Impact of COVID-19 on motor vehicle injuries and fatalities in older adults in Ontario, Canada.

BACKGROUND: Older adults constitute the group most vulnerable to COVID-19 mortality. As a result, in North America and elsewhere, older adults have been strongly advised to shelter in place. Older adults also represent the fastest growing segment of licensed drivers. OBJECTIVE: We examined the change in injuries and fatalities sustained by younger and older drivers and pedestrians during the first month of the COVID-19 pandemic. We hypothesized that adults ages 80 years and over would have a proportionally larger reduction than the other drivers and pedestrians. METHODS: Using a cohort design, we compared the proportion of drivers and pedestrians involved in injuries and fatalities attributable to individuals aged 80 years and over, as recorded in the Ministry of Transportation of Ontario (Canada) database, between the 30 days prior to shelter-in-place related to the COVID-19 pandemic and the subsequent 30 days. By way of comparison, we conducted a similar comparison for younger age cohorts (16-24 years, 25-34 years, 35-54 years, 55-64 years, and 65-79 years). RESULTS: Drivers aged 80 years and over represented 21 per 1000 injuries and fatalities in the 30 days prior to March 17, 2020 (95 % CI: 15-29), and 8 per 1000 injuries and fatalities in the 30 days beginning on that date (95 % CI: 2-20), a 64.7 % reduction (exp (ß) post 0.353, 95 % CI 0.105-0.892). Drivers in the 35-54 year age range underwent a significant but smaller reduction of 22.9 %; no significant changes were seen for drivers in other age groups, or for pedestrians of any age. CONCLUSIONS AND RELEVANCE: The physical distancing measures that aimed to reduce the spread of COVID-19 resulted in a marked reduction in driver injuries and fatalities in the oldest old, illustrating the impact of physical distancing recommendations in this population. The excess mortality burden faced by the oldest adults during the COVID-19 pandemic, by direct exposure to the virus, may be indirectly mitigated by the reduction in road-related deaths in this cohort.

Program design for incentivizing ignition interlock installation for alcohol-impaired drivers: The Ontario approach.

INTRODUCTION: Drinking and driving is a major risk factor for traffic injuries. Although ignition interlocks reduce drinking and driving while installed, several issues undermine their implementation including delayed eligibility for installation, low installation once eligible, and a return to previous risk levels after de-installation. The Canadian province of Ontario introduced a "Reduced Suspension with Ignition Interlock Conduct Review" Program, significantly changing pre-existing interlock policy. The Program incentivizes interlock installation and an "early" guilty plea. It also attempts to reduce long-term recidivism through behavioural feedback and compliance-based removal. This evaluation is the first in assessing Program impact. METHODS: Ontario drivers with a first time alcohol-impaired driving conviction between July 1, 2005 and November 25, 2014 comprised the study cohort. Longitudinal analyses, using interrupted time series and Cox regression, were conducted in which exposure was the Program and the outcomes were ignition interlock installation (N=30,200), pre-trial elapsed time (N=30,200), and post-interlock recidivism (N=9326). RESULTS: After Program implementation, installation rates increased by 54% and pre-trial elapsed time decreased by 146 days. Results suggest no effect on post-interlock recidivism. CONCLUSIONS: Through an incentive-based design, this Program was effective at addressing two commonly cited barriers to interlock implementation- delayed eligibility for installation and low installation once eligible. Results reveal that installation rates are responsive not only to incentivization but also to other external factors, thus presenting an opportunity for policy makers to find unique ways to influence interlock uptake, and thereby, to extend their deterrent effects to a larger subset of the population. This study is one of the few that do not rely on proxy measures of installation rate.

Vehicle impoundments improve drinking and driving licence suspension outcomes: Large-scale evidence from Ontario.

Although vehicle impoundment has become a common sanction for various driving offences, large-scale evaluations of its effectiveness in preventing drinking and driving recidivism are almost non-existent in the peer-reviewed literature. One reason is that impoundment programs have typically been introduced simultaneously with other countermeasures, rendering it difficult to disentangle any observed effects. Previous studies of impoundment effectiveness conducted when such programs were implemented in isolation have typically been restricted to small jurisdictions, making high-quality evaluation difficult. In contrast, Ontario's "long-term" and "seven-day" impoundment programs were implemented in relative isolation, but with tight relationships to already existing drinking and driving suspensions. In this work, we used offence data produced by Ontario's population of over 9 million licensed drivers to perform interrupted time series analysis on drinking and driving recidivism and on rates of driving while suspended for drinking and driving. Our results demonstrate two key findings: (1) impoundment, or its threat, improves compliance with drinking and driving licence suspensions; and (2) addition of impoundment to suspension reduces drinking and driving recidivism, possibly through enhanced suspension compliance.

Evaluation of the general deterrence capacity of recently implemented (2009-2010) low and Zero BAC requirements for drivers in Ontario.

The number of injuries and fatalities associated with drinking and driving continues to decline in the province of Ontario. However, this behavior remains as one of the major contributors to collision-related injuries and fatalities. Few large-scale studies of blood alcohol concentration (BAC) <0.08% limits exist in the literature, necessitating additional investigation. Here we evaluate the general deterrent effectiveness of three Ontario countermeasures implemented during 2009 and 2010, two of which impose lower allowable BAC on drivers in the province. Using ARIMA-based interrupted time-series analysis we found that Warn-range sanctions, which include immediate roadside suspension for the previously un-targeted BAC range of 0.05-0.08%, were associated with a 17% decrease in the number of people injured or killed in drinking and driving collisions (relative to the number injured or killed in other collisions). Similarly, we found that Zero BAC requirements newly applied to young drivers (<22y.o.) were associated with a reduction in the numbers of two other dissimilar drinking and driving sanctions received by young drivers (relative to the number of these sanctions received by non-young drivers). A roadside seven-day vehicle impoundment for BAC>0.08%, which was added to an already existing roadside 90-day license suspension, was not found to produce general deterrence. Taken together, our results suggest that sanctions which target previously untargeted groups, specifically via lower BAC requirements, are effective as general deterrents against drinking and driving.

Working in tandem: The contribution of remedial programs and roadside licence suspensions to drinking and driving deterrence in Ontario.

In 1998, Ontario implemented a remedial program called "Back On Track" (BOT) for individuals convicted of alcohol-impaired driving. Drivers convicted before October 2000 were exposed to a single-component program ("Edu BOT"); those convicted after participated in a multi-component program ("Full BOT"). We evaluated the impact of BOT, and the preceding 90-day roadside licence suspension, on drinking and driving recidivism, an outcome yet to be examined, using population-wide driver records. A Chi Square Test was used to compare the three-year cumulative incidence of recidivism between three historically-defined cohorts: No BOT, Edu BOT, and Full BOT. Stratified analyses by completion status and by age were also conducted. Analyses of the roadside suspension were conducted using an interrupted time series approach based on segmented Poisson/negative binomial regression. The roadside suspension was associated with a 65.2% reduction in drinking driving recidivism. In combination with indefinite suspensions for non-completion, the BOT program was also associated with a 21% decrease in drinking and driving recidivism in the three years following a CCC driving prohibition, from 8.5% to 6.7%. This reduction cannot be explained by pre-existing trends in recidivism. Conversion of the BOT program from the single-component version to the multi-component program further reduced the three-year cumulative incidence of recidivism to 5.5% (a total reduction of 35% from pre-BOT). Results provide strong converging evidence that remedial alcohol education/treatment programs in combination with other sanctions can produce substantial increases in road safety.

Quantifying Labial Strength and Function in Facial Paralysis: Effect of Targeted Lip Injection Augmentation.

IMPORTANCE: Facial muscle weakness from paralysis or muscle dystrophy can significantly affect lip strength and function. Lip muscle weakness may result in articulation difficulties and spillage of food, both of which are socially and functionally disruptive for patients. There are few quantitative data on the effect of facial paralysis on lip strength. OBJECTIVES: To quantify the effect of facial paralysis and muscular dystrophy on lip strength and evaluate the effectiveness of targeted lip injection augmentation. DESIGN, SETTING, AND PARTICIPANTS: Analysis of patients at the Johns Hopkins Hospital between January 1, 2008, and July 31, 2014, presenting for treatment of lip incompetence due to facial paralysis and facial muscular dystrophy was prospectively undertaken. Patients who had undergone direct surgical lip procedures were excluded. MAIN OUTCOMES AND MEASURES: Lip pressure measurements, anterior bolus spillage, and articulation of bilabial sounds before and after treatment were assessed by a single speech pathologist. Lip pressures were measured with the Iowa Oral Performance Instrument. RESULTS: Twenty-two patients with unilateral facial paralysis were evaluated for this study. Three patients with facioscapulohumeral muscular dystrophy were also evaluated. In unilateral facial paralysis, central lip strength was reduced in all patients compared with sex-corrected normative data (mean [SD] central lip strength, 5.5 [2.5] kPa in females and 9.6 [4.6] kPa in males). Compared with the nonparalyzed side, labial strength on the paralyzed sided was reduced by 69%. After injection augmentation of the paralyzed side, labial strength improved across the entire lip. Mean lip strength improved by 0.7-fold in the central lip from 5.60 to 9.30 kPa (P = .009), by 1.4-fold on the paralyzed side from 2.2 to 5.33 kPa (P = .006), and by 0.4-fold on the unaffected side from 7.11 to 9.56 kPa (P = .12). Lip strength in the 3 patients with facioscapulohumeral muscular dystrophy were uniformly reduced across the entire lip and improved by 6- to 7-fold after injection augmentation. All patients were noted by the speech pathologist to have improved articulation of plosive sounds and decreased anterior bolus spillage after the injection. CONCLUSIONS AND RELEVANCE: Labial strength is reduced across the lip in patients with unilateral facial paralysis. The Iowa Oral Performance Instrument is an effective tool for measuring labial strength and can be use to evaluate the effectiveness of facial reanimation procedures. Injection augmentation of the lip is a simple and effective means of improving labial strength, bilabial sounds, and anterior spillage in patients with facial paralysis or facial muscular dystrophy. LEVEL OF EVIDENCE: 3.

Visual targets aren't irreversibly converted to motor coordinates: eye-centered updating of visuospatial memory in online reach control.

Counter to current and widely accepted hypotheses that sensorimotor transformations involve converting target locations in spatial memory from an eye-fixed reference frame into a more stable motor-based reference frame, we show that this is not strictly the case. Eye-centered representations continue to dominate reach control even during movement execution; the eye-centered target representation persists after conversion to a motor-based frame and is continuously updated as the eyes move during reach, and is used to modify the reach plan accordingly during online control. While reaches are known to be adjusted online when targets physically shift, our results are the first to show that similar adjustments occur in response to changes in representations of remembered target locations. Specifically, we find that shifts in gaze direction, which produce predictable changes in the internal (specifically eye-centered) representation of remembered target locations also produce mid-transport changes in reach kinematics. This indicates that representations of remembered reach targets (and visuospatial memory in general) continue to be updated relative to gaze even after reach onset. Thus, online motor control is influenced dynamically by both the external and internal updating mechanisms.

When more is less: increasing allocentric visual information can switch visual-proprioceptive combination from an optimal to sub-optimal process.

When reaching for an object in the environment, the brain often has access to multiple independent estimates of that object's location. For example, if someone places their coffee cup on a table, then later they know where it is because they see it, but also because they remember how their reaching limb was oriented when they placed the cup. Intuitively, one would expect more accurate reaches if either of these estimates were improved (e.g., if a light were turned on so the cup were more visible). It is now well-established that the brain tends to combine two or more estimates about the same stimulus as a maximum-likelihood estimator (MLE), which is the best thing to do when estimates are unbiased. Even in the presence of small biases, relying on the MLE rule is still often better than choosing a single estimate. For this work, we designed a reaching task in which human subjects could integrate proprioceptive and allocentric (landmark-relative) visual information to reach for a remembered target. Even though both of these modalities contain some level of bias, we demonstrate via simulation that our subjects should use an MLE rule in preference to relying on one modality or the other in isolation. Furthermore, we show that when visual information is poor, subjects do, indeed, combine information in this way. However, when we improve the quality of visual information, subjects counter-intuitively switch to a sub-optimal strategy that occasionally includes reliance on a single modality.

Hand-related rather than goal-related source of gaze-dependent errors in memory-guided reaching.

Mechanisms for visuospatial cognition are often inferred directly from errors in behavioral reports of remembered target direction. For example, gaze-centered target representations for reach were first inferred from reach overshoots of target location relative to gaze. Here, we report evidence for the hypothesis that these gaze-dependent reach errors stem predominantly from misestimates of hand rather than target position, as was assumed in all previous studies. Subjects showed typical gaze-dependent overshoots in complete darkness, but these errors were entirely suppressed by continuous visual feedback of the finger. This manipulation could not affect target representations, so the suppressed gaze-dependent errors must have come from misestimates of hand position, likely arising in a gaze-dependent transformation of hand position signals into visual coordinates. This finding has broad implications for any task involving localization of visual targets relative to unseen limbs, in both healthy individuals and patient populations, and shows that response-related transformations cannot be ignored when deducing the sources of gaze-related errors.

Reach endpoint errors do not vary with movement path of the proprioceptive target.

Previous research has shown that reach endpoints vary with the starting position of the reaching hand and the location of the reach target in space. We examined the effect of movement direction of a proprioceptive target-hand, immediately preceding a reach, on reach endpoints to that target. Participants reached to visual, proprioceptive (left target-hand), or visual-proprioceptive targets (left target-hand illuminated for 1 s prior to reach onset) with their right hand. Six sites served as starting and final target locations (35 target movement directions in total). Reach endpoints do not vary with the movement direction of the proprioceptive target, but instead appear to be anchored to some other reference (e.g., body). We also compared reach endpoints across the single and dual modality conditions. Overall, the pattern of reaches for visual-proprioceptive targets resembled those for proprioceptive targets, while reach precision resembled those for the visual targets. We did not, however, find evidence for integration of vision and proprioception based on a maximum-likelihood estimator in these tasks.

Interactions between gaze-centered and allocentric representations of reach target location in the presence of spatial updating.

Numerous studies have investigated the phenomenon of egocentric spatial updating in gaze-centered coordinates, and some have studied the use of allocentric cues in visually-guided movement, but it is not known how these two mechanisms interact. Here, we tested whether gaze-centered and allocentric information combine at the time of viewing the target, or if the brain waits until the last possible moment. To do this, we took advantage of the well-known fact that pointing and reaching movements show gaze-centered 'retinal magnification' errors (RME) that update across saccades. During gaze fixation, we found that visual landmarks, and hence allocentric information, reduces RME for targets in the left visual hemifield but not in the right. When a saccade was made between viewing and reaching, this landmark-induced reduction in RME only depended on gaze at reach, not at encoding. Based on this finding, we argue that egocentric-allocentric combination occurs after the intervening saccade. This is consistent with previous findings in healthy and brain damaged subjects suggesting that the brain updates early spatial representations during eye movement and combines them at the time of action.

Cue reliability and a landmark stability heuristic determine relative weighting between egocentric and allocentric visual information in memory-guided reach.

It is not known how egocentric visual information (location of a target relative to the self) and allocentric visual information (location of a target relative to external landmarks) are integrated to form reach plans. Based on behavioral data from rodents and humans we hypothesized that the degree of stability in visual landmarks would influence the relative weighting. Furthermore, based on numerous cue-combination studies we hypothesized that the reach system would act like a maximum-likelihood estimator (MLE), where the reliability of both cues determines their relative weighting. To predict how these factors might interact we developed an MLE model that weighs egocentric and allocentric information based on their respective reliabilities, and also on an additional stability heuristic. We tested the predictions of this model in 10 human subjects by manipulating landmark stability and reliability (via variable amplitude vibration of the landmarks and variable amplitude gaze shifts) in three reach-to-touch tasks: an egocentric control (reaching without landmarks), an allocentric control (reaching relative to landmarks), and a cue-conflict task (involving a subtle landmark "shift" during the memory interval). Variability from all three experiments was used to derive parameters for the MLE model, which was then used to simulate egocentric-allocentric weighting in the cue-conflict experiment. As predicted by the model, landmark vibration--despite its lack of influence on pointing variability (and thus allocentric reliability) in the control experiment--had a strong influence on egocentric-allocentric weighting. A reduced model without the stability heuristic was unable to reproduce this effect. These results suggest heuristics for extrinsic cue stability are at least as important as reliability for determining cue weighting in memory-guided reaching.