Publications by authors named "Jeffrey R Brubacher"

57 Publications

Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis.

J Gen Intern Med 2021 May 4. Epub 2021 May 4.

Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada.

Background: In 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge.

Objective: To examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions.

Design: Interrupted time series analysis of population-based hospitalization data.

Participants: Individuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017.

Main Measures: The proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy.

Key Results: A total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval.

Conclusion: The introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere.

Trial Registration: ClinicalTrials.gov ID, NCT03256734.
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http://dx.doi.org/10.1007/s11606-021-06803-8DOI Listing
May 2021

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

Lancet Public Health 2021 Jun 20;6(6):e374-e385. Epub 2021 Apr 20.

Department of Ophthalmology, Medicine and Pharmacology, The University of British Columbia, Vancouver, BC, Canada.

Background: Many medications impair driving skills yet their influence on collision risk remains uncertain. We aimed to systematically investigate the risk of collision responsibility associated with common classes of prescription medications.

Methods: In this population-based case-control study we analysed linked driving and health records in British Columbia, Canada from Jan 1, 1997, to Dec 31, 2016. The study cohort included all drivers involved in an incident collision (defined as first collision after 3 collision-free years) that resulted in a police report. We scored police collision reports and classified drivers as responsible for the collision (cases) or not responsible (controls); drivers with indeterminate scores were excluded. We used logistic regression to determine odds of collision responsibility in drivers with current prescriptions for medications of interest versus drivers without prescriptions. To explore whether risk of collision responsibility was related to medication effect or driver factors, we compared risk in current medication users versus past users. To study whether drivers developed tolerance to medication effects, we compared risk in new (first 30 days of a prescription) versus established users.

Findings: During the study period, 4 906 925 drivers had their driving licence linked to health records; of these drivers, 747 662 unique drivers were involved in 837 919 incident collisions between Jan 1, 2000, and Dec 31, 2016. 382 685 drivers responsible for the collision (cases) and 332 259 drivers not responsible (controls) were included in the final analysis; 122 975 drivers with indeterminate responsibility were excluded. We found increased risk of collision responsibility in drivers prescribed sedating antipsychotics (adjusted odds ratio [aOR] 1·35 [98·75% CI 1·25-1·46]), long-acting benzodiazepines (aOR 1·30 [1·22-1·38]), short-acting benzodiazepines (aOR 1·25 [1·20-1·31]), and high-potency opioids (aOR 1·24 [1·17-1·30]). Among medications used for medical indications, the highest risk was seen in drivers prescribed neurological medications: cholinergic drugs (aOR 1·83 [1·39-2·40]), anticholinergic agents for Parkinson's disease (aOR 1·45 [1·08-1·96]), dopaminergic agents (aOR 1·20 [1·04-1·38]), and anticonvulsants (aOR 1·20 [1·14-1·26]). People currently taking benzodiazepines, non-sedating antidepressants, high-potency opioids, and anticonvulsants had increased risk compared with past users, and we did not find increased risk in new compared with established users of these drugs.

Interpretation: Drivers prescribed benzodiazepines or high-potency opioids are at increased risk of being responsible for collisions and this risk does not decrease over time. Several other classes of medications are associated with increased risk, but this association might be independent of medication effect. These findings can guide medication warnings and prescription choices and inform public education campaigns targeting impaired driving.

Funding: Canadian Institutes of Health Research.
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http://dx.doi.org/10.1016/S2468-2667(21)00027-XDOI Listing
June 2021

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

CJEM 2021 Apr 1. Epub 2021 Apr 1.

Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.

Objective: Social assistance helps fulfill the basic needs of low-income individuals. In British Columbia, social assistance is issued on the third or fourth Wednesday of every month. However, this sudden influx of resources may have negative health consequences. We investigated social assistance timing and emergency department (ED) visits related to trauma, mental health, and substance use.

Methods: We conducted a retrospective multi-centre observational study using 12 years of regional ED data from Vancouver, British Columbia (2008-2020). Each cheque week (the week following social assistance disbursement) was matched to a single control week (2 weeks prior to cheque week). We compared the number of ED visits for trauma, mental health, and substance use during cheque weeks versus control weeks.

Results: There were 253,360 visits during all weeks of interest. Cheque week was associated with significantly more ED visits for mental health and substance-related presentations (RR 1.07, 95% CI 1.03-1.11, p = 0.0006). These visits increased significantly for both males and females and for adults aged 17-64 years. Mental health and substance-related visits increased on the day of cheque disbursement (Wednesday) and the 4 days following (Thursday-Sunday). Trauma-related ED visits were elevated on the day of cheque disbursement, but not during other days of the week.

Conclusions: Social assistance disbursement is followed by an increase in mental health and substance-related ED presentations and may be associated with an increase in trauma presentations on the day of cheque disbursement. These findings support calls for clinical and policy-level changes and support to reduce cheque day-associated harm.
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http://dx.doi.org/10.1007/s43678-021-00115-wDOI Listing
April 2021

Duration of Neurocognitive Impairment With Medical Cannabis Use: A Scoping Review.

Front Psychiatry 2021 12;12:638962. Epub 2021 Mar 12.

Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.

While the recreational use of cannabis has well-established dose-dependent effects on neurocognitive and psychomotor functioning, there is little consensus on the degree and duration of impairment typically seen with medical marijuana use. Compared to recreational cannabis users, medical cannabis patients have distinct characteristics that may modify the presence and extent of impairment. The goal of this review was to determine the duration of acute neurocognitive impairment associated with medical cannabis use, and to identify differences between medical cannabis patients and recreational users. These findings are used to gain insight on how medical professionals can best advise medical cannabis patients with regards to automobile driving or safety-sensitive tasks at work. A systematic electronic search for English language randomized controlled trials (RCTs), clinical trials and systematic reviews (in order to capture any potentially missed RCTs) between 2000 and 2019 was conducted through Ovid MEDLINE and EMBASE electronic databases using MeSH terms. Articles were limited to medical cannabis patients using cannabis for chronic non-cancer pain or spasticity. After screening titles and abstracts, 37 relevant studies were subjected to full-text review. Overall, seven controlled trials met the inclusion/exclusion criteria and were included in the qualitative synthesis: six RCTs and one observational clinical trial. Neurocognitive testing varied significantly between all studies, including the specific tests administered and the timing of assessments post-cannabis consumption. In general, cognitive performance declined mostly in a THC dose-dependent manner, with steady resolution of impairment in the hours following THC administration. Doses of THC were lower than those typically reported in recreational cannabis studies. In all the studies, there was no difference between any of the THC groups and placebo on any neurocognitive measure after 4 h of recovery. Variability in the dose-dependent relationship raises the consideration that there are other important factors contributing to the duration of neurocognitive impairment besides the dose of THC ingested. These modifiable and non-modifiable factors are individually discussed.
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http://dx.doi.org/10.3389/fpsyt.2021.638962DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006301PMC
March 2021

Injury patterns and circumstances associated with electric scooter collisions: a scoping review.

Inj Prev 2021 Mar 11. Epub 2021 Mar 11.

Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada

Background: Electric scooters are personal mobility devices that have risen in popularity worldwide since 2017. Emerging reports suggest that both riders and other road users, such as pedestrians and cyclists, have been injured in electric scooter-associated incidents. We undertook a scoping review of the current literature to evaluate the injury patterns and circumstances of electric scooter-associated injuries.

Methods: A scoping review of literature published from 2010 to 2020 was undertaken following accepted guidelines. Relevant articles were identified in Medline, Embase, SafetyLit and Transport Research International Documentation using terms related to electric scooters, injuries and incident circumstances. Supplemental searches were conducted to identify relevant grey literature (non-peer-reviewed reports).

Results: Twenty-eight peer-reviewed studies and nine grey literature records were included in the review. The current literature surrounding electric scooter-associated injuries mainly comprises retrospective case series reporting clinical variables. Factors relating to injury circumstances are inconsistently reported. Findings suggest that the head, upper extremities and lower extremities are particularly vulnerable in electric scooter falls or collisions, while injuries to the chest and abdomen are less common. Injury severity was inconsistently reported, but most reported injuries were minor. Low rates of helmet use among electric scooter users were noted in several studies.

Conclusion: Electric scooters leave riders vulnerable to traumatic injuries of varying severity. Future work should prospectively collect standardised data that include information on the context of the injury event and key clinical variables. Research on interventions to prevent electric scooter injuries is also needed to address this growing area of concern.
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http://dx.doi.org/10.1136/injuryprev-2020-044085DOI Listing
March 2021

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

Inj Prev 2021 Jan 13. Epub 2021 Jan 13.

Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada.

Background: Opioids increase the risk of traffic crash by limiting coordination, slowing reflexes, impairing concentration and producing drowsiness. The epidemiology of prescription opioid use among drivers remains uncertain. We aimed to examine population-based trends and geographical variation in drivers' prescription opioid consumption.

Methods: We linked 20 years of province-wide driving records to comprehensive population-based prescription data for all drivers in British Columbia (Canada). We calculated age- and sex-standardised rates of prescription opioid consumption. We assessed temporal trends using segmented linear regression and examined regional variation in prescription opioid use using maps and graphical techniques.

Results: A total of 46 million opioid prescriptions were filled by 3.0 million licensed drivers between 1997 and 2016. In 2016 alone, 14.7% of all drivers filled at least one opioid prescription. Prescription opioid use increased from 238 morphine milligram equivalents per driver year (MMEs/DY) in 1997 to a peak of 834 MMEs/DY in 2011. Increases in MMEs/DY were greatest for higher potency and long-acting prescription opioids. The interquartile range of prescription opioid dispensation by geographical region increased from 97 (Q1=220, Q3=317) to 416 (Q1=591, Q3=1007) MMEs/DY over the study interval.

Implications: Patterns of prescription opioid consumption among drivers demonstrate substantial temporal and geographical variation, suggesting they may be modified by clinical and policy interventions. Interventions to curtail use of potentially impairing prescription medications might prevent impaired driving.
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http://dx.doi.org/10.1136/injuryprev-2020-043989DOI Listing
January 2021

Authors' reply to Comment on Comparison of rates of opioid withdrawal symptoms and reversal of opioid toxicity in patients treated with two naloxone dosing regimens.

Clin Toxicol (Phila) 2021 01 20;59(1):80-81. Epub 2020 Nov 20.

Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.

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http://dx.doi.org/10.1080/15563650.2020.1846744DOI Listing
January 2021

"Residual blood THC levels in frequent cannabis users after over four hours of abstinence: A systematic review."

Drug Alcohol Depend 2020 11 10;216:108177. Epub 2020 Jul 10.

The University of British Columbia, Faculty of Medicine, Department of Emergency Medicine, VGH Research Pavilion, Room 281 - 828 W 10th Ave, Vancouver, BC V5Z 1M9, Canada. Electronic address:

Background: Tetrahydrocannabinol (THC), the primary psychoactive component of cannabis, causes psychomotor impairment and puts drivers at increased risk of motor vehicle collisions. Many jurisdictions have per se limits for THC, often 2 or 5 ng/mL, that make it illegal to drive with THC above the "legal limit". People who use cannabis regularly develop partial tolerance to some of its impairing effects. Regular cannabis users may also have persistent elevation of THC even after a period of abstinence. Some stakeholders worry that current per se limits may criminalize unimpaired drivers simply because they use cannabis. We conducted a systematic review of published literature to investigate residual blood THC concentrations in frequent cannabis users after a period of abstinence.

Methods: We identified relevant articles by combining terms for "cannabis" and "blood" and "concentration" and "abstinence" and searching MEDLINE, EMBASE, PsycINFO, and Web of Science. We included studies that reported THC levels in frequent cannabis users after more than 4 h of abstinence.

Results: Our search identified 1612 articles of which 8 met our inclusion criteria. After accounting for duplicate publications, we had identified 6 independent studies. These studies show that blood THC over 2 ng/mL does do not necessarily indicate recent cannabis use in frequent cannabis users. Five studies reported blood THC >2 ng/mL (or plasma THC >3 ng/mL) in some participants after six days of abstinence and two reported participants with blood THC >5 ng/mL (or plasma THC > 7.5 ng/mL) after a day of abstinence.

Conclusions: Blood THC >2 ng/mL, and possibly even THC >5 ng/mL, does not necessarily represent recent use of cannabis in frequent cannabis users.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108177DOI Listing
November 2020

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

Inj Prev 2020 Jul 30. Epub 2020 Jul 30.

Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.

Introduction: Previous studies on the effect of prescription medications on MVCs are sparse, not readily applicable to real-world driving and/or subject to strong selection bias. This study examines whether the presence of prescription medication in drivers' blood is associated with being responsible for MVC.

Methods: This modified case-control study with responsibility analysis compares MVC responsibility rates among drivers with detectable levels of six classes of prescription medications (anticonvulsants, antidepressants, antihistamines, antipsychotics, benzodiazepines, opioids) versus those without. Data were collected between January 2010 and July 2016 from emergency departments in British Columbia, Canada. Collision responsibility was assessed using a validated and automated scoring of police collision reports. Multivariable logistic regression was used to determine OR of responsibility (analysed in 2018-2019).

Results: Unadjusted regression models show a significant association between anticonvulsants (OR 1.92; 95% CI 1.20 to 3.09; p=0.007), antipsychotics (OR 5.00; 95% CI 1.16 to 21.63; p=0.03) and benzodiazepines (OR 2.99; 95% CI 1.56 to 5.75; p=0.001) with collision responsibility. Fully adjusted models show a significant association between benzodiazepines with collision responsibility (aOR 2.29; 95% CI 1.16 to 4.53; p=0.02) after controlling for driver characteristics, blood alcohol and Δ-9-tetrahydrocannabinol concentrations, and the presence of other prescription medications. Antidepressants, antihistamines and opioids exhibited no significant associations.

Conclusion: There is a moderate increase in the risk of a responsible collision among drivers with detectable levels of benzodiazepines in blood. Physicians and pharmacists should consider collision risk when prescribing or dispensing benzodiazepines. Public education about benzodiazepine use and driving and change to traffic policy and enforcement measures are warranted.
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http://dx.doi.org/10.1136/injuryprev-2020-043840DOI Listing
July 2020

Epidemiology of drug driving: protocol from a national Canadian study measuring levels of cannabis, alcohol and other substances in injured drivers.

BMC Public Health 2020 Jul 6;20(1):1070. Epub 2020 Jul 6.

Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.

Background: Drug driving is an emerging global road safety problem. As the prevalence of alcohol-impaired driving decreases, and as more jurisdictions decriminalize or legalize cannabis, it is increasingly important for policy makers to have accurate information on the prevalence and pattern of drug driving. Unfortunately, this data is not widely available and the World Health Organization identifies lack of accurate data on the prevalence of drug driving as an important knowledge gap.

Methods: In this paper, we discuss the limitations of current methods of monitoring drug use in drivers. We then present a novel methodology from a multi-centre study that monitors the prevalence and pattern of drug use in injured drivers across Canada. This study uses "left-over" blood taken as part of routine medical care to quantify cannabis and other drugs in non-fatally injured drivers who present to participating emergency departments after a collision. Toxicology testing is done with waiver of consent as we have procedures that prevent results from being linked to any individual. These methods minimize non-response bias and have the advantages of measuring drug concentrations in blood obtained shortly after a collision.

Discussion: Our methods can be applied in other jurisdictions and provide a consistent approach to collect data on drug driving. Consistent methods allow comparison of drug driving prevalence from different regions. Data from this research can be used to inform policies designed to prevent driving under the influence of cannabis and other impairing drugs.
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http://dx.doi.org/10.1186/s12889-020-09176-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7339401PMC
July 2020

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

Clin Toxicol (Phila) 2021 Jan 13;59(1):38-46. Epub 2020 May 13.

Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.

Introduction: When managing opioid overdose (OD) patients, the optimal naloxone regimen should rapidly reverse respiratory depression while avoiding opioid withdrawal. Published naloxone administration guidelines have not been empirically validated and most were developed before fentanyl OD was common. In this study, rates of opioid withdrawal symptoms (OW) and reversal of opioid toxicity in patients treated with two naloxone dosing regimens were evaluated.

Methods: In this retrospective matched cohort study, health records of patients who experienced an opioid OD treated in two urban emergency departments (ED) during an ongoing fentanyl OD epidemic were reviewed. Definitions for OW and opioid reversal were developed . Low dose naloxone (LDN; ≤0.15 mg) and high dose naloxone (HDN; >0.15 mg) patients were matched in a 1:4 ratio based upon initial respiratory rate (RR). The proportion of patients who developed OW and who met reversal criteria were compared between those treated initially with LDN or HDN. Odds ratios (OR) for OW and opioid reversal were obtained logistic regression stratified by matched sets and adjusted for age, sex, pre-naloxone GCS, and presence of non-opioid drugs or alcohol.

Results: Eighty LDN patients were matched with 299 HDN patients. After adjustment, HDN patients were more likely than LDN patients to have OW after initial dose (OR = 8.43; 95%CI: 1.96, 36.3;  = 0.004) and after any dose (OR = 2.56; 95%CI: 1.17, 5.60;  = 0.019). HDN patients were more likely to meet reversal criteria after initial dose (OR = 2.73; 95%CI: 1.19, 6.26;  = 0.018) and after any dose (OR = 6.07; 95%CI: 1.81, 20.3;  = 0.003).

Conclusions: HDN patients were more likely to have OW but also more likely to meet reversal criteria versus LDN patients.
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http://dx.doi.org/10.1080/15563650.2020.1758325DOI Listing
January 2021

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

Emergency department visits during the 4/20 cannabis celebration.

Emerg Med J 2020 Apr 12;37(4):187-192. Epub 2019 Dec 12.

Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada.

Background: Annual '4/20' cannabis festivals occur around the world on April 20 and often feature synchronised consumption of cannabis at 4:20 pm. The relationship between these events and demand for emergency medical services has not been systematically studied.

Methods: We conducted a population-based retrospective cohort study in Vancouver, Canada, using 10 consecutive years of data (2009-2018) from six regional hospitals. The number of emergency department (ED) visits between 4:20 pm and 11:59 pm on April 20 were compared with the number of visits during identical time intervals on control days 1 week earlier and 1 week later (ie, April 13 and April 27) using negative binomial regression.

Results: A total of 3468 ED visits occurred on April 20 and 6524 ED visits occurred on control days. A non-significant increase in all-cause ED visits was observed on April 20 (adjusted relative risk: 1.06; 95% CI 1.00 to 1.12). April 20 was associated with a significant increase in ED visits among prespecified subgroups including a 5-fold increase in visits for substance misuse and a 10-fold increase in visits for intoxication. The hospital closest to the festival site experienced a clinically and statistically significant 17% (95% CI 5.1% to 29.6%) relative increase in ED visits on April 20 compared with control days.

Interpretation: Substance use at annual '4/20' festivals may be associated with an increase in ED visits among key subgroups and at nearby hospitals. These findings may inform harm reduction initiatives and festival medical care service planning.
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http://dx.doi.org/10.1136/emermed-2019-208947DOI Listing
April 2020

Reply to Beckson et al. (2019): Cannabis, crashes, and blood: challenges for observational research.

Addiction 2020 03 2;115(3):590-591. Epub 2020 Jan 2.

Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.

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http://dx.doi.org/10.1111/add.14913DOI Listing
March 2020

Cannabis use as a risk factor for causing motor vehicle crashes: a prospective study.

Addiction 2019 09 3;114(9):1616-1626. Epub 2019 Jul 3.

University of British Columbia, Vancouver, BC, Canada.

Aim: We conducted a responsibility analysis to determine whether drivers injured in motor vehicle collisions who test positive for Δ-9-tetrahydrocannabinol (THC) or other drugs are more likely to have contributed to the crash than those who test negative.

Design: Prospective case-control study.

Setting: Trauma centres in British Columbia, Canada.

Participants: Injured drivers who required blood tests for clinical purposes following a motor vehicle collision.

Measurements: Excess whole blood remaining after clinical use was obtained and broad-spectrum toxicology testing performed. The analysis quantified alcohol and THC and gave semiquantitative levels of other impairing drugs and medications. Police crash reports were analysed to determine which drivers contributed to the crash (responsible) and which were 'innocently involved' (non-responsible). We used unconditional logistic regression to determine the likelihood (odds ratio: OR) of crash responsibility in drivers with 0 < THC < 2 ng/ml, 2 ng/ml ≤ THC < 5 ng/ml and THC ≥ 5 ng/ml (all versus THC = 0 ng/ml). Risk estimates were adjusted for age, sex and presence of other impairing substances.

Findings: We obtained toxicology results on 3005 injured drivers and police reports on 2318. Alcohol was detected in 14.4% of drivers, THC in 8.3%, other drugs in 8.9% and sedating medications in 19.8%. There was no increased risk of crash responsibility in drivers with THC < 2 ng/ml or 2 ≤ THC < 5 ng/ml. In drivers with THC ≥ 5 ng/ml, the adjusted OR was 1.74 [95% confidence interval (CI) = 0.59-6.36; P = 0.35]. There was significantly increased risk of crash responsibility in drivers with blood alcohol concentration (BAC) ≥ 0.08% (OR = 6.00;95% CI = 3.87-9.75; P < 0.01), other recreational drugs detected (OR = 1.82;95% CI = 1.21-2.80; P < 0.01) or sedating medications detected (OR = 1.45; 95%CI = 1.11-1.91; P < 0.01).

Conclusions: In this sample of non-fatally injured motor vehicle drivers in British Columbia, Canada, there was no evidence of increased crash risk in drivers with Δ-9-tetrahydrocannabinol < 5 ng/ml and a statistically non-significant increased risk of crash responsibility (odds ratio = 1.74) in drivers with Δ-9-tetrahydrocannabinol ≥ 5 ng/ml.
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http://dx.doi.org/10.1111/add.14663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6771478PMC
September 2019

Low-impact strategy for capturing better emergency department injury surveillance data.

Inj Prev 2019 12 18;25(6):507-513. Epub 2018 Oct 18.

Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Objectives: Injury prevention should be informed by timely surveillance data. Unfortunately, most injury surveillance only captures patients with severe injuries and is not available in real time, hampering prevention efforts. We aimed to develop and pilot a simple injury surveillance strategy that can be integrated into routine emergency department (ED) workflow to collect more robust mechanism of injury information at time of visit for all injured ED patients with minimal impact on workflow.

Methods: We reviewed ED injury surveillance systems and considered ED workflow. Forms were developed to collect injury-related information on ED patients and refined to address workload concerns raised by key stakeholders. Research assistants observed ED staff as they registered injured patients and noted the time required to collect data and any ambiguities or concerns encountered. Interobserver agreement was recorded.

Results: Injury surveillance questions were based on a modification of the International Classification of External Causes of Injury. Research assistants observed 222 injured patients being admitted by registration clerks. The mean time required to complete the surveillance form was 64.9 s (95% CI 59.9 s to 69.9 s) for paper-based forms (120 cases) and 44.5 s (95% CI 41.7s to 47.4s) with direct electronic data entry (102 cases). Interobserver agreement (26 cases) was 100% for intent (kappa=1.0) of injury and 96% for mechanism of injury (kappa=0.74).

Conclusions: We report a simple injury surveillance strategy that ED staff can use to collect meaningful injury data in real time with minimal impact on workflow. This strategy can be adapted to enhance regional injury surveillance efforts.
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http://dx.doi.org/10.1136/injuryprev-2018-042958DOI Listing
December 2019

Frequent marijuana use and driving risk behaviours in Canadian youth.

Paediatr Child Health 2017 Mar 27;22(1):7-12. Epub 2017 Mar 27.

University of British Columbia, Vancouver, British Columbia.

Background: A better understanding of the relations between patterns of marijuana use and driving risks in young adulthood is needed.

Methods: Secondary analyses of self-report data from the Victoria Healthy Youth Survey. Youth (baseline ages 12 to 18; N=662; 52% females) were interviewed biannually (on six occasions) from 2003 to 2013 and classified as abstainers (i.e., used no marijuana in past 12 months), occasional users (i.e., used at most once per week), and frequent users (i.e., used more than once a week).

Results: In the frequent user group, 80% of males and 75% of females reported 'being in a car driven by driver (including themselves) using marijuana or other drugs in the last 30 days', 64% of males and 33% of females reported that they were 'intoxicated' with marijuana while operating a vehicle and 50% of males and 42% of females reported being in a car driven by a driver using alcohol. In addition, 28% of occasional users and also a small proportion of abstainers reported 'being in a car driven by a driver using marijuana or other drugs in the last 30 days'.

Interpretation: The high frequency of driving risk behaviours, particularly for frequent users, suggest that plans for legalization of recreational use should anticipate the costs of preventive education efforts that present an accurate picture of potential risks for driving. Youth also need to understand risks for dependence, and screening for and treatment of marijuana use disorders is needed.
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http://dx.doi.org/10.1093/pch/pxw002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819845PMC
March 2017

Police documentation of drug use in injured drivers: Implications for monitoring and preventing drug-impaired driving.

Accid Anal Prev 2018 Sep 23;118:200-206. Epub 2018 Feb 23.

Faculty of Law, Western University, London, Ontario, Canada.

Introduction: Most countries have laws against driving while impaired by drugs. However, in many countries, including Canada and the United States, police must have individualized suspicion that the driver has recently used an impairing substance before they can gather the evidence required for laying a criminal charge. This report studies police documentation of drug involvement among drivers who had a motor-vehicle crash after using an impairing substance.

Methods: We obtained blood samples and police reports on injured drivers treated in participating British Columbia trauma centres following a crash. Blood was analyzed for alcohol, cannabinoids, other recreational drugs, and impairing medications. Corresponding police reports were examined to determine whether police recorded that the driver's ability was impaired by alcohol, drug or medication, or that one of these substances was a possible contributory factor in the crash.

Results: We obtained blood samples and corresponding police reports on 1816 injured drivers. Mean driver age was 44 years, 63.2% were male, and 25.8% were admitted to hospital. Alcohol was detected in 272 drivers (15.0%), THC (tetrahydrocannabinol - the principal psychoactive ingredient in cannabis) in 136 (7.5%), other recreational drugs in 166 (9.1%), and potentially impairing medications in 363 (20.0%). Police reported that the driver's ability was impaired by alcohol or that alcohol was a possible contributory factor in 64.1% of the crashes involving alcohol-positive drivers. Drug impairment or drugs as a possible contributory factor was reported in 5.9% of the crashes involving THC-positive drivers, and in 16.9% of the crashes involving drivers who tested positive for other recreational drugs. Medication impairment was reported in only 2.2% of the crashes involving medication-positive drivers.

Conclusion: Police seldom document drug involvement in drivers who were in a crash after using cannabis, other recreational drugs or potentially impairing medications. This finding raises serious concerns about the ability of the police to effectively enforce current drug-impaired driving laws and public health officials' continued reliance on police crash reports to monitor the prevalence of drug-impaired driving.
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http://dx.doi.org/10.1016/j.aap.2018.02.018DOI Listing
September 2018

Syncope and Presyncope as a Presenting Symptom or Discharge Diagnosis in the Emergency Department: An Administrative Data Validation Study.

Can J Cardiol 2017 12 11;33(12):1729-1732. Epub 2017 Sep 11.

Centre for Clinical Epidemiology & Evaluation, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Emergency department (ED) visits for syncope are common. Validation of ED administrative diagnostic coding for syncope is required before these codes can be used for health services research. We performed a retrospective multicentre chart review using a regional ED database in British Columbia. We identified adults who visited 1 of 3 high-volume urban EDs between 2010 and 2015. Cohort 1 included 350 ED visits for patients with a presenting complaint (PC) of syncope/presyncope, a discharge diagnosis (DD) of syncope and collapse, or both. Cohort 2 included 100 patients with ED visits with neither a PC of syncope/presyncope nor a DD of syncope and collapse. The reference standard was abstractor conclusion regarding syncope and presyncope ("definite/very likely" vs "possible" vs "unlikely" vs "absent") after structured review of ED medical records. We found that in cohort 1, syncope or presyncope were definite/very likely or possible in 96% of visits with a PC of syncope/presyncope and a DD of syncope and collapse. Syncope alone was definite/very likely in only 56% of visits. In cohort 2, syncope was definitely absent for 94% of patients. The reference standard showed excellent face validity and abstractor inter-rater agreement (Cohen κ > 0.80). Vital signs and orthostatic vital signs were not documented for 8% and 84% of visits, respectively. Our results suggest that a PC of syncope/presyncope combined with a DD of syncope and collapse is highly predictive of syncope or presyncope. These findings will inform design and interpretation of syncope health services research.
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http://dx.doi.org/10.1016/j.cjca.2017.08.026DOI Listing
December 2017

Randomized controlled trial of emergency department initiated smoking cessation counselling and referral to a community counselling service.

CJEM 2018 07 11;20(4):556-564. Epub 2017 Jul 11.

*Department of Emergency Medicine,Vancouver General Hospital, Faculty of Medicine,University of British Columbia,Vancouver,BC.

Objective: Worldwide, tobacco smoke is still the leading cause of preventable morbidity and mortality. Many smokers develop chronic smoking-related conditions that require emergency department (ED) visits. However, best practices for ED smoking cessation counselling are still unclear.

Methods: A randomized controlled trial was conducted to determine whether an "ask, advise, and refer" approach increases 12-month, 30-day quit rates in the stable adult ED smoking population compared to usual care. Patients in the intervention group were referred to a community counselling service that offers a quitline, a text-based program, and a Web-based program. Longitudinal intention-to-treat analyses were performed.

Results: From November 2011 to March 2013, 1,295 patients were enrolled from one academic tertiary care ED. Six hundred thirty-five were allocated to usual care, and 660 were allocated to intervention. Follow-up data were available for 70% of all patients at 12 months. There was no statistically significant difference in 12-month, 30-day quit rates between the two groups. However, there was a trend towards higher 7-day quit attempts, 7-day quit rates, and 30-day quit rates at 3, 6, and 12 months in the intervention group.

Conclusion: In this study, there was a trend towards increased smoking cessation following referral to a community counselling service. There was no statistically significant difference. However, if ED smoking cessation efforts were to provide even a small positive effect, such an intervention may have a significant public health impact given the extensive reach of emergency physicians.
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http://dx.doi.org/10.1017/cem.2017.345DOI Listing
July 2018

Risk of injury from alcohol, marijuana and other drug use among emergency department patients.

Drug Alcohol Depend 2017 05 7;174:121-127. Epub 2017 Mar 7.

Department of Emergency Medicine, University of British Columbia,Vancouver, BC, V6T 1Z4, Canada.

Background: Alcohol is known to be associated with injury, but little is known of combined use of alcohol and other drugs on injury; especially important for marijuana, given increasing legalization of use in the U.S. and Canada.

Methods: Probability samples of patients 18 and older were interviewed in the emergency department at two sites in Vancouver and one in Victoria, BC (n=1191 injured and 1613 non-injured patients). Case-control and case-crossover analyses were used to analyze risk of injury, based on self-reported alcohol and drug use (marijuana, stimulants, depressants) prior to injury.

Results: Risk of injury was significantly elevated (p<0.001) for alcohol use alone in both case-control (OR=2.72) and case-crossover analyses (OR=2.80) but not for any of the three drug classes. The interaction of alcohol with each class of drug was tested, and marginally significant only for marijuana in case-control analysis (OR=4.42; p=0.088). The interaction of alcohol and two or more drugs was also significant in case-control analysis (OR=03; p=0.035). The volume of alcohol consumed prior to injury was greater for those also using drugs during this time and positively associated with the number of drugs reported.

Conclusion: Given the potential issues involved with both case-control and case-crossover study designs, the inconsistent findings suggest caution in reaching any definite conclusion regarding whether there is extra risk related to combined use of alcohol and marijuana, and is an important area for future research.
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http://dx.doi.org/10.1016/j.drugalcdep.2017.01.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400715PMC
May 2017

Minor Injury Crashes: Prevalence of Driver-Related Risk Factors and Outcome.

J Emerg Med 2017 May 7;52(5):632-638. Epub 2017 Mar 7.

Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Background: The majority of crashes cause "minor" injuries (i.e., treated and released from the emergency department [ED]). Minor injury crashes are poorly studied.

Objectives: This study aims to determine the prevalence of driver-related risk factors and subsequent outcome in drivers involved in minor crashes.

Methods: We interviewed a convenience sample of injured drivers, aged over 17 years, who were treated and released from the ED. Follow-up interviews were conducted 6 months after the crash.

Results: We approached 123 injured drivers; baseline interviews were completed in 69 and follow-up interviews in 45. Prior to the index crash, 1.4% of drivers drank alcohol, 1.4% used illicit drugs, and 7.2% used sedating prescription medications. Nine drivers (13%) were distracted. In this sample, 5.8% met criteria for being aggressive drivers, 7.2% were risky drivers, and 11.6% drove while experiencing negative emotions. At 6-month follow-up, many drivers were still having health problems, 53.3% were not fully recovered, 46.7% had not returned to usual activities, and 28.9% were off work. Of the 42 participants who resumed driving, 16.7% had a near miss and 4.8% had another crash. Nine (21.4%) reported drinking and driving, and 9.5% reported driving after cannabis use. Cell phone use (16.7%) and use of other electronics while driving (23.8%) were also common.

Conclusions: Driver-related risk factors are common in drivers involved in minor injury crashes, and drivers persist in taking risks after being involved in a crash. Despite their name, minor injury crashes are often associated with slow recovery and prolonged absenteeism from work.
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http://dx.doi.org/10.1016/j.jemermed.2017.01.044DOI Listing
May 2017

Reprint of "Media reporting of traffic legislation changes in British Columbia (2010)".

Accid Anal Prev 2016 Dec 10;97:335-341. Epub 2016 Nov 10.

British Columbia Injury Prevention and Research Unit, Faculty of Medicine, University of British Columbia, Canada.

Introduction: In 2010, British Columbia (BC) introduced new traffic laws designed to deter impaired driving, speeding, and distracted driving. These laws generated significant media attention and were associated with reductions in fatal crashes and in ambulance calls and hospital admissions for road trauma.

Objective: To understand the extent and type of media coverage of the new traffic laws and to identify how the laws were framed by the media.

Methods: We reviewed a database of injury related news coverage (May 2010-December 2012) and extracted reports that mentioned distracted driving, impaired driving, or speeding. Articles were classified according to: (i) Type, (ii) Issue discussed, (iii) 'Reference to new laws', and (iv) 'Pro/anti traffic law'. Articles mentioning the new laws were reread and common themes in how the laws were framed were identified and discussed.

Results: Over the course of the study, 1848 articles mentioned distraction, impairment, or speeding and 597 reports mentioned the new laws: 65 against, 227 neutral, and 305 supportive. Reports against the new laws framed them as unfair or as causing economic damage to the entertainment industry. Reports in favor of the new laws framed them in terms of preventing impaired driving and related trauma or of bringing justice to drinking drivers. Growing evidence of the effectiveness of the new laws generated media support.

Conclusions: BC's new traffic laws generated considerable media attention both pro and con. We believe that this media attention helped inform the public of the new laws and enhanced their deterrent effect.
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http://dx.doi.org/10.1016/j.aap.2016.11.005DOI Listing
December 2016

The Nature and Clinical Significance of Preinjury Recall Bias Following Mild Traumatic Brain Injury.

J Head Trauma Rehabil 2016 Nov/Dec;31(6):388-396

Division of Physical Medicine & Rehabilitation (Dr Silverberg), Department of Psychiatry (Drs Iverson and Lange), and Department of Emergency Medicine (Dr Brubacher), Department of Psychiatry, University of British Columbia (Ms Aquino), Vancouver, British Columbia, Canada; Rehabilitation Research Program, GF Strong Rehab Centre, Vancouver, British Columbia, Canada (Dr Silverberg); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts (Dr Iverson); Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Dr Iverson); Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada (Ms Hoshino); Defense and Veterans Brain Injury Center & National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland (Dr Lange). Ms Holland is in private practice at Victoria, British Columbia, Canada.

Objective: Patients with mild traumatic brain injury (MTBI) often underestimate their preinjury symptoms. This study aimed to clarify the mechanism underlying this recall bias and its contribution to MTBI outcome.

Setting: Level I trauma center.

Participants: Patients with uncomplicated MTBI (N = 88) and orthopedic injury (N = 67).

Design: Prospective longitudinal.

Main Measures: Current and retrospective ratings on the British Columbia Postconcussion Symptom Inventory, completed at 6 weeks and 1 year postinjury.

Results: Preinjury symptom reporting was comparable across groups, static across time, and associated with compensation-seeking. High preinjury symptom reporting was related to high postinjury symptom reporting in the orthopedic injury group but less so in the MTBI group, indicating a stronger positive recall bias in highly symptomatic MTBI patients. Low preinjury symptom reporting was not a risk factor for poor MTBI outcome.

Conclusion: The recall bias was stronger and more likely clinically significant in MTBI patients with high postinjury symptoms. Multiple mechanisms appear to contribute to recall bias after MTBI, including the reattribution of preexisting symptoms to MTBI as well as processes that are not specific to MTBI (eg, related to compensation-seeking).
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http://dx.doi.org/10.1097/HTR.0000000000000198DOI Listing
March 2018

Alcohol Consumption Does not Impede Recovery from Mild to Moderate Traumatic Brain Injury.

J Int Neuropsychol Soc 2016 09 18;22(8):816-27. Epub 2016 Aug 18.

6Department of Psychiatry,University of British Columbia,Vancouver,Canada.

Objectives: To examine the effect of pre-injury alcohol use, acute alcohol intoxication, and post-injury alcohol use on outcome from mild to moderate traumatic brain injury (TBI).

Methods: Prospective inception cohort of patients who presented to the Emergency Department with mild to moderate TBI and had a blood alcohol level (BAL) taken for clinical purposes. Those who completed the 1-year outcome assessment were eligible for this study (N=91). Outcomes of interest were the count of post-concussion symptoms (British Columbia Post-Concussion Symptom Inventory), low neuropsychological test scores (Neuropsychological Assessment Battery), and abnormal regions of interest on diffusion tensor imaging (low fractional anisotropy). The main predictors were pre-injury alcohol consumption (Cognitive Lifetime Drinking History interview), BAL, and post-injury alcohol use.

Results: The alcohol use variables were moderately to strongly inter-correlated. None of the alcohol use variables (whether continuous or categorical) were related to 1-year TBI outcomes in generalized linear modeling. Participants in this cohort generally had a good clinical outcome, regardless of their pre-, peri-, and post-injury alcohol use.

Conclusions: Alcohol may not significantly alter long-term outcome from mild to moderate TBI. (JINS, 2016, 22, 816-827).
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http://dx.doi.org/10.1017/S1355617716000692DOI Listing
September 2016

The impact of child safety restraint legislation on child injuries in police-reported motor vehicle collisions in British Columbia: An interrupted time series analysis.

Paediatr Child Health 2016 May;21(4):e27-31

Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia.

Background/objective: Motor vehicle collisions (MVCs) remain a leading cause of death and serious injury in Canadian children. In July 2008, British Columbia introduced child safety seat legislation that aimed to reduce the number of children killed or injured in MVCs. This legislation upgraded previous child seat legislation (introduced in 1985) and affected children zero to three and those four to eight years of age. The objective of the present study was to evaluate the effectiveness of this legislation.

Methods: Deidentified police reports for all MVCs involving zero- to 14-year-olds (2000 to 2012) were used to compare injury rates, booster seat use, and seating position among children before and after booster seat laws. An interrupted time series design was used to estimate the effect of the new law on injuries among children zero to three and four to eight years of age. Estimates were adjusted using children nine to 14 years of age as controls.

Results: The booster seat law was associated with a 10.8% (95% CI 2.7% to 18.9%) reduction in the monthly rate of injuries in four- to eight-year-old children (P=0.01). This was equivalent to a decrease of 14.3 injuries per 1,000,000 children. Similarly, the monthly injury rate among children zero to three years of age decreased by 13.0% (95% CI 1.5% to 24.6% [9.8 injuries per 1,000,000]; P=0.03).

Conclusion: The results provide evidence that British Columbia's new child safety restraint law was associated with fewer injuries among children covered by the new laws.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934166PMC
http://dx.doi.org/10.1093/pch/21.4.e27DOI Listing
May 2016

The Association between Regional Environmental Factors and Road Trauma Rates: A Geospatial Analysis of 10 Years of Road Traffic Crashes in British Columbia, Canada.

PLoS One 2016 21;11(4):e0153742. Epub 2016 Apr 21.

Department of Geography, Simon Fraser University, Burnaby, British Columbia, Canada.

Background: British Columbia, Canada is a geographically large jurisdiction with varied environmental and socio-cultural contexts. This cross-sectional study examined variation in motor vehicle crash rates across 100 police patrols to investigate the association of crashes with key explanatory factors.

Methods: Eleven crash outcomes (total crashes, injury crashes, fatal crashes, speed related fatal crashes, total fatalities, single-vehicle night-time crashes, rear-end collisions, and collisions involving heavy vehicles, pedestrians, cyclists, or motorcyclists) were identified from police collision reports and insurance claims and mapped to police patrols. Six potential explanatory factors (intensity of traffic law enforcement, speed limits, climate, remoteness, socio-economic factors, and alcohol consumption) were also mapped to police patrols. We then studied the association between crashes and explanatory factors using negative binomial models with crash count per patrol as the response variable and explanatory factors as covariates.

Results: Between 2003 and 2012 there were 1,434,239 insurance claim collisions, 386,326 police reported crashes, and 3,404 fatal crashes. Across police patrols, there was marked variation in per capita crash rate and in potential explanatory factors. Several factors were associated with crash rates. Percent roads with speed limits ≤ 60 km/hr was positively associated with total crashes, injury crashes, rear end collisions, and collisions involving pedestrians, cyclists, and heavy vehicles; and negatively associated with single vehicle night-time crashes, fatal crashes, fatal speeding crashes, and total fatalities. Higher winter temperature was associated with lower rates of overall collisions, single vehicle night-time collisions, collisions involving heavy vehicles, and total fatalities. Lower socio-economic status was associated with higher rates of injury collisions, pedestrian collisions, fatal speeding collisions, and fatal collisions. Regions with dedicated traffic officers had fewer fatal crashes and fewer fatal speed related crashes but more rear end crashes and more crashes involving cyclists or pedestrians. The number of traffic citations per 1000 drivers was positively associated with total crashes, fatal crashes, total fatalities, fatal speeding crashes, injury crashes, single vehicle night-time crashes, and heavy vehicle crashes. Possible explanations for these associations are discussed.

Conclusions: There is wide variation in per capita rates of motor vehicle crashes across BC police patrols. Some variation is explained by factors such as climate, road type, remoteness, socioeconomic variables, and enforcement intensity. The ability of explanatory factors to predict crash rates would be improved if considered with local traffic volume by all travel modes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153742PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4839631PMC
September 2016

Prevalence of alcohol and drug use in injured British Columbia drivers.

BMJ Open 2016 Mar 10;6(3):e009278. Epub 2016 Mar 10.

Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Objectives: Determine the prevalence of drug use in injured drivers and identify associated demographic factors and crash characteristics.

Design: Prospective cross-sectional study.

Setting: Seven trauma centres in British Columbia, Canada (2010-2012).

Participants: Automobile drivers who had blood obtained within 6 h of a crash.

Main Outcome Measures: We analysed blood for cannabis, alcohol and other impairing drugs using liquid chromatography/mass spectrometry (LCMS).

Results: 1097 drivers met inclusion criteria. 60% were aged 20-50 years, 63.2% were male and 29.0% were admitted to hospital. We found alcohol in 17.8% (15.6% to 20.1%) of drivers. Cannabis was the second most common recreational drug: cannabis metabolites were present in 12.6% (10.7% to 14.7%) of drivers and we detected Δ-9-tetrahydrocannabinol (Δ-9-THC) in 7.3% (5.9% to 9.0%), indicating recent use. Males and drivers aged under 30 years were most likely to use cannabis. We detected cocaine in 2.8% (2.0% to 4.0%) of drivers and amphetamines in 1.2% (0.7% to 2.0%). We also found medications including benzodiazepines (4.0% (2.9% to 5.3%)), antidepressants (6.5% (5.2% to 8.1%)) and diphenhydramine (4.7% (3.5% to 6.2%)). Drivers aged over 50 years and those requiring hospital admission were most likely to have used medications. Overall, 40.1% (37.2% to 43.0%) of drivers tested positive for alcohol or at least one impairing drug and 12.7% (10.7% to 14.7%) tested positive for more than one substance.

Conclusions: Alcohol, cannabis and a broad range of other impairing drugs are commonly detected in injured drivers. Alcohol is well known to cause crashes, but further research is needed to determine the impact of other drug use, including drug-alcohol and drug-drug combinations, on crash risk. In particular, more work is needed to understand the role of medications in causing crashes to guide driver education programmes and improve public safety.
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http://dx.doi.org/10.1136/bmjopen-2015-009278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800149PMC
March 2016

Media reporting of traffic legislation changes in British Columbia (2010).

Accid Anal Prev 2015 Sep 17;82:227-33. Epub 2015 Jun 17.

British Columbia Injury Prevention and Research Unit, Faculty of Medicine, University of British Columbia, Canada.

Introduction: In 2010, British Columbia (BC) introduced new traffic laws designed to deter impaired driving, speeding, and distracted driving. These laws generated significant media attention and were associated with reductions in fatal crashes and in ambulance calls and hospital admissions for road trauma.

Objective: To understand the extent and type of media coverage of the new traffic laws and to identify how the laws were framed by the media.

Methods: We reviewed a database of injury related news coverage (May 2010-December 2012) and extracted reports that mentioned distracted driving, impaired driving, or speeding. Articles were classified according to: (i) Type, (ii) Issue discussed, (iii) 'Reference to new laws', and (iv) 'Pro/anti traffic law'. Articles mentioning the new laws were reread and common themes in how the laws were framed were identified and discussed.

Results: Over the course of the study, 1848 articles mentioned distraction, impairment, or speeding and 597 reports mentioned the new laws: 65 against, 227 neutral, and 305 supportive. Reports against the new laws framed them as unfair or as causing economic damage to the entertainment industry. Reports in favor of the new laws framed them in terms of preventing impaired driving and related trauma or of bringing justice to drinking drivers. Growing evidence of the effectiveness of the new laws generated media support.

Conclusions: BC's new traffic laws generated considerable media attention both pro and con. We believe that this media attention helped inform the public of the new laws and enhanced their deterrent effect.
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http://dx.doi.org/10.1016/j.aap.2015.05.022DOI Listing
September 2015

Neuropsychological outcome and diffusion tensor imaging in complicated versus uncomplicated mild traumatic brain injury.

PLoS One 2015 27;10(4):e0122746. Epub 2015 Apr 27.

Department of Psychiatry, University of British Columbia, Vancouver, Canada; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, & Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, Massachusetts, United States of America.

This study examined whether intracranial neuroimaging abnormalities in those with mild traumatic brain injury (MTBI) (i.e., "complicated" MTBIs) are associated with worse subacute outcomes as measured by cognitive testing, symptom ratings, and/or diffusion tensor imaging (DTI). We hypothesized that (i) as a group, participants with complicated MTBIs would report greater symptoms and have worse neurocognitive outcomes than those with uncomplicated MTBI, and (ii) as a group, participants with complicated MTBIs would show more Diffusion Tensor Imaging (DTI) abnormalities. Participants were 62 adults with MTBIs (31 complicated and 31 uncomplicated) who completed neurocognitive testing, symptom ratings, and DTI on a 3T MRI scanner approximately 6-8 weeks post injury. There were no statistically significant differences between groups on symptom ratings or on a broad range of neuropsychological tests. When comparing the groups using tract-based spatial statistics for DTI, no significant difference was found for axial diffusivity or mean diffusivity. However, several brain regions demonstrated increased radial diffusivity (purported to measure myelin integrity), and decreased fractional anisotropy in the complicated group compared with the uncomplicated group. Finally, when we extended the DTI analysis, using a multivariate atlas based approach, to 32 orthopedic trauma controls (TC), the findings did not reveal significantly more areas of abnormal DTI signal in the complicated vs. uncomplicated groups, although both MTBI groups had a greater number of areas with increased radial diffusivity compared with the trauma controls. This study illustrates that macrostructural neuroimaging changes following MTBI are associated with measurable changes in DTI signal. Of note, however, the division of MTBI into complicated and uncomplicated subtypes did not predict worse clinical outcome at 6-8 weeks post injury.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0122746PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411162PMC
April 2016