months to model differences in return to work at the 25th, 50th, 75th and 90th percentiles. ETHICS AND DISSEMINATION: The study uses de-identified data and is approved by the University of British Columbia Clinical Research Ethics Board (H20-03644). This research is funded by the Insurance Corporation of British Columbia (ICBC). Findings will be published in the peer-reviewed literature and summarised in a report prepared for ICBC. We anticipate that our findings will inform policy decisions in other jurisdictions considering switching to no-fault auto-insurance schemes.

Syncope and subsequent traffic crash: A responsibility analysis.

BACKGROUND: Physicians are often asked to counsel patients about driving safety after syncope, yet little empirical data guides such advice. METHODS: We identified a population-based retrospective cohort of 9,507 individuals with a driver license who were discharged from any of six urban emergency departments (EDs) with a diagnosis of 'syncope and collapse'. We examined all police-reported crashes that involved a cohort member as a driver and occurred between 1 January 2010 and 31 December 2016. We categorized crash-involved drivers as 'responsible' or 'non-responsible' for their crash using detailed police-reported crash data and a validated responsibility scoring tool. We then used logistic regression to test the hypothesis that recent syncope was associated with driver responsibility for crash. RESULTS: Over the 7-year study interval, cohort members were involved in 475 police-reported crashes: 210 drivers were deemed responsible and 133 drivers were deemed non-responsible for their crash; the 132 drivers deemed to have indeterminate responsibility were excluded from further analysis. An ED visit for syncope occurred in the three months leading up to crash in 11 crash-responsible drivers and in 5 crash-non-responsible drivers, suggesting that recent syncope was not associated with driver responsibility for crash (adjusted odds ratio, 1.31; 95%CI, 0.40-4.74; p = 0.67). However, all drivers with cardiac syncope were deemed responsible, precluding calculation of an odds ratio for this important subgroup. CONCLUSIONS: Recent syncope was not significantly associated with driver responsibility for traffic crash. Clinicians and policymakers should consider these results when making fitness-to-drive recommendations after syncope.

Syncope and the Risk of Subsequent Motor Vehicle Crash: A Population-Based Retrospective Cohort Study.

Importance: Medical driving restrictions are burdensome, yet syncope recurrence while driving can cause a motor vehicle crash (MVC). Few empirical data inform current driving restrictions after syncope. Objective: To examine MVC risk among patients visiting the emergency department (ED) after first-episode syncope. Design, Setting, and Participants: A population-based, retrospective observational cohort study of MVC risk after first-episode syncope was performed in British Columbia, Canada. Patients visiting any of 6 urban EDs for syncope and collapse were age- and sex-matched to 4 control patients visiting the same ED in the same month for a condition other than syncope. Patients' ED medical records were linked to administrative health records, driving history, and detailed crash reports. Crash-free survival among individuals with syncope was then compared with that among matched control patients. Data analyses were performed from May 2020 to March 2022. Exposures: Initial ED visit for syncope. Main Outcomes and Measures: Involvement as a driver in an MVC in the year following the index ED visit. Crashes were identified using insurance claim data and police crash reports. Results: The study cohort included 43 589 patients (9223 patients with syncope and 34 366 controls; median [IQR] age, 54 [35-72] years; 22 360 [51.3%] women; 5033 [11.5%] rural residents). At baseline, crude MVC incidence rates among both the syncope and control groups were higher than among the general population (12.2, 13.2, and 8.2 crashes per 100 driver-years, respectively). In the year following index ED visit, 846 first crashes occurred in the syncope group and 3457 first crashes occurred in the control group, indicating no significant difference in subsequent MVC risk (9.2% vs 10.1%; adjusted hazard ratio [aHR], 0.93; 95% CI, 0.87-1.01; P = .07). Subsequent crash risk among patients with syncope was not significantly increased in the first 30 days after index ED visit (aHR, 1.07; 95% CI, 0.84-1.36; P = .56) or among subgroups at higher risk of adverse events after syncope (eg, age >65 years; cardiogenic syncope; Canadian Syncope Risk Score ≥1). Conclusions and Relevance: The findings of this population-based retrospective cohort study suggest that patients visiting the ED with first-episode syncope exhibit a subsequent crash risk no different than the average ED patient. More stringent driving restrictions after syncope may not be warranted.

Cannabis Legalization and Detection of Tetrahydrocannabinol in Injured Drivers.

BACKGROUND: The effect of cannabis legalization in Canada (in October 2018) on the prevalence of injured drivers testing positive for tetrahydrocannabinol (THC) is unclear. METHODS: We studied drivers treated after a motor vehicle collision in four British Columbia trauma centers, with data from January 2013 through March 2020. We included moderately injured drivers (those whose condition warranted blood tests as part of clinical assessment) for whom excess blood remained after clinical testing was complete. Blood was analyzed at the provincial toxicology center. The primary outcomes were a THC level greater than 0, a THC level of at least 2 ng per milliliter (Canadian legal limit), and a THC level of at least 5 ng per milliliter. The secondary outcomes were a THC level of at least 2.5 ng per milliliter plus a blood alcohol level of at least 0.05%; a blood alcohol level greater than 0; and a blood alcohol level of at least 0.08%. We calculated the prevalence of all outcomes before and after legalization. We obtained adjusted prevalence ratios using log-binomial regression to model the association between substance prevalence and legalization after adjustment for relevant covariates. RESULTS: During the study period, 4339 drivers (3550 before legalization and 789 after legalization) met the inclusion criteria. Before legalization, a THC level greater than 0 was detected in 9.2% of drivers, a THC level of at least 2 ng per milliliter in 3.8%, and a THC level of at least 5 ng per milliliter in 1.1%. After legalization, the values were 17.9%, 8.6%, and 3.5%, respectively. After legalization, there was an increased prevalence of drivers with a THC level greater than 0 (adjusted prevalence ratio, 1.33; 95% confidence interval [CI], 1.05 to 1.68), a THC level of at least 2 ng per milliliter (adjusted prevalence ratio, 2.29; 95% CI, 1.52 to 3.45), and a THC level of at least 5 ng per milliliter (adjusted prevalence ratio, 2.05; 95% CI, 1.00 to 4.18). The largest increases in a THC level of at least 2 ng per milliliter were among drivers 50 years of age or older (adjusted prevalence ratio, 5.18; 95% CI, 2.49 to 10.78) and among male drivers (adjusted prevalence ratio, 2.44; 95% CI, 1.60 to 3.74). There were no significant changes in the prevalence of drivers testing positive for alcohol. CONCLUSIONS: After cannabis legalization, the prevalence of moderately injured drivers with a THC level of at least 2 ng per milliliter in participating British Columbia trauma centers more than doubled. The increase was largest among older drivers and male drivers. (Funded by the Canadian Institutes of Health Research.).

Impact of 24/7 Onsite Emergency Radiology Staff Coverage on Emergency Department Workflow.

PURPOSE: Assess the impact of 24/7/365 emergency trauma radiology (ETR) coverage on Emergency Department (ED) patient flow in an urban, quaternary-care teaching hospital. METHODS: Patient ED visit and imaging information were extracted from the hospital patient care information system for 2008 to 2018. An interrupted time-series approach with a comparison group was used to study the impact of 24/7/365 ETR on average monthly ED length of stay (ED-LOS) and Emergency Physician to disposition time (EP-DISP). Linear regression models were fit with abrupt and permanent interrupts for 24/7/365 ETR, a coefficient for comparison series and a SARIMA error term; subgroup analyses were performed by patient arrival time, imaging type and chief complaint. RESULTS: During the study period, there were 949,029 ED visits and 739,796 diagnostic tests. Following implementation of 24/7/365 coverage, we found a significant decrease in EP-DISP time for patients requiring only radiographs (-29 min;95%CI:-52,-6) and a significant increase in EP-DISP time for major trauma patients (46 min;95%CI:13,79). No significant change in patient throughput was observed during evening hours for any patient subgroup. For overnight patients, there was a reduction in EP-DISP for patients with symptoms consistent with stroke (-78 min;95%CI:-131,-24) and for high acuity patients who required imaging (-33 min;95%CI:-57,-10). Changes in ED-LOS followed a similar pattern. CONCLUSIONS: At our institution, 24/7/365 in-house ETR staff radiology coverage was associated with improved ED flow for patients requiring only radiographs and for overnight stroke and high acuity patients. Major trauma patients spent more time in the ED, perhaps reflecting the required multidisciplinary management.

Motor vehicle incidents in postgraduate trainees in British Columbia.

INTRODUCTION: Postgraduate medical trainees frequently work ≥ 24- hour shifts causing fatigue and adverse consequences such as motor vehicle incidents (MVIs). We aim to determine the incidence of MVIs during the commutes of trainees in British Columbia (BC) in the preceding year. METHODS: We completed a retrospective, cross-sectional survey of trainees regarding work hours, shifts, and MVIs in the previous year. MVIs included falling asleep while driving, sudden braking or swerving to avoid a collision, unintentionally running a red light or stop sign, or collisions. RESULTS: Of 273 respondents, over half (54.6%) reported ≥1 MVI, one in 14 were in a collision (7.0%), and two thirds (66.3%) reported that the safety of their commute had been impacted by fatigue in the past year. After adjustment for road exposure and shift-related factors, every ten km increase in commute length was associated with an increased risk of MVI (aOR=1.54;95%CI:1.15-2.12). Reported attentional failures, such as unintentionally running a red light and/or stop sign, increased for every ten hours on-call (aOR=1.44;95%CI:1.03-2.04) and for every additional past-midnight shift worked (aOR=1.13;95%CI:1.01-1.26). DISCUSSION: Trainees with longer and more frequent commutes had an increased risk of MVIs. Trainees who worked more hours on-call and more past-midnight shifts reported significantly more attentional failures while commuting. This study helps us understand factors affecting trainee commuter safety and supports calls for the provision of safe alternatives to commuting for postgraduate trainees.

INTRODUCTION: Les résidents et moniteurs cliniques (fellows) en médecine travaillent souvent ≥ 24 heures d'affilée, ce qui entraîne de la fatigue et des conséquences néfastes comme les accidents de la route, parfois évités de justesse. Notre objectif était de déterminer la fréquence des accidents de la route et des incidents qui auraient pu entraîner un accident, survenus lors des déplacements des résidents ou moniteurs cliniques en Colombie-Britannique (C.-B.) au cours de l'année précédente. MÉTHODES: Nous avons réalisé une enquête rétrospective transversale auprès des résidents. Les questions portaient sur les heures travaillées, les quarts de travail et les accidents ou les incidents pouvant entraîner un accident de la route, au cours de l'année précédente. Les incidents et accidents visés comprenaient la somnolence au volant, le freinage brusque ou l'embardée pour éviter une collision, le non-respect involontaire d'un feu rouge ou d'un panneau d'arrêt, et la collision. RÉSULTATS: Pour l'année de référence, parmi les 273 répondants, plus de la moitié (54,6 %) ont signalé ≥1 accident, un répondant sur 14 a été impliqué dans une collision (7,0 %) et deux tiers (66,3 %) ont déclaré que la fatigue avait affecté la sécurité de leur déplacement. Après ajustement pour tenir compte de l'exposition à la route et des facteurs liés aux quarts de travail, chaque portion de 10 km qui s'ajoutait au trajet était associée à une augmentation du risque d'accident ou incident de la circulation (aOR=1.54;IC95%:1.15-2.12). Les baisses d'attention signalées, liées par exemple au franchissement involontaire d'un feu rouge ou d'un panneau d'arrêt, augmentaient pour chaque période de 10 heures de garde (aOR=1,44 ; 95 % IC:1,03-2,04) et pour chaque quart supplémentaire effectué après minuit (aOR=1,13 ; 95 % IC:1,01-1,26). DISCUSSION: Les stagiaires dont les trajets étaient plus longs et plus fréquents présentaient un risque plus élevé d'implication dans un accident ou incident de la route. Les stagiaires qui travaillaient plus d'heures de garde et plus de quarts de nuit ont signalé une fréquence considérablement plus élevée de pertes d'attention pendant les trajets. Cette étude nous aide à comprendre les facteurs qui affectent la sécurité des trajets domicile-travail des résidents et moniteurs cliniques et montre la pertinence des appels à la mise en place d'options sécuritaires pour les déplacements concernés.

The physical examination is unreliable in determining the location of the distal fibular physis.

OBJECTIVES: Salter-Harris type 1 (SH1) fractures of the distal fibula are acute orthopedic injuries with tenderness over the physis without radiographic evidence of fracture. Our primary objective was to establish the accuracy of the physical examination performed by pediatric emergency medicine (PEM) physicians in determining the location of the distal fibular physis compared to a criterion standard of ultrasound. METHODS: This was a prospective, observational study at an urban academic pediatric emergency department of a convenience sample of children aged 4 to 10 years old between March 2019 and March 2020. A PEM physician or fellow examined the patient's distal fibula and marked the location of the physis with a marker. A study investigator scanned the distal fibula to establish the location of the physis on ultrasound and measured the distance between the clinician's estimated position and the actual sonographic position. We a priori defined a clinically accurate position as a distance of ≤5 mm. We compared the accuracy rate of physical examination to ultrasound landmarking using proportions with 95% confidence intervals (CI). RESULTS: We enrolled 71 patients, of whom 52 (73%) were male. The mean age was 6.7 years and the mean weight was 25.5 kg. Participating PEM physicians included 18 attending physicians and 2 fellows. The distal fibular physis was correctly identified in 24 patients, yielding an accuracy rate of 34% (95% CI 23%-46%). The mean distance between the physician's estimated position and the sonographic position was 7.4 mm (95% CI 6.4-8.4 mm). CONCLUSIONS: PEM physicians were unable to accurately identify the distal fibular physis on physical examination.

Medications and risk of motor vehicle collision responsibility in British Columbia, Canada: a population-based case-control study.

BACKGROUND: Many medications impair driving skills yet their influence on collision risk remains uncertain. We aimed to systematically investigate the risk of collision responsibility associated with common classes of prescription medications. METHODS: In this population-based case-control study we analysed linked driving and health records in British Columbia, Canada from Jan 1, 1997, to Dec 31, 2016. The study cohort included all drivers involved in an incident collision (defined as first collision after 3 collision-free years) that resulted in a police report. We scored police collision reports and classified drivers as responsible for the collision (cases) or not responsible (controls); drivers with indeterminate scores were excluded. We used logistic regression to determine odds of collision responsibility in drivers with current prescriptions for medications of interest versus drivers without prescriptions. To explore whether risk of collision responsibility was related to medication effect or driver factors, we compared risk in current medication users versus past users. To study whether drivers developed tolerance to medication effects, we compared risk in new (first 30 days of a prescription) versus established users. FINDINGS: During the study period, 4 906 925 drivers had their driving licence linked to health records; of these drivers, 747 662 unique drivers were involved in 837 919 incident collisions between Jan 1, 2000, and Dec 31, 2016. 382 685 drivers responsible for the collision (cases) and 332 259 drivers not responsible (controls) were included in the final analysis; 122 975 drivers with indeterminate responsibility were excluded. We found increased risk of collision responsibility in drivers prescribed sedating antipsychotics (adjusted odds ratio [aOR] 1·35 [98·75% CI 1·25-1·46]), long-acting benzodiazepines (aOR 1·30 [1·22-1·38]), short-acting benzodiazepines (aOR 1·25 [1·20-1·31]), and high-potency opioids (aOR 1·24 [1·17-1·30]). Among medications used for medical indications, the highest risk was seen in drivers prescribed neurological medications: cholinergic drugs (aOR 1·83 [1·39-2·40]), anticholinergic agents for Parkinson's disease (aOR 1·45 [1·08-1·96]), dopaminergic agents (aOR 1·20 [1·04-1·38]), and anticonvulsants (aOR 1·20 [1·14-1·26]). People currently taking benzodiazepines, non-sedating antidepressants, high-potency opioids, and anticonvulsants had increased risk compared with past users, and we did not find increased risk in new compared with established users of these drugs. INTERPRETATION: Drivers prescribed benzodiazepines or high-potency opioids are at increased risk of being responsible for collisions and this risk does not decrease over time. Several other classes of medications are associated with increased risk, but this association might be independent of medication effect. These findings can guide medication warnings and prescription choices and inform public education campaigns targeting impaired driving. FUNDING: Canadian Institutes of Health Research.

The association between monthly social assistance disbursement days and emergency department visits for trauma, mental health, and substance use.

OBJECTIVE: Social assistance helps fulfill the basic needs of low-income individuals. In British Columbia, social assistance is issued on the third or fourth Wednesday of every month. However, this sudden influx of resources may have negative health consequences. We investigated social assistance timing and emergency department (ED) visits related to trauma, mental health, and substance use. METHODS: We conducted a retrospective multi-centre observational study using 12 years of regional ED data from Vancouver, British Columbia (2008-2020). Each cheque week (the week following social assistance disbursement) was matched to a single control week (2 weeks prior to cheque week). We compared the number of ED visits for trauma, mental health, and substance use during cheque weeks versus control weeks. RESULTS: There were 253,360 visits during all weeks of interest. Cheque week was associated with significantly more ED visits for mental health and substance-related presentations (RR 1.07, 95% CI 1.03-1.11, p = 0.0006). These visits increased significantly for both males and females and for adults aged 17-64 years. Mental health and substance-related visits increased on the day of cheque disbursement (Wednesday) and the 4 days following (Thursday-Sunday). Trauma-related ED visits were elevated on the day of cheque disbursement, but not during other days of the week. CONCLUSIONS: Social assistance disbursement is followed by an increase in mental health and substance-related ED presentations and may be associated with an increase in trauma presentations on the day of cheque disbursement. These findings support calls for clinical and policy-level changes and support to reduce cheque day-associated harm.

RéSUMé: OBJECTIF: L'aide sociale permet de répondre aux besoins fondamentaux des personnes à faible revenu. En Colombie-Britannique, l'aide sociale est versée le troisième ou le quatrième mercredi de chaque mois. Cependant, cet afflux soudain de ressources peut avoir des conséquences négatives sur la santé. Nous avons étudié le calendrier de l'aide sociale et les visites aux urgences liées aux traumatismes, à la santé mentale et à la toxicomanie. MéTHODES: Nous avons mené une étude d'observation rétrospective multicentrique en utilisant 12 années de données sur les urgences régionales de Vancouver, en Colombie-Britannique (2008-2020). Chaque semaine de chèque (la semaine suivant le versement de l'aide sociale) a été appariée à une seule semaine de contrôle (deux semaines avant la semaine de chèque). Nous avons comparé le nombre de visites aux urgences pour traumatisme, santé mentale et toxicomanie pendant les semaines de chèque et les semaines de contrôle. RéSULTATS: Il y a eu 253 360 visites pendant toutes les semaines d'intérêt. La semaine des chèques a été associée à un nombre significativement plus élevé de visites aux urgences pour des présentations liées à la santé mentale et à la toxicomanie (RR 1,07, IC 95 % 1,03-1,11, p = 0,0006). Ces visites ont augmenté considérablement chez les hommes et les femmes et chez les adultes de 17 à 64 ans. Les visites liées à la santé mentale et aux substances ont augmenté le jour du versement du chèque (mercredi) et les quatre jours suivants (jeudi ­ dimanche). Les visites aux urgences liées à un traumatisme étaient plus nombreuses le jour de la remise du chèque, mais pas les autres jours de la semaine. CONCLUSIONS: Le versement de l'aide sociale est suivi d'une augmentation des présentations aux urgences liées à la santé mentale et à la toxicomanie et peut être associé à une augmentation des présentations de traumatismes le jour du versement du chèque. Ces résultats appuient les appels à des changements et à un soutien au niveau clinique et politique afin de réduire les préjudices associés au jour du chèque.

Prescription opioid use among drivers in British Columbia, 1997-2016.

BACKGROUND: Opioids increase the risk of traffic crash by limiting coordination, slowing reflexes, impairing concentration and producing drowsiness. The epidemiology of prescription opioid use among drivers remains uncertain. We aimed to examine population-based trends and geographical variation in drivers' prescription opioid consumption. METHODS: We linked 20 years of province-wide driving records to comprehensive population-based prescription data for all drivers in British Columbia (Canada). We calculated age- and sex-standardised rates of prescription opioid consumption. We assessed temporal trends using segmented linear regression and examined regional variation in prescription opioid use using maps and graphical techniques. RESULTS: A total of 46 million opioid prescriptions were filled by 3.0 million licensed drivers between 1997 and 2016. In 2016 alone, 14.7% of all drivers filled at least one opioid prescription. Prescription opioid use increased from 238 morphine milligram equivalents per driver year (MMEs/DY) in 1997 to a peak of 834 MMEs/DY in 2011. Increases in MMEs/DY were greatest for higher potency and long-acting prescription opioids. The interquartile range of prescription opioid dispensation by geographical region increased from 97 (Q1=220, Q3=317) to 416 (Q1=591, Q3=1007) MMEs/DY over the study interval. IMPLICATIONS: Patterns of prescription opioid consumption among drivers demonstrate substantial temporal and geographical variation, suggesting they may be modified by clinical and policy interventions. Interventions to curtail use of potentially impairing prescription medications might prevent impaired driving.

Prescription medication use as a risk factor for motor vehicle collisions: a responsibility study.

INTRODUCTION: Previous studies on the effect of prescription medications on MVCs are sparse, not readily applicable to real-world driving and/or subject to strong selection bias. This study examines whether the presence of prescription medication in drivers' blood is associated with being responsible for MVC. METHODS: This modified case-control study with responsibility analysis compares MVC responsibility rates among drivers with detectable levels of six classes of prescription medications (anticonvulsants, antidepressants, antihistamines, antipsychotics, benzodiazepines, opioids) versus those without. Data were collected between January 2010 and July 2016 from emergency departments in British Columbia, Canada. Collision responsibility was assessed using a validated and automated scoring of police collision reports. Multivariable logistic regression was used to determine OR of responsibility (analysed in 2018-2019). RESULTS: Unadjusted regression models show a significant association between anticonvulsants (OR 1.92; 95% CI 1.20 to 3.09; p=0.007), antipsychotics (OR 5.00; 95% CI 1.16 to 21.63; p=0.03) and benzodiazepines (OR 2.99; 95% CI 1.56 to 5.75; p=0.001) with collision responsibility. Fully adjusted models show a significant association between benzodiazepines with collision responsibility (aOR 2.29; 95% CI 1.16 to 4.53; p=0.02) after controlling for driver characteristics, blood alcohol and Δ-9-tetrahydrocannabinol concentrations, and the presence of other prescription medications. Antidepressants, antihistamines and opioids exhibited no significant associations. CONCLUSION: There is a moderate increase in the risk of a responsible collision among drivers with detectable levels of benzodiazepines in blood. Physicians and pharmacists should consider collision risk when prescribing or dispensing benzodiazepines. Public education about benzodiazepine use and driving and change to traffic policy and enforcement measures are warranted.

Comparison of rates of opioid withdrawal symptoms and reversal of opioid toxicity in patients treated with two naloxone dosing regimens: a retrospective cohort study.

INTRODUCTION: When managing opioid overdose (OD) patients, the optimal naloxone regimen should rapidly reverse respiratory depression while avoiding opioid withdrawal. Published naloxone administration guidelines have not been empirically validated and most were developed before fentanyl OD was common. In this study, rates of opioid withdrawal symptoms (OW) and reversal of opioid toxicity in patients treated with two naloxone dosing regimens were evaluated. METHODS: In this retrospective matched cohort study, health records of patients who experienced an opioid OD treated in two urban emergency departments (ED) during an ongoing fentanyl OD epidemic were reviewed. Definitions for OW and opioid reversal were developed a priori. Low dose naloxone (LDN; ≤0.15 mg) and high dose naloxone (HDN; >0.15 mg) patients were matched in a 1:4 ratio based upon initial respiratory rate (RR). The proportion of patients who developed OW and who met reversal criteria were compared between those treated initially with LDN or HDN. Odds ratios (OR) for OW and opioid reversal were obtained via logistic regression stratified by matched sets and adjusted for age, sex, pre-naloxone GCS, and presence of non-opioid drugs or alcohol. RESULTS: Eighty LDN patients were matched with 299 HDN patients. After adjustment, HDN patients were more likely than LDN patients to have OW after initial dose (OR = 8.43; 95%CI: 1.96, 36.3; p = 0.004) and after any dose (OR = 2.56; 95%CI: 1.17, 5.60; p = 0.019). HDN patients were more likely to meet reversal criteria after initial dose (OR = 2.73; 95%CI: 1.19, 6.26; p = 0.018) and after any dose (OR = 6.07; 95%CI: 1.81, 20.3; p = 0.003). CONCLUSIONS: HDN patients were more likely to have OW but also more likely to meet reversal criteria versus LDN patients.

The effect of patient positioning on ultrasound landmarking for cricothyrotomy.

PURPOSE: Our primary objective was to assess the difference in position of the ultrasound-guided landmark of the cricothyroid membrane (CTM) when performed with the supine patient positioned at different head of bed (HOB) elevations. METHODS: In this prospective observational study of patients presenting to the emergency department with non-life-threatening complaints, subjects underwent ultrasound-guided landmarking of the CTM with HOB elevation at 0°, 30°, and 90°. A linear mixed effects regression model was used to assess the change in the CTM landmark associated with head position. We used a second adjusted linear mixed effects model to assess possible confounding patient factors associated with these changes. RESULTS: One-hundred and ten patients were enrolled, with a median [interquartile range] age of 39 [29-59] yr and 51:49 female:male ratio. Head of bed elevation at 30° and 90° resulted in a cephalad change in the CTM landmark of 2.7 mm (99% confidence interval [CI], 1.7 to 3.8; P < 0.001) and 4.2 mm (99% CI, 3.2 to 5.3; P < 0.001) respectively compared with the landmark at 0°. Body mass index (BMI) was associated with a change of 4.6 mm (99% CI, 0.5 to 8.7; P = 0.004) for BMI ≥ 30 compared with < 18.5 kg·m-2 The impact of patient age on distance depended on HOB elevation, where patients > 70 yr had a change of 2.6 mm (99% CI, 0.01 to 5.1; P = 0.009) at 90° HOB elevation compared with 30°. CONCLUSION: The location of the ultrasound-identified surface landmark of the CTM moves in a cephalad direction by changing the position of the HOB from supine 0° to elevation at 30° and 90°. This may be clinically important when attempting cricothyrotomy using a percutaneous (blind) technique, particularly when CTM identification and cricothyrotomy are performed at different head elevations.

RéSUMé: OBJECTIF: Notre objectif principal était d'évaluer la différence de position de la membrane cricothyroïdienne en tant que repère échoguidé selon qu'elle est identifiée à différentes élévations de la tête du lit avec le patient en décubitus dorsal. MéTHODE: Cette étude observationnelle prospective a inclus des patients se présentant à l'urgence pour des problèmes de santé ne mettant pas leur vie en danger. Les repères échoguidés de la membrane cricothyroïdienne ont été identifiés chez ces patients en positionnant la tête de lit à 0°, 30° et 90°. Un modèle de régression linéaire à effets mixtes a été utilisé pour évaluer les modifications du repère de la membrane cricothyroïdienne associés à la position de la tête. Nous avons utilisé un deuxième modèle linéaire à effets mixtes ajustés pour évaluer les facteurs confondants potentiels liés au patient et associés à ces changements. RéSULTATS: Cent dix patients ont été recrutés, d'un âge médian [écart interquartile] de 39 [29-59] ans et avec un ratio femmes : hommes de 51 : 49. L'élévation de la tête de lit à 30° et 90° a entraîné un glissement céphalade de 2,7 mm (intervalle de confiance [IC] 99 %, 1,7 à 3,8; P < 0,001) et de 4,2 mm (IC 99 %, 3,2 à 5,3; P < 0,001) du marquage de la membrane cricothyroïdienne, respectivement, comparativement au repère identifié à un angle de 0°. L'indice de masse corporelle (IMC) était associé à un changement de 4,6 mm (IC 99 %, 0,5 à 8,7; P = 0,004) pour un IMC ≥ 30, comparativement à < 18,5 kg·m−2. L'impact de l'âge du patient sur la distance dépendait de l'élévation de la tête de lit : chez les patients > 70 ans, le changement était de 2,6 mm (IC 99 %, 0,01 à 5,1; P = 0,009) à une élévation de la tête de lit de 90° comparativement à un angle de 30°. CONCLUSION: L'emplacement du repère de surface identifié par échoguidage de la membrane cricothyroïdienne se déplace en direction céphalade lorsqu'on change la position de la tête de lit d'un décubitus dorsal à 0° à une élévation de 30° et 90°. Cela pourrait avoir une importance clinique lors d'une tentative de cricothyrotomie à l'aide d'une technique percutanée (en aveugle), particulièrement si l'identification de la membrane cricothyroïdienne et la cricothyrotomie sont réalisées à différentes élévations de la tête.