20-year mortality after discharge in a cohort of 1,099 former trauma inpatients with and without substance use disorders.

INTRODUCTION: Psychoactive substance use disorders (SUDs) are common in trauma patients and substance use has become a leading cause of death in the United States. The purpose of this study is to examine the impact of a lifetime SUD and SUD characteristics (substance used, current SUD versus in remission from dependence, etc.) on the long-term survival of trauma patients. METHODS: Cohort study of consecutive adult trauma inpatients who were discharged alive from a level-one trauma center (1994-1996). The presence of lifetime SUD was determined at the time of admission by the Structured Clinical Interview for the Diagnostic and Statistical Manual III-R. Mortality follow-up through the end of 2017 was obtained by linking patients to a national database of death certificates. Cox proportional hazards analysis was used to determine the association of lifetime SUD and death after adjusting for age and tobacco use. RESULTS: 1,220 patients were approached, 1,118 consented to participate, and 1,099 had personal identifiers for matching. 789 (71.8%) of subjects were men, 596 (54.2%) had lifetime SUDs, and 325 (29.6%) died. Injury was the most common cause of death (24.6%, 80/325), with poisonings (40.0%, 32/80) being the most common injury-related cause of death. Compared to those without a lifetime SUD, lifetime SUD was associated with increased all-cause mortality (adjusted hazard ratio [HRadj]=1.83; 95% CI, 1.4 to 2.4), injury death (HRadj=2.47; 95% CI: 1.4 to 4.2), and fatal opioid overdose (HRadj=12.96; 95% CI, 1.7 to 100.4)(p ≤ 0.01 for all HRadj). CONCLUSIONS: The presence of a lifetime SUD was associated with early death, particularly from reinjury, in trauma patients. It is important to address a patient's SUD during admission to decrease their chances of dying after discharge, especially due to injury-related causes.

Social Support Moderates the Negative Association Between Reduced Driving and Life Satisfaction in Older Adults.

When older adults reduce their driving, there can be subsequent decreases in life satisfaction. In this cross-sectional study, we used baseline data from the multi-site Longitudinal Research on Aging Drivers (LongROAD) study to examine whether social support moderates the negative association between reduced driving and life satisfaction. The outcome variable was life satisfaction, and the main predictor variable was past-year reduced driving (yes/no). Emotional, instrumental, and informational social support were measured using PROMIS v2.0 (Patient-Reported Outcomes Measurement Information System) items. We used generalized linear regression models to examine how social support moderated the association between reduced driving and life satisfaction. Statistical adjustment for social support attenuated the negative effect of reduced driving on life satisfaction by ~10% for all three types of social support.

Resistance towards nondepolarising muscle relaxants: prolonged onset time: A systematic review.

BACKGROUND: Nondepolarising muscle relaxants (NDMRs) provide optimal conditions for tracheal intubation and improve surgical conditions. Several clinical conditions, diseases and pharmacological interactions have been suggested to cause resistance towards NDMRs that may translate into difficult intubation or inadequate operating conditions during surgery. OBJECTIVE: The aim of this study was to evaluate the current evidence of patient groups with resistance towards NDMRs. A prolonged onset time was defined as a difference that exceeded 25% compared with controls. DESIGN: A systematic review of randomised controlled trials and cohort studies. DATA SOURCES: A comprehensive search was performed in 2016 in PubMed and EMBASE. ELIGIBILITY CRITERIA: Patients with conditions or diseases, or patients taking medication, which lead to resistance towards current NDMRs (rocuronium, vecuronium, cisatracurium, atracurium, mivacurium and pancuronium). Included outcomes were onset time defined as the time between administration of NDMR to maximal (90, 95 or 100%) depression of baseline twitch height of the first twitch in a train-of-four. RESULTS: Twenty-five studies were included. Strong evidence supports a prolonged onset time of rocuronium in patients with thermal injury and Duchenne muscular dystrophy. Moderate evidence supports a prolonged onset time of NDMRs during hypothermia and in patients with infection, oculopharyngeal muscular dystrophy, liver cirrhosis treated with ulinastatin, when remifentanil is administered prior to administration of an NDMR, in fasting patients being rehydrated intravenously prior to administration of NDMR, in children with end-stage renal failure and in patients with atrial or ventricular septal defects. CONCLUSION: A prolonged onset time should be suspected in patients with thermal injury and Duchenne's muscular dystrophy. Further, evidence supports a prolonged onset time in patients with infection, oculopharyngeal muscular dystrophy, congenital heart defects, kidney failure, liver cirrhosis treated with ulinastatin along with remifentanil or intravenous fluids administered prior to NDMR.

Reversal of mivacurium-induced neuromuscular blockade with a cholinesterase inhibitor: A systematic review.

BACKGROUND: Mivacurium is a short-acting non-depolarizing muscle relaxant, which is hydrolyzed by butyrylcholinesterase. The neuromuscular block (NMB) can be antagonized with cholinesterase inhibitors (CHEI), but the short duration of action of mivacurium questions the need. This systematic review evaluated if the use of CHEIs (neostigmine, pyridostigmine or edrophonium) facilitates reversal of mivacurium-induced NMB. METHOD: Randomized controlled trials and crossover-studies comparing spontaneous recovery with CHEI reversal in patients with mivacurium-induced NMB, assessed with quantitative neuromuscular monitoring, were included. Mean time from injection of the CHEI or allowing of spontaneous recovery to an endpoint representing full recovery was used as outcome. First response to train-of-four nerve stimulation (T1 ) described the level of NMB for administration of the CHEI. Moderate NMB refers to T1  ≥ 5% and deeper NMB refers to T1  < 5%. Systematic critical appraisal was performed using the Scottish Intercollegiate Guidelines Network guidelines. Overall quality assessment was done using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Sixteen studies with data from 546 patients were included. Low quality of evidence was found that neostigmine and edrophonium administered at moderate NMB accelerated recovery with up to approximately 5.5-6.5 and 6.5-9.0 minutes, respectively. At deeper NMB only edrophonium accelerated recovery. The effect of neostigmine was not clarified at deeper mivacurium-induced NMB. No studies with reversal by pyridostigmine were identified. CONCLUSION: Low quality of evidence supports that neostigmine and edrophonium accelerate the recovery of mivacurium-induced NMB with 5-6.5 and 6-9.0 minutes respectively, when administered at moderate NMB. At deeper NMB only edrophonium accelerated the recovery.

Test characteristics of a drug CAGE questionnaire for the detection of non-alcohol substance use disorders in trauma inpatients.

BACKGROUND: Non-alcohol substance use disorders (drug use disorders [DUDs]) are common in trauma patients. OBJECTIVE: To determine the test characteristics of a 4-item drug CAGE questionnaire to detect DUDs in a cohort of adult trauma inpatients. METHODS: Observational cross-sectional cohort of 1,115 adult patients admitted directly to a level-one trauma center between September, 1994 and November, 1996. All participants underwent both a 4-item drug CAGE questionnaire and the substance use disorder section of a structured psychiatric diagnostic clinical interview (SCID) (DSM-IIIR criteria), administered by staff unaware of their clinical status. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), positive (LR+) and negative likelihood ratios (LR-), and the area under the receiver operating curve (AUC) were calculated for each individual question and the overall questionnaire, using SCID-generated DUD diagnoses as the standard. Performance characteristics of the screen were also compared across selected sociodemographic, injury mechanism, and diagnostic sub-groups. RESULTS: Subjects with DUDs were common (n = 349, 31.3%), including cannabis (n = 203, 18.2%), cocaine (n = 199, 17.8%), and opioids (n = 156, 14.0%). The screen performed well overall (AUC = 0.90, 95% CI: 0.88-0.91) and across subgroups based on age, sex, race, marriage status, income, education, employment status, mechanism of injury, and current/past DUD status (AUCs 0.75-1.00). Answering any one question in the affirmative had a sensitivity = 83.4% (95% CI: 79.1-87.1), specificity = 92.3% (95% CI: 90.2-94.1), PPV = 83.1%, LR+ = 10.8. CONCLUSIONS: The 4-item drug CAGE and its individual questions had good-to-excellent ability to detect DUDs in this adult trauma inpatient population, suggesting its usefulness as a screening tool.

Deep neuromuscular blockade and surgical conditions during laparoscopic ventral hernia repair: A randomised, blinded study.

BACKGROUND: Laparoscopic ventral hernia repair is a common surgical procedure. However, muscle contractions and general muscle tension may impair the surgical view and cause difficulties suturing the hernial defect. Deep neuromuscular blockade (NMB) paralyses the abdominal wall muscles and may help to create better surgical conditions. OBJECTIVES: The current study investigated if deep compared with no NMB improved the surgical view during laparoscopic ventral hernia repair. DESIGN: Crossover study. SETTING: The study was carried out at Herlev and Gentofte Hospital, University of Copenhagen, Denmark and conducted from May 2015 until February 2017. PARTICIPANTS: A total of 34 patients were randomised in an investigator-initiated, assessor-blinded crossover design of deep vs. no NMB during laparoscopic ventral hernia repair. INCLUSION CRITERIA: Adults scheduled for elective laparoscopic ventral hernia repair. EXCLUSION CRITERIA: Known allergy to any study medication, known homozygous variants in the butyrylcholinesterase gene, severe renal disease, neuromuscular disease, lactating or pregnant women, any indication for rapid sequence induction. INTERVENTIONS: Deep NMB was established with rocuronium and reversed with sugammadex. Anaesthesia was conducted with propofol and remifentanil. MAIN OUTCOME MEASURES: The primary outcome was evaluation of surgical view assessed on a five-point rating scale. Other outcomes included the surgical conditions during laparoscopic suturing of the hernia defect. RESULTS: We found no difference in ratings for the surgical view when comparing deep with no NMB: mean -0.1 (95% confidence interval -0.4 to 0.2) (P = 0.521, paired t test). However, deep compared with no NMB improved the rating score for surgical conditions while suturing the hernia defect (P = 0.012, Mann-Whitney U test). No differences were found in either total length of surgery (P = 0.76) or hernia suturing time (P = 0.81). CONCLUSION: Deep compared with no NMB did not change the rating score of the surgical view immediately after introduction of trocars during laparoscopic ventral hernia repair, but the surgical condition were improved during suturing of the hernia. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02247466.

Regulating drivers with epilepsy in Maryland: Results of the application of a United States consensus guideline.

OBJECTIVE: Driving regulations for people with seizures vary widely throughout the United States and the world. Maryland updated their guidelines in 2003 to reflect those of a U.S. consensus guideline requiring a minimum 3-month seizure-free period as well as an individual risk assessment by a Medical Advisory Board (MAB). This retrospective study provides the first analysis of outcomes after the implementation of the consensus guidelines and an assessment of their predictive validity through longitudinal outcome data. METHODS: MAB reviews and licensing records for Maryland driver applicants with seizures between 2004 and 2005 were reviewed, during which 254 first-time applicants were processed. The initial licensing decisions were assessed and the subsequent seizure recurrence and crash rates over the following 7 years were evaluated. RESULTS: The MAB approved driving for 74.8% of initial applicants; most had been seizure-free for over 6 months. Approved drivers had a longer median seizure-free period (563 days) compared to those who were denied (104.5 days, p < 0.01), and 22.7% of approved drivers had seizures recur during monitoring over the next year, although none resulted in crashes or deaths. Of applicants initially denied (n = 50), 89.3% were eventually licensed. Treating physicians recommended driving for 84.4% of applicants rejected by the MAB. SIGNIFICANCE: Maryland's individualized system for assessing driving applicants with seizures resulted in a dynamic process of approvals and denials based on favorable and unfavorable risk factors and lengths of seizure freedom. Seizure recurrences were comparable to internationally accepted rates. Over the course of monitoring, most applicants were eventually licensed. Treating physicians recommended that nearly all their patient applicants be permitted to drive, which raises safety concerns for the 10 states that rely solely on physician recommendations. Further assessment is needed of the risk factors deemed favorable and unfavorable by the U.S. consensus guidelines.

Loop Diuretics Diminish Hemolysis Induced by α-Hemolysin from Escherichia coli.

Uropathogenic Escherichia coli often produce the virulence factor α-hemolysin (HlyA), and the more severe the infection, the likelier it is to isolate HlyA-producing E. coli from patients. HlyA forms pores upon receptor-independent insertion of the toxin into biological membranes and it has been substantiated that HlyA-induced hemolysis is amplified by toxin-induced ATP release and activation of P2X receptors. Thus, hemolysis inflicted by HlyA is a protracted process involving signal transduction. It consists of early, marked cell shrinkage followed by swelling and eventually lysis. The initially shrinkage is a consequence of a substantial Ca2+-influx and activation of Ca2+-sensitive K+ and Cl- channels (KCa3.1/TMEM16A). The shrinkage is followed by gradual cell swelling, which ultimately lyses the cells. These findings clearly show that the HlyA pore provides a substantial volume challenge for the cells, and the fate of the given cell is co-determined by intrinsic erythrocytal volume regulation. We therefore speculated that other mechanisms involved in erythrocyte volume regulation may influence the hemolytic process inflicted by HlyA. Strikingly, HlyA-induced hemolysis is markedly reduced in erythrocytes isolated from NKCC1-deficient (NKCC1-/-) mice compared to controls. The NKCC1 inhibitors furosemide and bumetanide concentration-dependently inhibit HlyA-induced lysis of human and murine erythrocytes. However, in high concentrations bumetanide further reduced hemolysis in erythrocytes from NKCC1-/- mice and, thus, also exhibit indirect effects on hemolysis. The effect of loop diuretics on the hemolysis is not unique to HlyA but is similarly seen in LtxA- and α-toxin-induced hemolysis. Bumetanide clearly potentiates HlyA-induced volume reduction and delays the following erythrocyte swelling. This allows increased phagocytosis of damaged erythrocytes by THP-1 cell as a result of prolonged cell shrinkage. These data suggest that erythrocyte susceptibility to cytolysins is modified by NKCC1 and signifies intrinsic volume regulators as important determinants of cellular outcome of pore-forming toxins.

Leukotoxin from Aggregatibacter actinomycetemcomitans causes shrinkage and P2X receptor-dependent lysis of human erythrocytes.

Leukotoxin (LtxA) is a virulence factor secreted by the bacterium Aggregatibacter actinomycetemcomitans, which can cause localized aggressive periodontitis and endocarditis. LtxA belongs to the repeat-in-toxin (RTX) family of exotoxins of which other members inflict lysis by formation of membrane pores. Recently, we documented that the haemolytic process induced by another RTX toxin [α-haemolysin (HlyA) from Escherichia coli] requires P2X receptor activation and consists of sequential cell shrinkage and swelling. In contrast, the cellular and molecular mechanisms of LtxA-mediated haemolysis are not fully understood. Here, we investigate the effect of LtxA on erythrocyte volume and whether P2 receptors also play a part in LtxA-mediated haemolysis. We observed that LtxA initially decreases the cell size, followed by a gradual rise in volume until the cell finally lyses. Moreover, LtxA triggers phosphatidylserine (PS) exposure in the erythrocyte membrane and both the shrinkage and the PS-exposure is preceded by increments in the intracellular Ca(2+) concentration ([Ca(2+)](i)). Interestingly, LtxA-mediated haemolysis is significantly potentiated by ATP release and P2X receptor activation in human erythrocytes. Furthermore, the LtxA-induced [Ca(2+)](i) increase and following volume changes partially depend on P2 receptor activation. Theseobservations imply that intervention against local P2-mediated auto- and paracrine signalling may prevent LtxA-mediated cell damage.

Impulsive or depressive personality traits do not impede behavioral change after brief alcohol interventions.

The authors investigated whether impulsivity and depression affect the success of interventions to reduce alcohol use. Unadjusted and adjusted regression models were constructed to analyze the effect of impulsivity and depression on 12-month outcomes of participants of a trauma center based randomized trial of brief personalized motivational interventions versus information and advice. Of 497 problem drinkers enrolled in the program, 248 completed the 12-month follow-up. Impulsivity, male gender, being older than 35, and intentional mechanism of injury had a direct association with drinking. After interventions, a decrease in drinking was found that was unaffected by the presence of impulsivity or depression indicators.

Pursuit of Licensure by Senior Drivers Referred by Police to a State Licensing Agency's Medical Advisory Board.

In all fifty United States and the District of Columbia, police Requests for Re-examination (RRE) concerning fitness to driver are accepted by licensing agencies. This study assessed licensing outcomes of senior drivers, ≥75 years of age, who had RREs submitted to the Medical Advisory Board (MAB) of a Maryland Motor Vehicle Administration from March 2005 through April 2007. RRE traffic event information (including crashed, did not crash), driver demographic information, initial MAB recommendations (suspension vs no suspension), driving occupational therapists assessments, and drivers' pursuit of continued licensure were entered into a database. During the period of study, 475 RREs were referred to the MAB. The percent of referred senior drivers (n=240, 50.4%) was similar to that of younger drivers (n=235, 49.5%). A higher percentage of senior drivers retired from driving compared to younger drivers; being, 57.1% vs 23.8% (p <.01), respectively. Further analyses limited to the 240 senior drivers found: 139 (57.9%) were men, 150 (62.5%) were 75-84 years of age, 119 (49.5%) were noted to be disoriented at the traffic scene, 141 (58.8%) were involved in a crash, and 127 (52.9%) were initially suspended as the result of MAB review. The following factors were significantly related to retiring from driving, initial MAB suspension and greater age. Of the 127 drivers who were initially suspended, 82 (64.6%) retired from driving, and 45 (35.4%) pursued further licensure (p <0.01). In contrast, the percentage of non-suspended drivers who did or did not pursue further licensure was similar; being 48.7% vs 51.3%. Among drivers ≥85 years of age, 68.9% retired from driving, compared with 50% of the drivers who were 75 to 84 years of age (p <0.01) While not statisically significant, higher percentages of driving retirement were noted for the following: sex - a greater percentage of men compared to women (61.9% vs 49.5%); confusion at the traffic scene (confused, 57.1% vs non-confused, 42.9%); and crash involvement (56.7% who crashed, retired vs 43.3% of those who did not crash, retired). Overall, the most important finding of this study is that as a result of police referral, only one-fifth (20.4%) of senior drivers 75 years of age or older, continued to maintain their driving privilege. However, only 40 drivers (16.7%) retained their original driving privilege without added restrictions. The data suggest that senior drivers who are not medically fit to drive may be identified by police referrals to a licensing agency. Driving occupational therapy assessments and training, and additional driving restrictions are recommended to facilitate continuation of the driving privilege for some drivers.

Suicides, homicides, and unintentional injury deaths after trauma center discharge: cocaine use as a risk factor.

BACKGROUND: : To study whether trauma center patients with positive toxicology findings for cocaine-positive (COC+) are at a higher risk for suicide, homicide, and unintentional injury death after discharge than cocaine-negative (COC+) trauma patients. METHODS: : Patients admitted between July 1983 and June 1995 and discharged alive from a level I trauma center were prospectively followed up for 1.5 years to 14.5 years. The occurrence of suicide, homicide, and unintentional injury death was explored in relation to COC+ status at admission using Cox proportional hazards methodology. Models included possible confounders. Interactions with each of the main effects were explored. RESULTS: : Of the 27,399 admissions, 21,500 had urine COC toxicology testing performed and were included in the study. COC was positive in 11.4% of the studied population. COC+ patients were significantly younger, with 72% of COC+ versus 43% of COC- in the 25 to 44 years age group. COC+ patients were more likely to be men, positive for alcohol, and intentional injury victims. COC+ status was not associated with subsequent suicide. Furthermore, the COC+ status association with subsequent homicide became nonsignificant after adjusting for confounders. Unadjusted COC+ status was associated with unintentional injury death (odds ratio = 1.65 [1.14-2.40]). Interactions were found in the association with unintentional injury death such that COC+ status tripled the odds of injury death (odds ratio = 2.75 [1.58-4.78]) among the alcohol-negative patients within the 25 to 45 years age group. CONCLUSION: : COC+ trauma patients are at an increased risk of subsequent unintentional injury death after discharge from a trauma center. Suicide and homicide occurrence seems to be unaffected.

Police referral of drivers to the Maryland Motor Vehicle Administration's Medical Advisory Board.

In the 50 United States and the District of Columbia law enforcement medical referrals are accepted by licensing agencies. This study assessed driving actions, medical concerns, and medical conditions in 486 police referrals to the Medical Advisory Board of the Maryland Motor Vehicle Administration during a 25-month period. Driving actions, medical concerns, and medical conditions were grouped into categories and entered into a database. These elements were analyzed relative to driver age and sex. In addition, the issuance of citations for driving violations was studied relative to age and sex. A greater percentage of drivers 60 years of age or greater (senior adults) were referred compared to the general population of licensed drivers that age, being 71.4% vs 20.6% (p <0.01). Crashing, the most common driving action, was not associated with age or sex. Among driving actions frequently mentioned relative to older drivers, only confusion of pedals was associated with senior adults drivers as compared to younger drivers (6.1% vs 0.1%, p <0.01). Of the most frequently mentioned medical concerns, confusion/disorientation was associated with being a senior adult (p <0.01), while loss of consciousness was associated with younger drivers (p <0.01). The most frequently mentioned medical conditions, diabetes and seizure, were associated with being under 60 years of age. All mentions of dementia were in senior adult drivers. Compared with younger drivers, drivers 60 years of age or older, were less often summoned for driving violations, being 33.0% vs 53.5% (p <0.01), respectively. The threshold for the issuance of fewer citations was lower for men (40 to 59 years of age) compared to women (60 years of age or greater). Studies are needed to correlate specific traffic violations and/or crashes to specific medical conditions.

Applying research to licensing agency screening of seniors for fitness to drive.

The aging process is associated with medical conditions that can negatively affect medical fitness to drive. Traditional licensing agency methods to identify at-risk drivers have significant limitations. These include testing of visual acuity and driving tests. Recently, methods have been developed to allow for screening for cognitive decline in older drivers. This article highlights deficiencies in traditional licensing practices to screen for at-risk senior drivers. It also addresses the possible use of newer screening techniques and procedures. Application of these new methods to overcome deficiencies in traditional license screening practices to identify at-risk drivers is discussed, along with the implications for gerontology and geriatrics education.

Adult correlates of early behavioral maladjustment: a study of injured drivers.

OBJECTIVE: To establish whether a history of school suspension (HSS) predicts adult driver behavior. METHODS: 323 injured drivers were interviewed as part of a study of psychoactive substance use disorders (PSUD) and injury. Drivers with a HSS were compared to those without HSS in relation to demographics, SES, PSUD, risky behaviors, trauma history and driving history using student's t test and chi-square. Multiple logistic regression models were constructed to adjust for demographics, SES and PSUD. RESULTS: HSS drivers represented 31% of the population and were younger, more likely to be male and had higher rates of alcohol and drug dependence than drivers without HSS. Educational achievement was worse for drivers with HSS. Drivers with HSS were more likely to have a history of prior vehicular trauma and assault. Seat-belt non-use, drinking and driving, riding with drunk driver, binge drinking, driving fast for the thrill, license suspension and drinking and driving convictions were more common among drivers with HSS. In multiple logistic regression models adjusting for demographics and SES, HSS revealed higher odds ratios for the same outcomes. After adding PSUD to the models HSS remained significant only for seat belt non use, binge drinking and previous assault history. CONCLUSION: HSS is associated with risky behaviors, repeated vehicular injury, and poor driver history. The association with driver history, however, disappears when PSUD are included in the models. The association of HSS (a marker of early behavioral maladjustment) with behavioral risks suggests that undiagnosed psychopathology may be linked to injury recidivism.

School suspensions, injury-prone behaviors, and injury history.

PURPOSE: To investigate the association of history of school suspension (HSS) to risky behaviors and injury history. METHODS: Adult patients admitted to a Level I trauma center (n = 774) were assessed for demographics, socioeconomic status, educational history, risky behaviors (infrequent seat belt use, drinking and driving, binge drinking, and speeding for a thrill), substance abuse disorders, and prior injury history. Student's t test and chi statistics were used to compare subjects with and without a HSS in relation to risky behaviors and injury history (alpha = 0.05). Logistic regression models were constructed with each risky behavior and injury history as the outcome adjusting for demographics, socioeconomic status, and substance abuse disorders. RESULTS: Patients with HSS (n = 260) were significantly younger, more likely to be male, not married, low income, Black, unemployed, smokers, and alcohol and drug dependent than patients without such history (n = 514). They had higher rates of binge drinking (66% vs. 33%), infrequent seat belt use (50% vs. 26%), drinking and driving (24% vs. 12%), and driving fast for a thrill (21% vs. 8%). Similarly, they had more frequent previous history of vehicular injuries (44% vs. 31%) and assaults (36% vs. 16%). Multivariate models revealed school suspension to be associated with infrequent seat belt use (Odds ratio [OR] = 2.02 [1.44-2.83]), binge drinking (OR = 1.95 [1.25-3.04]), speeding for a thrill (OR = 1.83 [1.15-2.92]), prior vehicular injuries (OR = 1.46 [1.06-2.02]), and assaults (OR = 1.67 [1.13-2.47]). CONCLUSION: HSS is associated with risky behaviors, and history of prior vehicular crashes and assaults.

Medical review of fitness to drive in older drivers: the Maryland experience.

BACKGROUND: Over the next several decades, both the number and percentage of older drivers will increase dramatically. Older age is inherently associated with medical conditions, particularly those involving cognition and vision, that can affect medical fitness to drive. Over a 60-year period, the Maryland Motor Vehicle Administration (MVA) in conjunction with its medical advisory board (MAB) has matured a comprehensive system to identify at-risk older drivers and to assess their medical fitness to drive. METHODS: This paper describes the medical review process in general, and in particular for older drivers, that has evolved in the state of Maryland. The resources, philosophy and research underpinnings of its MAB review process are examined. RESULTS: Studies of functional screening measures in older drivers indicate that older drivers at risk of being at-fault for future crashes can be identified. The feasibility of using such screening measures for drivers referred to the MVA has been confirmed by practical use for a period of seven years. CONCLUSIONS: It is possible to create a medical review process with a goal of "safe mobility for life" that supports preservation of the driving privilege among many older drivers.

Alcohol use and testing among older trauma victims in Maryland.

BACKGROUND: Few studies have examined alcohol use in the older trauma population. The purpose of the present study was to examine blood alcohol level testing and results among older trauma patients. METHODS: All patients aged 65 years or older directly admitted from the injury scene and entered into the Maryland Trauma Registry during a 6-year period were reviewed. RESULTS: The annual proportion of directly admitted patients of age 65 or older increased by 44% from 1996 to 2000. Blood alcohol concentration (BAC) was measured for 66% of older patients; 9% were alcohol positive, and 81% had BAC > or = 80 mg/dL. Mean BAC was 165 mg/dL for all alcohol-positive patients. The highest mean BAC was noted in patients with fall-related injuries, followed by pedestrians struck, then by those in a motor vehicle crash. The most common cause of injury was motor vehicle crash (47%). Among all injury causes, patients with fall-related injuries had the greatest proportional increase from 28% in 1996 to 44% in 2000. Alcohol positive status was most frequent (13%) and mean BAC was highest among patients admitted because of fall-related injuries. CONCLUSION: Identifying and addressing alcohol use problems remains an important injury prevention measure for the older trauma population.

Smoking is a marker of risky behaviors independent of substance abuse in injured drivers.

OBJECTIVE: Smoking has been linked to disease and injury. The purpose of this study is to investigate the smoking habits of motor vehicular driver trauma center patients and their association with previous injury history and risky behaviors. METHODS: The studied population included 323 motor vehicular driver injury patients (123 smokers and 200 non-smokers) interviewed as part of a larger study of psychoactive substance use disorders at an adult Level I trauma center. Patients with head injuries, hospital stays of less than two days, and diminished cognition were excluded. Interviews included demographics (age, gender, race, marital status), socioeconomic status (SES; income, education, employment), risky behaviors (seatbelt non-use, drinking and driving, riding with drunk driver, binge drinking), and trauma history information (vehicular, assault, and other injuries). Substance abuse (alcohol and drug dependence) was evaluated in depth using DSM III-R criteria. Smokers and non-smokers were compared in relation to control and dependent variables using student's t test and chi-square (alpha = 0.05). Outcome variables included previous trauma history and risky behaviors. Multiple logistic regression models using step-down selection methods (alpha = 0.05) were constructed with risky behaviors and trauma history as dependent variables including demographics, SES and substance as independent variables. RESULTS: Smokers represented 38 percent of the 323 patients studied. Smokers (n = 123) were younger (34 vs. 43 years), more likely to be male (72 percent vs. 50 percent), not married (72 percent vs. 56 percent), and had higher rates of alcohol (29 percent vs. 9 percent) and drug dependence (14 percent vs. 3 percent) than non-smokers (n = 200). Educational achievement (20 percent vs. 15 percent less than high school) and income level (24 percent vs. 23 percent with less than $15,000 of yearly income) were not different between smokers and non-smokers. Smokers were more likely than non-smokers to have a history of prior vehicular trauma (48 percent vs. 26 percent), assault (25 percent vs. 9 percent), or other injury (50 percent vs 37 percent). The following injury-prone behaviors were also more common among the smokers than non-smokers: seatbelt non-use (49 percent vs. 29 percent), drinking and driving (38 percent vs. 15 percent), riding with drunk driver (38 percent vs. 13 percent), and binge drinking (68 percent vs. 26 percent). In multiple logistic regression models adjusting for demographics, SES, and substance abuse, smoking revealed significantly higher odds ratios (OR) for the following dependent variables: seatbelt non-use (OR = 2.9), riding with drunk driver (OR = 2.2), binge drinking (OR = 2.4), previous vehicular (OR = 2.0), and assault injuries (OR = 2.5). Smoking did not reach significance for drinking and driving and other (non-vehicular and non-assault) injury. CONCLUSION: Smoking is independently associated with risky behaviors and repeated history of vehicular or assault injury within the vehicular trauma population.