Publications by authors named "Andrew Howard"

324 Publications

Patient-Proxy and Societal Perspectives of Quality-of-Life Utilities in Children With Cleft Lip and Palate Managed With Surgical Repair vs No Repair in Ethiopia.

JAMA Netw Open 2022 07 1;5(7):e2220900. Epub 2022 Jul 1.

Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada.

Importance: In Ethiopia, more than 70% of infants with cleft lip and/or palate (CL/P) lack access to surgery. Infants who are untreated can experience severe malnutrition and extreme social stigma resulting in abandonment. Utilities are standardized measures of health-related quality of life (HRQOL) that inform health care resource allocation. However, CL/P utilities are missing from low- and middle-income countries (LMICs).

Objective: To elicit utilities for untreated and surgically treated children with CL/P with consideration for social determinants of health from patient-proxy and societal participants.

Design, Setting, And Participants: This cross-sectional study used patient proxies and societal participants in Addis Ababa, Ethiopia, from July 1, 2019, to January 30, 2020. Eligible patient proxies were caregivers of children younger than 18 years with nonsyndromic CL/P who were untreated or received surgery. Proxies were necessary as most patients were 0 to 4 years old and cannot reliably self-report. Eligible societal participants were 18 years and older with no family history of CL/P.

Exposures: Surgical treatment and social determinants of health.

Main Outcomes And Measures: Participants measured utilities using the visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG).

Results: In this study, 312 patient proxies and 135 societal participants were recruited. Mean (SD) utilities for untreated CL/P ranged from 0.57 (0.23) to 0.70 (0.22) from patient proxies and from 0.35 (0.21) to 0.8 (0.23) from societal participants, depending on utility instrument and cleft type. Surgical treatment was associated with a better HRQOL from the patient-proxy perspective (VAS, 0.17; 95% CI, 0.09 to 0.26; TTO, 0.15; 95% CI, 0.05 to 0.25) from the societal perspective (VAS, 0.21; 95% CI, 0.16 to 0.26; TTO, 0.17; 95% CI, 0.13 to 0.22; SG, 0.11; 95% CI, 0.06 to 0.15). Social determinants of health that were associated with patient-proxy utilities were income above the national mean (VAS, 0.10; 95% CI, 0.02 to 0.17; TTO, 0.11; 95% CI, 0.02 to 0.20), and religion (Christian vs other: TTO, -0.10; 95% CI, -0.17 to -0.03). From the societal perspective, the association between treatment and utilities was smaller in females compared with males (TTO, -0.05; 95% CI, -0.10 to -0.01).

Conclusions And Relevance: The findings of this study suggest that CL/P disease severity and surgical impact in Ethiopia were undervalued by previous estimates from high-income countries and were associated with social determinants of health. Utility studies from participants from LMICs are feasible and necessary for representing HRQOL in LMICs and addressing health inequalities.
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http://dx.doi.org/10.1001/jamanetworkopen.2022.20900DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9284333PMC
July 2022

Multichannel photodissociation dynamics in CS studied by ultrafast electron diffraction.

Phys Chem Chem Phys 2022 Jun 29;24(25):15416-15427. Epub 2022 Jun 29.

Linac Coherent Light Source, SLAC National Accelerator Laboratory, Menlo Park, California 94025, USA.

The structural dynamics of photoexcited gas-phase carbon disulfide (CS) molecules are investigated using ultrafast electron diffraction. The dynamics were triggered by excitation of the optically bright B(Σ) state by an ultraviolet femtosecond laser pulse centred at 200 nm. In accordance with previous studies, rapid vibrational motion facilitates a combination of internal conversion and intersystem crossing to lower-lying electronic states. Photodissociation these electronic manifolds results in the production of CS fragments in the electronic ground state and dissociated singlet and triplet sulphur atoms. The structural dynamics are extracted from the experiment using a trajectory-fitting filtering approach, revealing the main characteristics of the singlet and triplet dissociation pathways. Finally, the effect of the time-resolution on the experimental signal is considered and an outlook to future experiments provided.
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http://dx.doi.org/10.1039/d2cp01268eDOI Listing
June 2022

Memory Perfectionism is Associated with Persistent Memory Complaints after Concussion.

Arch Clin Neuropsychol 2022 Apr 19. Epub 2022 Apr 19.

Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.

Objective: The etiology of persistent memory complaints after concussion is poorly understood. Memory perfectionism (highly valuing memory ability and intolerance of minor memory lapses) may help explain why some people report persistent subjective memory problems in the absence of corresponding objective memory impairment. This study investigated the relationship between memory perfectionism and persistent memory complaints after concussion.

Methods: Secondary analysis of baseline data from a randomized controlled trial. Adults (N = 77; 61% women) with persistent symptoms following concussion were recruited from outpatient specialty clinics. Participants completed the National Institutes of Health Toolbox Cognition Battery, Test of Memory Malingering-Trial 1, and questionnaires measuring memory perfectionism (Metamemory in Adulthood-Achievement subscale), forgetfulness and other postconcussion symptoms (Rivermead Postconcussion Symptoms Questionnaire; RPQ), and depression (Patient Health Questionnaire-2) at M = 17.8 weeks postinjury. Patients with versus without severe memory complaints (based on the RPQ) were compared.

Results: Memory perfectionism was associated cross-sectionally with severe memory complaint, after controlling for objective memory ability, overall cognitive ability, and depression (95% confidence interval for odds ratio = 1.11-1.40). Sensitivity analyses showed that this relationship did not depend on use of specific objective memory tests nor on inclusion of participants who failed performance validity testing. In a control comparison to test the specificity of identified relationships, memory perfectionism was not associated with severe fatigue (95% confidence interval for odds ratio = 0.91-1.07).

Conclusions: Memory perfectionism may be a risk factor for persistent memory symptoms after concussion, with potential relevance to the spectrum of functional cognitive disorders more broadly.
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http://dx.doi.org/10.1093/arclin/acac021DOI Listing
April 2022

Opioid Use in Patients With Cervical Cancer at Two Urban Medical Centers.

Adv Radiat Oncol 2022 Mar-Apr;7(2):100833. Epub 2021 Oct 20.

Department of Radiation & Cellular Oncology, University of Chicago, Chicago, Illinois.

Purpose: Patients with cervical cancer are at high risk for opioid use. This study aimed to characterize opioid prescribing patterns at 2 urban hospitals.

Methods And Materials: Data from patients with cervical cancer treated with curative intent from 2011 to 2018 were retrospectively collected. Women with unrelated chronic opioid use before diagnosis, persistent/recurrent disease at 3 months after initiation of treatment, or initiation of opioids >6 months after treatment were excluded. Demographics, disease characteristics, treatment, and outpatient prescription practices were collected. Endpoints included duration of opioid use ≥6 and ≥12 months.

Results: There were 106 women included, of whom 83% received definitive radiation. Most patients (n = 91, 85.8%) received outpatient opioids. Most common timing of prescriptions were before cancer therapy (35.9%), postprocedure (26.4%), and during radiation therapy (17.0%). Median duration was 3 (interquartile range, 1-11) months; 35.2% of these patients received opioids ≥6 months and 22% received opioids ≥12 months. Greater International Federation of Gynaecology and Obstetrics (FIGO) stage, recurrent/residual disease, initiation of opioids before treatment, history of depression or anxiety, and use of gabapentin or steroids were associated with long-term opioid use.

Conclusions: Most patients were prescribed outpatient opioids, many of whom used opioids for 12 months. Improvement in provider communication and education, increased posttreatment monitoring, and further evaluation of nonopioid therapies are needed in this patient population to reduce long-term opioid use.
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http://dx.doi.org/10.1016/j.adro.2021.100833DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8977857PMC
October 2021

Does the Skeletal Phenotype of Osteogenesis Imperfecta Differ for Patients With Non-COL1A1/2 Mutations? A Retrospective Study in 113 Patients.

J Pediatr Orthop 2022 May-Jun 01;42(5):e507-e514

Division of Orthopaedic Surgery.

Background: Osteogenesis imperfecta (OI) is a heritable disease characterized by bone fragility and other extra skeletal manifestations. Most patients with OI have mutations in the COL1A1 or COL1A2 genes. However, a significant minority of patients with clinical OI have non-COL1A1/2 mutations, which have become easier to detect with the use of genetic panels. Traditional understanding of OI pathogenesis was expanded because of these new mutations, and their phenotypic-genotypic relationship is largely unknown. We hypothesized that patients with non-COL1A1/2 mutations have different skeletal clinical presentations from those with OI caused by COL1A1/2 mutations.

Methods: Patients were categorized into 4 groups according to our modified functional classification, namely, quantitative COL1A1/2 haploinsufficiency (group 1), qualitative COL1A1/2 dominant negative mutations (group 2), mutations indirectly affecting type I collagen synthesis, processing and posttranslational modification (group 3) and mutations altering osteoblast differentiation and function (group 4). Both group 3 and 4 were classified as non-COL1A1/2 mutation group.

Results: Of 113 OI patients included, 51 had COL1A1/2 quantitative haploinsufficiency mutations (group 1), 39 had COL1A1/2 qualitative dominant negative mutations (group 2), and 23 patients had OI caused by mutations in 1 of 9 other noncollagen genes (groups 3/4). Patients with non-COL1A1/2 mutations (groups 3 and 4) have severe skeletal presentations. Specifically, OI patients with non-COL1A1/2 mutations experienced more perinatal fractures, vertebral compression fractures and had more long bone deformities. Although the occurrence of scoliosis was similar, the cobb angle was larger in the non-COL1A1/2 mutation group. Radial head dislocations, ossification of interosseous membrane, extraskeletal ossification, cervical kyphosis, and champagne glass deformity of the pelvis were more frequent in this group.

Conclusions: The clinical phenotype of OI in patients with non-COL1A1/2 is severe and has unique features. This information is useful for clinical diagnosis and prognosis.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000002116DOI Listing
April 2022

Progressive neurocognitive decline in schizophrenia: A diagnostic dilemma for clinicians.

Schizophr Res 2022 03 25;241:59-62. Epub 2022 Jan 25.

BC Neuropsychiatry Program, Departments of Psychiatry and Neurology (Medicine), Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.schres.2022.01.027DOI Listing
March 2022

Child pedestrian and cyclist injuries, and the built and social environment across Canadian cities: the Child Active Transportation Safety and the Environment Study (CHASE).

Inj Prev 2022 Aug 20;28(4):311-317. Epub 2022 Jan 20.

Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.

Introduction: Traffic injury is a leading and preventable cause of child death and disability, with child pedestrians and cyclists particularly vulnerable. Examining built environment correlates of child pedestrian and cyclist motor vehicle collisions (PCMVC) in different settings is needed to promote an evidence-based approach to road safety.

Methods: We conducted a cross-sectional study across multiple urban/suburban environments in Canada (Calgary, Toronto, Montreal, Laval, Peel Region). All public elementary schools were included (n=1030). We examined the role of land use/social environments, road environments and traffic safety interventions on the rates of child PCMVC within 1000 m of schools. Multivariable negative binomial regression was conducted for all cities and by individual city. In a subset of schools (n=389), we examined associations when controlling for active school transportation (AST).

Results: Mean PCMVC rate per school ranged from 0.13 collisions/year in Peel to 0.35 in Montreal. Child PCMVC were correlated with land use, social and road environments and traffic safety interventions. In fully adjusted models, social and land use features remained the most important correlates. New immigrant population had the largest positive association with child PCMVC (incidence rate ratio (IRR): 1.26, 95% CI 1.06 to 1.50), while old housing (pre-1960) density was most protective (IRR: 0.83, 95% CI 0.77 to 0.90). AST was associated with PCMVC, but it had no effect on the relationships between PCMVC and other social/environmental correlates.

Conclusion: The built environment and social factors influence rates of child PCMVC. Opportunities to reduce child PCMVC exist through modifications to city design and road environments and implementing traffic safety interventions.
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http://dx.doi.org/10.1136/injuryprev-2021-044459DOI Listing
August 2022

Complications of Elongating Intramedullary Rods in the Treatment of Lower Extremity Fractures for Osteogenesis Imperfecta: A Meta-Analysis of 594 Patients in 40 Years.

J Pediatr Orthop 2022 Mar;42(3):e301-e308

Division of Orthopedic Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.

Background: Osteogenesis imperfecta is a collagen mutation-related disease characterized by bone fragility and other extraskeletal manifestations. Intramedullary fixation for deformity correction or fracture is the standard care. Elongating rods are designed to accommodate growth, with the aim of preventing additional operations and/or complications associated with nonelongating rods. Although elongating rods have been in use for many years, estimates of the clinical outcomes vary. We conducted a systematic review and meta-analysis to synthesize the literature on outcomes of elongating rods and nonelongating rods. Meta-analysis was used to compare the complication rates and reoperation rates.

Methods: We conducted the literature search, systematic review, and meta-analysis in accordance with Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. Comparative cohort studies and large case series detailing complication rates and reoperation rates of elongating and nonelongating rods were included. Random effect models were used to summarize the complication rates and reoperation rates of intramedullary rod procedures.

Results: A total of 397 studies were identified and 24 studies were included in the final cohort. Compared with rates from nonelongating rods, osteogenesis imperfecta Patients using elongating rods had a complication rate of 61% and a reoperation rate of 78%. Reoperation rates dropped with succeeding generations of elongating rods. Pooling data from 600 patients, we identified a 9% complication rate per rod per follow up year and 5% reoperation rate per rod and per follow up year in the cohort of elongating rod fixation. The Bailey-Dubow rod had the highest complication rate per rod per follow up year (12%), largely because of its T piece relate problems. The most popular fixator Fassier-Duval rod had a complication rate per rod per follow up year of 9%. About 68% of complications were mechanical-biological related.

Conclusion: Pooling data from published literature demonstrates the advantage of elongating rods over nonelongating rods. However, as high as 9% complication rate per rod per follow up year was associated with elongating fixation. Notably, most complications are both mechanical and biological related.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000002040DOI Listing
March 2022

Pilot study to evaluate school safety zone built environment interventions.

Inj Prev 2022 06 30;28(3):243-248. Epub 2021 Aug 30.

Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.

Background: School safety zones were created in 2017 under the City of Toronto's Vision Zero Road Safety Plan. This pilot study examined the effect of built environment interventions on driver speeds, active school transportation (AST) and dangerous driving.

Methods: Interventions were implemented at 34 schools and 45 matched controls (2017-2019). Drivers travelling over the speed limit of >30 km/hour and 85th percentile speeds were measured using pneumatic speed tubes at school frontages. Observers examined AST and dangerous driving at school arrival times. Repeated measures beta and multiple regression analyses were used to study the intervention effects.

Results: Most schools had posted speed limits of 40 km/hour (58%) or ≥50 km/hour (23%). A decrease in drivers travelling over the speed limit was observed at intervention schools post-intervention (from 44% to 40%; OR 0.79, 95% CI 0.66 to 0.96). Seventy-one per cent of drivers travelled >30 km/hour and the 85th percentile speed was 47 km/hour at intervention schools, with no change in either postintervention. There were no changes in speed metrics in the controls. AST increased by 5% (OR 1.22, 95% CI 0.97 to 1.54) at intervention schools. Reductions in dangerous driving were observed at all schools.

Conclusions: Posted speed limits were >30 km/hour at most schools and high proportions of drivers were travelling above the speed limits. There were reductions in drivers exceeding the speed limit and in dangerous driving, and modest increased AST post intervention. Bolder interventions to slow traffic are required to effectively reduce speeding around schools, which may increase safe AST.
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http://dx.doi.org/10.1136/injuryprev-2021-044299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9132849PMC
June 2022

Local Control and Use of External Beam Parametrial Boost in the Era of Image-Guided Brachytherapy for Locally Advanced Cervical Cancer.

Am J Clin Oncol 2021 11;44(11):565-571

Radiation and Cellular Oncology, University of Chicago.

Objective: Historically, external beam parametrial boost (EBPB) has been used in locally advanced cervical cancers to supplement radiation dose. However, it has become controversial in the era of image-guided brachytherapy. Modern 3D imaging and brachytherapy techniques have improved delineation and coverage of tumor. Outcomes with and without parametrial boost were analyzed.

Methods: Women with cervical cancer involving the parametria (clinically or radiographically) diagnosed between 2001 and 2017 were identified. Clinicopathologic and treatment features, survival and patterns of failure data were collected. Univariate and multivariable data analysis was performed to evaluate association of these variables, including parametrial boost, with local failure-free survival and overall survival. Competing risks analysis was performed for cumulative incidence of local failure, with death and other failures treated as competing events.

Results: A total of 100 women were identified (median follow-up 26.8 mo). Forty-one (41%) received EBPB; these patients were less likely to have received magnetic resonance imaging, positron emission tomography, interstitial, or high-dose rate brachytherapy. Magnetic resonance imaging, positron emission tomography, dose rate, and treatment era were highly correlated (Cramer's V: 0.43 to 0.68, P<0.01). Two-year overall survival and local failure were 78% and 12% for the entire cohort. While the use of EBPB was not associated with any outcome on multivariable analysis, treatment year after 2009 was highly associated with improved outcomes in all models.

Conclusions: In this study, omission of EBPB did not compromise local control or survival in the modern era, supporting a decreased need for standardized use of parametrial boost.
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http://dx.doi.org/10.1097/COC.0000000000000863DOI Listing
November 2021

Multi-Particle Three-Dimensional Covariance Imaging: "Coincidence" Insights into the Many-Body Fragmentation of Strong-Field Ionized DO.

J Phys Chem Lett 2021 Sep 24;12(34):8302-8308. Epub 2021 Aug 24.

Stanford PULSE Institute, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, United States.

We demonstrate the applicability of covariance analysis to three-dimensional velocity-map imaging experiments using a fast time stamping detector. Studying the photofragmentation of strong-field doubly ionized DO molecules, we show that combining high count rate measurements with covariance analysis yields the same level of information typically limited to the "gold standard" of true, low count rate coincidence experiments, when averaging over a large ensemble of photofragmentation events. This increases the effective data acquisition rate by approximately 2 orders of magnitude, enabling a new class of experimental studies. This is illustrated through an investigation into the dependence of three-body DO dissociation on the intensity of the ionizing laser, revealing mechanistic insights into the nuclear dynamics driven during the laser pulse. The experimental methodology laid out, with its drastic reduction in acquisition time, is expected to be of great benefit to future photofragment imaging studies.
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http://dx.doi.org/10.1021/acs.jpclett.1c02481DOI Listing
September 2021

The effectiveness of booster seat use in motor vehicle collisions.

Accid Anal Prev 2021 Sep 17;159:106296. Epub 2021 Jul 17.

Department of Paediatrics, University of Calgary, Calgary, Canada; Department of Community Health Sciences, University Calgary, Calgary, Canada; Sports Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.

Background: Alberta remains the only province in Canada without booster seat legislation. To date, analyses of booster seat effectiveness compared with seatbelt only use have demonstrated mixed findings using observational data.

Methods: This study uses Alberta police collision report data for the years 2010-2016, inclusive. Using a case-control study design, children aged four to eight years, who were reported by police to be injured (cases), were compared with uninjured controls for restraint use (seatbelt, booster seat or no restraint). Logistic regression was used to estimate the relation between booster seat use and injury with adjusted odds ratios (aORs) and 95% confidence intervals (CI), stratified by collision types.

Results: There were 12,922 children involved in collisions, of whom 570 were injured. Approximately 62% of all children included in the analysis were in a booster seat or safety seat at the time of collision. Crude analysis indicates higher odds of injury for seatbelt wearers compared with booster seat use (OR = 1.21; 95% CI: 1.02-1.44). Front-end vehicle-vehicle collisions, demonstrated higher odds of injury for seatbelt wearers relative to those in booster seats (aOR = 1.46; 95% CI: 1.03-2.07).

Conclusion: This analysis indicates a protective effect of booster seats that varies depending on the type of collision and impact location. These regionally-specific injury data may encourage and inform policy on the use of booster seats. Moreover, stratification by collision type may be necessary to inform analyses on booster seat effectiveness.
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http://dx.doi.org/10.1016/j.aap.2021.106296DOI Listing
September 2021

Factors affecting management of children's low-risk distal radius fractures in the emergency department: a population-based retrospective cohort study.

CMAJ Open 2021 Apr-Jun;9(2):E659-E666. Epub 2021 Jun 15.

Division of Orthopaedic Surgery (Baxter), Faculty of Medicine, University of Toronto; Child Health Evaluative Sciences (To), The Hospital for Sick Children; ICES (Chiu); Division of Epidemiology (Chiu), University of Toronto; Department of Surgery (Camp), The Hospital for Sick Children; Division of Orthopaedics (Howard), Department of Surgery, The Hospital for Sick Children, Toronto, Ont.

Background: Ten randomized controlled trials over the last 2 decades support treating low-risk pediatric distal radius fractures with removable immobilization and without physician follow-up. We aimed to determine the proportion of these fractures being treated without physician follow-up and to determine whether different hospital and physician types are treating these injuries differently.

Methods: We conducted a retrospective population-based cohort study using ICES data. We included children aged 2-14 years (2-12 yr for girls and 2-14 yr for boys) with distal radius fractures having had no reduction or operation within a 6-week period, and who received treatment in Ontario emergency departments from 2003 to 2015. Proportions of patients receiving orthopedic, primary care and no follow-up were determined. Multivariable log-binomial regression was used to quantify associations between hospital and physician type and management.

Results: We analyzed 70 801 fractures. A total of 20.8% ( = 14 742) fractures were treated without physician follow-up, with the proportion of physician follow-up consistent across all years of the study. Treatment in a small hospital emergency department (risk ratio [RR] 1.86, 95% confidence interval [CI] 1.72-2.01), treatment by a pediatrician (RR 1.22, 95% CI 1.11-1.34) or treatment by a subspecialty pediatric emergency medicine-trained physician (RR 1.73, 95% CI 1.56-1.92) were most likely to result in no follow-up.

Interpretation: While small hospital emergency departments, pediatricians and pediatric emergency medicine specialists were most likely to manage low-risk distal radius fractures without follow-up, the majority of these fractures in Ontario were not managed according to the latest research evidence. Canadian guidelines are required to improve care of these fractures and to reduce the substantial overutilization of physician resources we observed.
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http://dx.doi.org/10.9778/cmajo.20200116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248581PMC
August 2021

Identifying modifiable factors related to novice adolescent driver fault in motor vehicle collisions.

Traffic Inj Prev 2021 7;22(6):437-442. Epub 2021 Jun 7.

Department of Paediatrics, University of Calgary, Calgary, Canada.

Objective: Novice adolescent drivers have a higher propensity to engage in risky driving and are at higher odds of being involved in collisions. Graduated driver licensing programs have been instituted to help novice drivers gain experience while avoiding higher risk driving circumstances. This study examines modifiable risk factors contributing to novice adolescent driver fault in collisions.

Methods: Police traffic collision report data from municipalities in Alberta for the years 2010-2016, inclusive, were used. Fault in collision was assigned using an automated and previously validated tool for assigning culpability. Factors contributing to novice adolescent (16-19 years of age) fault in collision were examined using multivariable logistic regression.

Results: Novice adolescent drivers had higher adjusted odds ratios (aOR) of being at-fault in collision when driving from 01:00-05:00 (aOR = 1.38; 95% Confidence Interval [CI]: 1.26-1.50). Novice adolescent drivers had lower odds of fault when driving with an adult (aOR= 0.62; 95% CI: 0.57-0.68) or a single peer (aOR= 0.87; 95% CI: 0.80-0.94), but higher odds of causing a severe collision with a single peer present (aOR= 2.23; 95% CI: 1.21-4.11). Impairment of the teen driver was reported in 25% of all fatal collisions, and 40% of late-night fatal collisions.

Conclusions: The findings support policies that allow driving with a single adult or peer passenger during daytime hours. Driving during late-night hours should be restricted for novice adolescent drivers.
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http://dx.doi.org/10.1080/15389588.2021.1923700DOI Listing
August 2021

Diagnostic utility of next-generation sequence genetic panel testing in children presenting with a clinically significant fracture history.

Arch Osteoporos 2021 06 5;16(1):88. Epub 2021 Jun 5.

Division of Orthopedics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.

We assessed the diagnostic utility of genetic panel testing to detect pathogenic variants associated with osteogenesis imperfecta in children presenting with multiple fractures. Thirty-five percent of children had a pathogenic variant. A history of a femur fracture or a first fracture occurring under 2 years of age were significant clinical predictors.

Purpose: The use of next-generation sequencing (NGS) genetic panels offers a comprehensive rapid diagnostic test to evaluate for pathogenic variants in the expanding list of genes associated with osteogenesis imperfecta (OI). We aimed to assess the diagnostic utility of this method in children with a clinically significant fracture history.

Methods: NGS panel testing was performed in 87 children presenting with multiple long bone or vertebral fractures. Subjects with a known family history of OI were excluded. Associations between genetic findings and clinical characteristics were analyzed in a retrospective observational study.

Results: Thirty-five percent of patients were found to have a disease-causing variant, with a higher detection rate in those patients with extra-skeletal features of OI (94 vs. 20%, p < 0.001). In subjects with extra-skeletal clinical OI features, 69% were found to have pathogenic variants in COL1A1 or COL1A2. In children without extra-skeletal features, 14 of 70 (20%) had pathogenic variants, of which 7 were variants in type 1 collagen, and the remaining 7 variants were associated with osteoblast function or signaling (PLS3, SP7, LRP5). Clinical predictors for detecting a disease-causing variant included a history of having a first fracture that occurred under 2 years of age (Odds ratio 5.5, 95%CI 1.8, 16.9) and a history of a femur fracture (Odds ratio 3.3, 95%CI 1.0, 11.1).

Conclusion: NGS panel testing will detect causative pathogenic variants in up to a third of children with a clinically significant fracture history, particularly where there is a history of early femur fracture.
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http://dx.doi.org/10.1007/s11657-021-00943-4DOI Listing
June 2021

Implications of the End-Stage Renal Disease Treatment Choices Model among U.S. Dialysis Providers.

Nephrol Nurs J 2021 Jan-Feb;48(1):11-17

Executive Director, Quality Insights.

The End Stage Renal Disease Treatment Choices (ETC) Model is a mandatory payment model designed to encourage greater use of home dialysis and kidney transplantation among Medicare beneficiaries with kidney failure and to reduce Medicare expenditures while enhancing the quality of care offered to patients with kidney failure. The ETC model will run for six years, from January 1, 2021, to June 30, 2027. This article provides an overview of the ETC Model and analyzes its implications for dialysis providers.
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March 2021

Supracondylar Humerus Fractures in Older Children: Success of Closed Reduction and Percutaneous Pinning.

J Pediatr Orthop 2021 Apr;41(4):242-248

Division of Pediatric Orthopaedics.

Background: The incidence of supracondylar humerus (SCH) fracture declines and fracture types change as children grow. Optimal treatment method is unclear in older children. The aim of the study was to determine if fracture type and configuration of distal humerus fractures changes as patients approach skeletal maturity, and to assess the success of closed reduction and percutaneous pin (CRPP) in extra-articular SCH fractures in this transitional age group.

Methods: Inclusion criteria for this retrospective review were (1) distal humerus fractures with extension types 2 and 3, flexion type, T-type; (2) surgically managed, and (3) modified Sauvegrain score ≥1. Reviewed parameters included fracture type and configuration, grade of skeletal maturity, fixation technique, and loss of reduction. Primary analysis was to determine the distribution of fracture type and configuration with age or grade of skeletal maturity. Secondary analysis was used to determine the factors affecting treatment success of CRPP in extra-articular fractures.

Results: A total of 142 patients were included (58 males and 84 females). Fracture types revealed significant changes with increased age (P=0.031) and skeletal maturity grade (P<0.005). Skeletal maturity was a better predictor of changing fracture type than chronological age. T-type fractures were only seen in patients with modified Sauvegrain score ≥6 and flexion-type fractures were only seen in patients with modified Sauvegrain score ≤4. Loss of reduction rate after CRPP was 5%. The success of CRPP was not affected by age, sex, modified Sauvegrain score, fracture type, direction of displacement, coronal fracture pattern, number of pins or medial pin use. Fracture obliquity in the sagittal plane (P=0.05), suboptimal pin spread (P<0.01), and lack of bicolumnar fixation (P<0.01) were found as statistically significant factors associated with failed CRPP.

Conclusion: The distribution of fracture type changed with increased age and skeletal maturity. CRPP of extra-articular fractures in older children is a reliable option regardless of the stage of skeletal maturity. Determinants of a good outcome include optimal pinning technique with adequate pin spread at the fracture site and bicolumnar fixation.

Level Of Evidence: Level IV-retrospective case series.
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http://dx.doi.org/10.1097/BPO.0000000000001732DOI Listing
April 2021

Active school transportation and the built environment across Canadian cities: Findings from the child active transportation safety and the environment (CHASE) study.

Prev Med 2021 05 24;146:106470. Epub 2021 Feb 24.

Faculty of Health Sciences, Simon Fraser University, 8888 University Dr, Burnaby, BC V5A 1S6, Canada.

Walking and bicycling to school (active school transportation, AST) has been in decline for decades in North America and globally with the rise of automobility. This cross-sectional study estimated associations between the built environment and AST in seven Canadian communities. We observed the travel behaviours of almost 118,000 students at 552 schools. Using beta regression, we modeled the proportion of children using AST, considering built environment and social environment factors around schools. Across all schools, the average proportion of children using AST was 54.3% (SD 18.9%), with variability among cities from a low of 39.5% (SD 22.1%) in Laval, Quebec to 69.7% (SD 18.1%) in Montreal, Quebec. Overall, several modifiable road design features were associated with AST, including the presence of school crossing guards, cycling infrastructure, Walk Score® and traffic signal density. There was variability in the directionality and statistical significance of associations with design variables across cities, suggesting that the local context and directed local interventions are important to support AST. Natural experiment studies are necessary to examine local approaches related to the built environment to increase AST and ensure appropriate new policy and program interventions are developed.
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http://dx.doi.org/10.1016/j.ypmed.2021.106470DOI Listing
May 2021

Home Management Versus Primary Care Physician Follow-up of Patients With Distal Radius Buckle Fractures: A Randomized Controlled Trial.

Ann Emerg Med 2021 02 21;77(2):163-173. Epub 2020 Oct 21.

Division of Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada. Electronic address:

Study Objective: In patients with a distal radius buckle fracture, we determine whether home removal of a splint and physician follow-up as needed (home management) is noninferior to primary care physician follow-up in 1 to 2 weeks with respect to functional recovery. We also compare groups with respect to health care and patient-level costs.

Methods: This was a noninferiority randomized controlled trial conducted at a tertiary care children's hospital. Eligible patients were randomized to home management versus primary care physician follow-up and received telephone contact at 3 and 6 weeks after the index ED visit. Functional recovery was measured with the Activities Scale for Kids-performance, and participants reported wrist-injury-related health care interventions and expenses. The primary outcome was a comparison of the performance score between groups at 3 weeks.

Results: We enrolled 149 patients with mean age 9.5 years (SD 2.7 years), and 81 (54.4%) were male patients. Of the 133 patients (89.3%) with completed 3-week follow-up, the mean Activities Scale for Kids-performance score was 95.4% in the home management group (n=66) and 95.9% in the primary care physician follow-up group (n=67) (mean difference -0.4%; lower bound of the 95% confidence interval -2.4%). There was a mean costs savings of -$100.10 (95% confidence interval -$130.0 to -$70.20) in health care and -$28.2 (95% confidence interval -$49.6 to -$7.0) in patient costs in the home management versus primary care physician follow-up group.

Conclusion: In patients with distal radius buckle fractures, home management is at least as good as primary care physician follow-up with respect to functional recovery. Implementation of the home management strategy also demonstrated significant cost savings.
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http://dx.doi.org/10.1016/j.annemergmed.2020.07.039DOI Listing
February 2021

Methodological considerations in MVC epidemiological research.

Inj Prev 2021 04 16;27(2):155-160. Epub 2020 Nov 16.

Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.

Background: The global burden of MVC injuries and deaths among vulnerable road users, has led to the implementation of prevention programmes and policies at the local and national level. MVC epidemiological research is key to quantifying MVC burden, identifying risk factors and evaluating interventions. There are, however, several methodological considerations in MVC epidemiological research.

Methods: This manuscript collates and describes methodological considerations in MVC epidemiological research, using examples drawn from published studies, with a focus on the vulnerable road user population of children and adolescents.

Results: Methodological considerations in MVC epidemiological research include the availability and quality of data to measure counts and calculate event rates and challenges in evaluation related to study design, measurement and statistical analysis. Recommendations include innovative data collection (eg, naturalistic design, stepped-wedge clinical trials), combining data sources for a more comprehensive representation of collision events, and the use of machine learning/artificial intelligence for large data sets.

Conclusions: MVC epidemiological research can be challenging at all levels: data capture and quality, study design, measurement and analysis. Addressing these challenges using innovative data collection and analysis methods is required.
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http://dx.doi.org/10.1136/injuryprev-2020-043987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005794PMC
April 2021

State-of-the-art review: preventing child and youth pedestrian motor vehicle collisions: critical issues and future directions.

Inj Prev 2021 02 4;27(1):77-84. Epub 2020 Nov 4.

School of Occupational and Public Health, Ryerson University, Toronto, Ontario, Canada.

Aim: To undertake a comprehensive review of the best available evidence related to risk factors for child pedestrian motor vehicle collision (PMVC), as well as identification of established and emerging prevention strategies.

Methods: Articles on risk factors were identified through a search of English language publications listed in Medline, Embase, Transport, SafetyLit, Web of Science, CINHAL, Scopus and PsycINFO within the last 30 years (~1989 onwards).

Results: This state-of-the-art review uses the road safety Safe System approach as a new lens to examine three risk factor domains affecting child pedestrian safety (built environment, drivers and vehicles) and four cross-cutting critical issues (reliable collision and exposure data, evaluation of interventions, evidence-based policy and intersectoral collaboration).

Conclusions: Research conducted over the past 30 years has reported extensively on child PMVC risk factors. The challenge facing us now is how to move these findings into action and intervene to reduce the child PMVC injury and fatality rates worldwide.
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http://dx.doi.org/10.1136/injuryprev-2020-043829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848053PMC
February 2021

Tibial tuberosity ossification predicts reoperation for growth disturbance in distal femoral physeal fractures.

J Child Orthop 2020 Aug;14(4):299-303

The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose: Distal femoral physeal fractures (DFPF) can cause growth disturbance that requires further surgical intervention. The aim of this study is to determine if Tibial Tuberosity Ossification Stage (TTOS) at the time of injury predicts secondary surgery for growth disturbance in patients who have sustained a DFPF.

Methods: We retrospectively investigated all patients who had operative treatment for a DFPF at a single centre over a 17-year period. Regression analysis was performed investigating associations between secondary surgery to treat growth disturbance and TTOS, age, Salter-Harris fracture classification type, mode of fixation or mechanism of injury.

Results: In all, 85 consecutive patients were identified. A total of 74 met the inclusion criteria. The mean age at time of injury was 13.1 years (2.0 to 17.1). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with the need for further surgery (p < 0.001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis (compared with not fused) were 0.12 (95% confidence interval (CI) 0.04 to 0.34). The estimate of the effect of TTOS on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter-Harris type. When accounting for age, the odds of any further operation if the tibial tuberosity is fused to the metaphysis (compared with not fused) were 0.28 (95% CI 0.08 to 0.94).

Conclusion: TTOS at the time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures.

Level Of Evidence: Diagnostic Level II.
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http://dx.doi.org/10.1302/1863-2548.14.190073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453177PMC
August 2020

Appalachian Regional Commission Recovery Ecosystem Background and Overview.

J Appalach Health 2020 19;2(3):10-13. Epub 2020 Jul 19.

Chief of Staff, Federal Co-Chair, Appalachian Regional Commission.

The Appalachian Regional Commission (ARC) has long addressed issues of substance abuse through funded community-based interventions, research, and sponsored conferences. Recently, the opioid crisis created a new urgency for cross-sector collaboration among various partners and funders dealing with this issue. This commentary provides an overview of recent efforts by the ARC to convene stakeholders to focus on assisting individuals with substance abuse disorder to access recovery services while pursuing education and training necessary to reenter the workforce and gain employment. Two papers have been prepared to describe this year-long effort. One paper focuses on the participatory methods used to gather ideas and turn them into regional intervention programs. The second paper describes and analyzes the wealth of ideas collected through the process. Both are intended to inform policymakers, researchers, and local leaders in ways to strengthen the substance abuse recovery ecosystem in their own communities.
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http://dx.doi.org/10.13023/jah.0203.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9138749PMC
July 2020

A planet within the debris disk around the pre-main-sequence star AU Microscopii.

Nature 2020 06 24;582(7813):497-500. Epub 2020 Jun 24.

University Corporation for Atmospheric Research, Boulder, CO, USA.

AU Microscopii (AU Mic) is the second closest pre-main-sequence star, at a distance of 9.79 parsecs and with an age of 22 million years. AU Mic possesses a relatively rare and spatially resolved edge-on debris disk extending from about 35 to 210 astronomical units from the star, and with clumps exhibiting non-Keplerian motion. Detection of newly formed planets around such a star is challenged by the presence of spots, plage, flares and other manifestations of magnetic 'activity' on the star. Here we report observations of a planet transiting AU Mic. The transiting planet, AU Mic b, has an orbital period of 8.46 days, an orbital distance of 0.07 astronomical units, a radius of 0.4 Jupiter radii, and a mass of less than 0.18 Jupiter masses at 3σ confidence. Our observations of a planet co-existing with a debris disk offer the opportunity to test the predictions of current models of planet formation and evolution.
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http://dx.doi.org/10.1038/s41586-020-2400-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323865PMC
June 2020

Very regular high-frequency pulsation modes in young intermediate-mass stars.

Nature 2020 05 13;581(7807):147-151. Epub 2020 May 13.

Stellar Astrophysics Centre, Department of Physics and Astronomy, Aarhus University, Aarhus, Denmark.

Asteroseismology probes the internal structures of stars by using their natural pulsation frequencies. It relies on identifying sequences of pulsation modes that can be compared with theoretical models, which has been done successfully for many classes of pulsators, including low-mass solar-type stars, red giants, high-mass stars and white dwarfs. However, a large group of pulsating stars of intermediate mass-the so-called δ Scuti stars-have rich pulsation spectra for which systematic mode identification has not hitherto been possible. This arises because only a seemingly random subset of possible modes are excited and because rapid rotation tends to spoil regular patterns. Here we report the detection of remarkably regular sequences of high-frequency pulsation modes in 60 intermediate-mass main-sequence stars, which enables definitive mode identification. The space motions of some of these stars indicate that they are members of known associations of young stars, as confirmed by modelling of their pulsation spectra.
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http://dx.doi.org/10.1038/s41586-020-2226-8DOI Listing
May 2020

Somatic Symptom Disorder, Medically Unexplained Symptoms, Somatoform Disorders, Functional Neurological Disorder: How 5 Got It Wrong.

Can J Psychiatry 2020 05 19;65(5):301-305. Epub 2020 Mar 19.

UBC Neuropsychiatry Program, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1177/0706743720912858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265612PMC
May 2020

Atypical Somatic Symptoms in Adults With Prolonged Recovery From Mild Traumatic Brain Injury.

Front Neurol 2020 4;11:43. Epub 2020 Feb 4.

Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.

Somatization may contribute to persistent symptoms after mild traumatic brain injury (mTBI). In two independently-recruited study samples, we characterized the extent to which symptoms atypical of mTBI but typical for patients suffering from somatization (e.g., gastrointestinal upset, musculoskeletal, and cardiorespiratory complaints) were present in adult patients with prolonged recovery following mTBI. The first sample was cross-sectional and consisted of mTBI patients recruited from the community who reported ongoing symptoms attributable to a previous mTBI ( = 16) along with a healthy control group ( = 15). The second sample consisted of patients with mTBI prospectively recruited from a Level 1 trauma center who had either good recovery (GOSE = 8; = 32) or poor recovery (GOSE < 8; = 29). In all participants, we evaluated atypical somatic symptoms using the Patient Health Questionnaire-15 and typical post-concussion symptoms with the Rivermead Post-Concussion Symptom Questionnaire. Participants with poor recovery from mTBI had significantly higher "atypical" somatic symptoms as compared to the healthy control group in Sample 1 ( = 4.308, < 0.001) and to mTBI patients with good recovery in Sample 2 ( = 3.169, < 0.001). As would be expected, participants with poor outcome in Sample 2 had a higher burden of typical rather than atypical symptoms [ = 4.750, < 0.001, = 0.88]. However, participants with poor recovery still reported atypical somatic symptoms that were significantly higher (1.4 standard deviations, on average) than those with good recovery. Our results suggest that although "typical" post-concussion symptoms predominate after mTBI, a broad range of somatic symptoms also frequently accompanies mTBI, and that somatization may represent an important, modifiable factor in mTBI recovery.
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http://dx.doi.org/10.3389/fneur.2020.00043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7010927PMC
February 2020

Effect of reducing the posted speed limit to 30 km per hour on pedestrian motor vehicle collisions in Toronto, Canada - a quasi experimental, pre-post study.

BMC Public Health 2020 Feb 10;20(1):56. Epub 2020 Feb 10.

Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.

Background: Pedestrian related deaths have recently been on the rise in Canada. The effect of changing posted speeds on the frequency and severity of pedestrian motor vehicle collisions (PMVC) is not well studied using controlled quasi-experimental designs. The objective of this study was to examine the effect of lowering speed limits from 40 km/h to 30 km/h on PMVC on local roads in Toronto, Canada.

Methods: A 30 km/h speed limit on local roads in Toronto was implemented between January 2015 and December 2016. Streets that remained at a 40 km/h speed limit throughout the study period were selected as comparators. A quasi-experimental, pre-post study with a comparator group was used to evaluate the effect of the intervention on PMVC rates before and after the speed limit change using repeated measures Poisson regression. PMVC data were obtained from police reports for a minimum of two years pre- and post-intervention (2013 to 2018).

Results: Speed limit reductions from 40 km/h to 30 km/h were associated with a 28% decrease in the PMVC incidence rate in the City of Toronto (IRR = 0.72, 95% CI: 0.58-0.89). A non-significant 7% decrease in PMVC incidence rates were observed on comparator streets that remained at 40 km/h speed limits (IRR = 0.93, 95% CI: 0.70-1.25). Speed limit reduction also influenced injury severity, with a significant 67% decrease in major and fatal injuries in the post intervention period on streets with speed limit reductions (IRR = 0.33, 95% CI: 0.13-0.85) compared with a 31% not statistically significant decrease in major and fatal injuries on comparator streets (IRR = 0.69, 95% CI: 0.37-1.31). The interaction term for group and pre-post comparisons was not statistically significant (p = 0.14) indicating that there was no evidence to suggest a pre-post difference in IRRs between the intervention and comparator streets.

Conclusions: Declines in the rate of PMVC were observed on roads with posted speed limit reductions from 40 km/h to 30 km/h, although this effect was not statistically greater than reductions on comparator streets.
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http://dx.doi.org/10.1186/s12889-019-8139-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008529PMC
February 2020

Cyclist-motor vehicle collisions before and after implementation of cycle tracks in Toronto, Canada.

Accid Anal Prev 2020 Feb 27;135:105360. Epub 2019 Nov 27.

Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, 686 Bay Street, Toronto, M5G 0A4, Canada.

Background: Cycling, as a mode of active transportation, has numerous health and societal benefits, but carries risks of injury when performed on-road with vehicles. Cycle tracks are dedicated lanes with a physical separation or barrier between bicycles and motor vehicles. Studies on the effectiveness of cycle tracks in urban areas in North America, as well as the area-wide effects of cycle tracks are limited.

Aims: Study objectives were to examine the effect of cycle track implementation on cyclist-motor vehicle collisions (CMVC) occurring: (1) on streets treated with new cycle tracks; (2) on streets surrounding new cycle tracks in Toronto, Canada.

Methods: Intervention and outcome data were obtained from the City of Toronto. All police-reported CMVC from 2000 to 2016 were mapped. Analyses were restricted to 2 years pre- and 2 years post-track implementation. Rates were calculated for CMVC on streets with cycle tracks (objective 1) and in five defined areas surrounding cycle tracks (objective 2). Zero-Inflated Poisson regression was used to compare changes to CMVC rates before and after cycle track implementation for both objectives. All models controlled for season of collision and cycle track.

Results: The majority of CMVC on cycle tracks occurred at intersections (75%). The crude CMVC rate increased two-fold after cycle track implementation (IRR = 2.06, 95% CI: 1.51-2.81); however, after accounting for the increase in cycling volumes post-implementation, there was a 38% reduction in the CMVC rate per cyclist-month (IRR = 0.62, 95% CI: 0.44-0.89). On streets between 151 m - 550 m from cycle tracks, there was a significant 35% reduction in CMVC rates per km-month following track implementation (IRR = 0.65, 95% CI: 0.54-0.76).

Conclusions: Cycle track implementation was associated with increased safety for cyclists on cycle tracks, after adjusting for cycling volume. In addition, there was a significant reduction in CMVC on streets surrounding cycle tracks between 151 m - 550 m distance from the tracks (a 'safety halo' effect), suggesting an area-wide safety effect of cycle track implementation.
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http://dx.doi.org/10.1016/j.aap.2019.105360DOI Listing
February 2020
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