A larger sample size can help clarify the results. Third, because the sample was naturalistic and included veterans with other comorbid non-PTSD and non-alcohol use disorders and concurrent medication use , such broad inclusion/exclusion criteria may have contributed to some of the non-significant findings given in Tables III and IV. A future study with more stringent delineation of primary psychiatric disorder, substance use disorder, and medication use criteria may help clarify the relationship between alcohol use biomarkers and cognitive performance in veterans specifically with alcohol dependence and PTSD. Fourth, because most EtG and EtS values were undetectable, dichotomizing the continuous variables of EtG and EtS most likely resulted in a loss of statistical power.As a result, the non-significant results for EtG and EtS may have been due to a “floor effect.” A future study with more accurate EtG and EtS detection at levels below the current threshold can help maintain these variables as continuous when conducting data analyses. Finally, a more comprehensive neurocognitive battery evaluating other cognitive domains may add further information on the relationship between alcohol use biomarkers and other cognitive domains. In 2018 in the United States, over 650 bicyclists died,vertical grow light and there were almost 158,000 bicycle-automobile collision–related injuries.1 Current bicycle injury prevention measures that have been proven include bicycle helmet programs and bicycle helmet laws.Promising prevention measures include active lighting, increased rider visibility, and roadway modifications.
Trauma registries can be used to identify modifiable injury risk factors for trauma prevention efforts, including bicyclist collisions with automobiles. However, these may miss factors useful for prevention of bicycle-automobile collisions, such as vehicle speeds, driver intoxication, and patient group characteristics, such as financial stress, educational level, and languages spoken. Geographic information systems use software that can relate seemingly unrelated data to provide better understanding of spatial patterns and relationships. The GIS studies in the trauma literature include optimizing trauma center location,identifying under serviced areas for quality trauma care,hotspot and cluster analysis for traffic collisions,and helicopter basing and efficacy.Trauma registries typically already contain some geospatial data, such as home and injury location addresses. Traffic records databases contain details about bicyclist automobile collisions not typically found in trauma registries, such as vehicle speeds, driver intoxication, street and lighting conditions, and driver or cyclist fault.These records also include accurate exact collision locations, allowing GIS mapping. The GIS analysis also allows the use of census tract demographic data for both the collision location and patient’s home for analysis.We hypothesize that GIS analysis of trauma registry data matched with a traffic records database could identify additional risk factors for bicycle-automobile injury helmet use or intoxication. We also hypothesize that the addition of GIS analysis to the trauma registry will better inform injury prevention efforts.The trauma registry of the UC San Diego Level I trauma center was used retrospectively to identify bicycle-motor vehiclecollision admissions from January 1, 2010, to December 31, 2018. Data collected included demographics, home and injury location addresses, injury severity scores, blood alcohol, toxicology, helmet use, hospital length of stay and mortality.
Matching of the registry cases with the California Statewide Integrated Traffic Records System was done to provide collision, bicyclist, driver, and geospatial information for bicycle-automobile collisions within the County of San Diego for the same period. Statewide Integrated Traffic Records System is administered by the California Highway Patrol, and includes all traffic collisions in California with a law enforcement report. Matching was deterministic and was done by bicyclist age, bicyclist sex, zip code, date and time ±1 hour between the SWITRS collision time and the trauma registry admission time transfers from outside the County of San Diego were excluded. Outcomes of interest included toxicology—available as “Alcohol Involved” in SWITRS collision data and “Party Sobriety” under SWITRS party data or from blood alcohol and urine toxicology in the trauma registry. Helmet use was found as reported in SWITRS or the trauma registry. Missing variables in either database were managed by excluding such cases from analysis using that variable. Geocoding, mapping, and geospatial analysis of matched case SWITRS collision locations was done using ArcGIS Pro 2.6 . Registry home addresses of cases were also geocoded and used with US Census Bureau census tract data to provide the below poverty level percentage for home census tracts. The educational attainment level for cases was done by selecting the predominant education level within the patient’s home address census tract from the US Census Bureau’s American Community Survey 2014 to 2018 5-year estimates, Table B15002. The language spoken at home was selected by home address census tract in the U.S. Census Bureau’s American Community Survey 2014 to 2018 5-year estimates, Table B16007.
Locations of bike lanes in San Diego County for analysis of their associations with collisions were obtained from SanGIS for Bike Paths , which are physically separated from traffic; bike lanes , which are defined by pavement striping and signage on streets; and Bike Routes , which are shared use with motor vehicle traffic in the same travel lane and designated by signs only. Locations of alcoholic beverage control licenses in San Diego County for analysis of association with intoxicated bicyclist collisions was obtained from the California Department of Alcoholic Beverage Control via SanGIS and esri.We have shown that GIS analysis of trauma registry data matched with a traffic accident records database can identify additional risk factors for bicycle-automobile injuries. We have also shown that our injury prevention efforts will be better informed by the hotspot analysis which clearly demonstrates clusters in specific geographic areas of the catchment area. The ability to add census tract data to registry data shows associations of education level and poverty level on bicycle helmet use. Census tract data also provides useful information for injury prevention efforts such as the predominant language spoken at home in target areas. Trauma registries, whether trauma center-based or nationally collected, should be constructed to allow geospatial analysis. Helmet use by bicyclists has been shown to reduce the risk of serious injury.Despite this, we saw relatively low use of helmets in admitted bicyclists. Some of the barriers to helmet use include psychological, financial and educational issues.This may be reflected in our results showing adverse census tract poverty level and educational levels having an association with lack of helmet use. Unhelmeted cyclists in this study were also less likely to be discharged to rehabilitation or long-term care facilities, this is likely due to their being relatively underinsured compared with helmeted cyclists. A meta-analysis of 21 studies shows that the effect of mandatory bicycle helmet legislation for all cyclists on head injuries results in a 20% reduction in serious injuries; however, such legislation currently seems unlikely in many US jurisdictions, except for children.Nonlegislative interventions appear to be effective in increasing observed helmet use, particularly community-based interventions and those programs providing free helmets.The clustering of unhelmeted bicyclists in automobile collisions provides the trauma center with good targets for injury prevention. The hotspots for lack of helmet use were predominantly at traffic light intersections on straight city boulevards,vertical grow rack which may provide a joint opportunity with local officials and bicycle advocates to evaluate bicycle traffic safety and policies. The census tract home language data for the unhelmeted hotspots indicates that any injury prevention efforts should be culturally appropriate and made available in multiple languages. The class of bike lane in San Diego County also influences the number of bicyclist-automobile collisions, with the signage-only “Bike Route” being the most common involved bike lane with injuries. Separating bicycles from automobiles is an obvious prevention measure and in our study is associated with very low rates of bicycle versus automobile injury. Advocacy for better classes of bike lanes, including more Class I Bike Paths is warranted. The cluster of bicyclists with positive toxicology constrained a dense area of only about 3 sq miles containing AQ4 513 establishments licensed to sell alcohol. The injured bicyclist intoxicated by alcohol or drugs is a problem that has had relatively little research. Alcohol and cannabis are associated with increased risk of bicycle collisions and increased injury severity.Among bicyclist fatalities in the United States in 2014, about 21% had high blood alcohol concentrations.In the past 30 years,targeted prevention interventions and legislation have been directed at automobile drunk drivers with a dramatic reduction in fatality numbers. However, no such efforts exist for intoxicated bicyclists. In this data set of bicycle-automobile collisions, we found many more intoxicated bicyclists than drivers.
One factor in some intoxicated bicyclist collisions is a history of driving under the influence in a motor vehicle, which in one study of AQ5 149 injured bicyclists in the ED, found 66 had prior driving under the influence convictions with suspension of driving privileges.There appear to be opportunities for targeted injury prevention efforts for intoxicated bicyclists in our catchment, given the small geographic area. Unfortunately, we do not have data on owned bikes versus rented ride share bikes which became ubiquitous at the end of the study period. The trauma registry kept by US trauma centers is largely used for quality and performance improvement, and to provide data to the Trauma Quality Improvement Program to allow national bench marking standards.Trauma registries can also be linked to emergency medical services registries and a call has been issued by the American College of Surgeons’ Trauma Quality Programs and the National Association of State Emergency Medical Services Officials, with support from the National Highway Traffic Safety Administration.The addition of EMS registry data provides additional information about the prehospital care of the trauma patient and this may provide additional risk factors for analysis of outcomes as well as additional data for quality and performance improvement of EMS. The California Highway Patrol’s SWITRS database is a rich source on each injury traffic collision in the state of California, providing over 122 data fields per case. Since 2002, each SWITRS record starts with a unique barcode ID number, allowing collection of scene data by law-enforcement agencies across the state. However, there has yet been no attempt to link SWITRS to EMS data in California. There have been efforts to link EMS records and traffic records in some regions of Oregon, which is accomplished by sharing of a universally unique and anonymous identifier between agencies at the accident scene.However, in California, legal concerns over privacy have halted progress by the state EMS agency despite the low cost of such a useful improvement in the trauma and EMS registries. We believe that this should be an area for continued advocacy and research for trauma centers, providers, and their national associations. Limitations of our study approach include the inability to assign financial, educational, or language characteristics to individual patients, for those variables we can only speak of the characteristics of a census tract for a patient’s given home address,which is only useful for assessing associations in large groups of patients. In some cases, opiates or benzodiazepines may have been administered by EMS crews or trauma teams prior to urinalysis. It is possible that there are systemic errors that mean that many individual bicycle-automobile victims may be systemic outliers from their census tract characteristics, although we believe that the results are representative from our experience. Missing and incorrect data are always an issue for large databases, which may be why we were unable to match 20% of our bicyclists injured in automobile collisions in our catchment to SWITRS data, although we believe that the remainder in the study is a representative sample of our experience. The adoption of a secure linkage between traffic records databases and the EMS and trauma registries would resolve this issue. Further studies of combination of traffic records databases and trauma center registries are needed to validate our approach. Although exact determination of educational level, income and languages spoken may be impractical and excessively intrusive for individual patients, use of census tract demographic data may allow for determination of likely characteristics of groups of patients for epidemiological and injury prevention purposes. The amount of GIS data available free online has exploded in the past 10 years. Future GIS analysis will include new social determinants for access to quality trauma care and trauma outcomes.Common psychiatric problems, including conduct disorder, depression and anxiety, are important risk factors for alcohol and marijuana use in adolescence.