Age-related mortality risk in cycling trauma: analysis of the National Trauma Databank 2017–2023

Buttazzoni A., Pham J., Nelson Ferguson K., Fabri E., Clark A., Tobin D., Frisbee N., Gilliland J.

Keppner V., Krumpoch S., Kob R., Rappl A., Sieber C.C., Freiberger E., Siebentritt H.M.

Abstract Background The risk of older adults being injured or killed in a bicycle accident increases significantly due to the age-related decline of physical function. Therefore, targeted interventions for older adults to improve safe cycling competence (CC) are urgently needed. Methods The “Safer Cycling in Older Age” (SiFAr) randomized controlled trial investigated if a progressive multi-component training program related to cycling improves CC of older adults. Between June 2020 and May 2022, 127 community-dwelling persons living in the area Nürnberg-Fürth-Erlangen, Germany aged 65 years and older were recruited, who are either (1) beginners with the e-bike or (2) feeling self-reported unsteadiness when cycling or (3) uptaking cycling after a longer break. Participants were either randomized 1:1 to an intervention group (IG; cycling exercise program, 8 sessions within 3 months) or an active control group (aCG; health recommendations). The CC as primary outcome was tested not blinded in a standardized cycle course prior and after the intervention period and after 6–9 months, which consists of variant tasks requiring skills related to daily traffic situations. Regression analyses with difference of errors in the cycling course as dependent variable and group as independent variable adjusted for covariates (gender, number of errors at baseline, bicycle type, age and cycled distance) were performed. Results 96 participants (73.4 ± 5.1 years; 59.4% female) were analyzed for primary outcome. Compared to the aCG (n = 49), the IG (n = 47) made an average of 2.37 fewer errors in the cycle course after the 3 months intervention period (p = 0.004). People with more errors at baseline had higher potential for improvement (B=-0.38; p < 0.001). Women on average made 2.31 (p = 0.016) more errors than men, even after intervention. All other confounders had no significant effect on the difference in errors. The intervention effect was very stable until 6–9 months after the intervention (B=-3.07, p = 0.003), but decreased with a higher age at baseline in the adjusted model (B = 0.21, p = 0.0499). Conclusion The SiFAr program increases cycling skills among older adults with self-perceived needs for improvement in CC and could easily be made available to a broad public due to its standardized structure and a train-the-trainer approach. Trial Registration This study was registered with clinicaltrials.gov: NCT04362514 (27/04/2020), https://clinicaltrials.gov/ct2/show/NCT04362514.

Barbiellini Amidei C., Trevisan C., Dotto M., Ferroni E., Noale M., Maggi S., Corti M.C., Baggio G., Fedeli U., Sergi G.

IntroductionCardiovascular benefits deriving from physical activity are well known, but it is unclear whether physical activity trajectories in late life are associated with different risks of cardiovascular diseases.MethodsProgetto Veneto Anziani (Pro.V.A.) is a cohort study of 3099 Italians aged ≥65 years with baseline assessment in 1995–1997 and follow-up visits at 4 and 7 years. Surveillance was extended to 2018 by linkage with hospital and mortality records. Prevalent and incident cardiovascular diseases (coronary heart disease, heart failure and stroke) were identified through clinical examination, questionnaire, or hospital records. Moderate to vigorous physical activity was considered as a time-varying variable. Physical activity trajectories were categorised as: stable-low, high-decreasing, low-increasing and stable-high. Exposure was also assessed at 70, 75, 80 and 85 years.ResultsOverall, physical activity was associated with lower rates of incident cardiovascular diseases. A significant risk reduction was present among men and was stronger earlier in late life (70–75 years). Trajectories of stable-high physical activity were associated with a significantly lower risk of cardiovascular outcomes among men (HR 0.48, 95% CI 0.27 to 0.86) compared with those with stable-low trajectories (p for trend 0.002). No significant association was found with stroke. The greatest cardiovascular risk reduction was observed for >20 min/day of physical activity, and was more marked at 70 years.ConclusionIncreasingly active trajectories of physical activity were associated with lower rates of cardiovascular diseases and overall mortality. Promoting at least 20 min/day of physical activity early in late life seems to provide the greatest cardiovascular benefits.

Salmon P.M., Naughton M., Hulme A., McLean S.

• Bicycle crash causation is a critical area for road safety research. • We conducted a systematic review of bicycle crash contributory factors. • Most studies focus on the road environment, cyclist infrastructure, and cyclist and driver behaviour. • Few studies examined causal relationships between contributory factors. • Gaps exist in the knowledge base regarding bicycle crash causation. There is a growing body of road safety research that seeks to identify crash contributory factors beyond road users, their vehicles, and the immediate road environment. Although cyclist safety represents a critical research area, this ‘systems thinking’ approach has received less attention in bicycle crash analysis. This article presents the findings from a systematic literature review which aimed to synthesise the peer reviewed literature regarding bicycle crash contributory factors (defined as factors which play a contributory role in bicycle crashes, as opposed to risk factors which are factors which may increase the probability of crashes). Crash contributory factors were extracted from included articles and mapped onto a systems thinking framework comprising seven hierarchical road transport system levels. The findings show that a majority of the included studies identified contributory factors relating to the road environment, cycling infrastructure, and cyclist and driver behaviour. No studies identified contributory factors outside of cyclists and road users, bicycles and vehicles, and the road environment and few specifically examined causal relationships between contributory factors. It is concluded that there are gaps in the knowledge base regarding the broader transport system features that play a role in bicycle crashes and how contributory factors interact to create crashes. We argue that more expansive research into the systemic factors involved in bicycle crashes is required and that initial work should focus on the development of new data sources and analysis methods.

Karam B.S., Patnaik R., Murphy P., deRoon-Cassini T.A., Trevino C., Hemmila M.R., Haines K., Puzio T.J., Charles A., Tignanelli C., Morris R.

Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care.This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality.There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49).Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics.Therapeutic/Care Management, Level IV.

Boufous S., Beck B., Macniven R., Pettit C., Ivers R.

To investigate facilitators and barriers to all types of cycling in adults aged ≥50 years. An online survey of 1335 cyclists aged ≥50 years residents of New South Wales (NSW), Australia. Almost all participants (98.5%) reported physical health and fitness as a reason for riding a bicycle, followed by mental health (68.1%), social (58.3%) and environmental reasons (44%). Top reported barriers to cycling included motorist behaviour or aggression (34.4%), speed and volume of traffic (27.1%), proximity to motor vehicle traffic (26%) and not enough separated bike lanes (22.7%). Females and occasional riders were significantly more likely to report these barriers than men and regular riders respectively. Key facilitators included improved attitudes towards cyclists compared to current attitudes (69.5%), separate bike lanes (63.4%), education and training of motorists (57.5%). Strategies designed to improve cycling participation in older adults need to address barriers to cycling and to tailor interventions for under-represented groups such females. • Physical and mental health are the main reasons for riding among older adult cyclists. • Safety concerns are the main barriers to cycling among older cyclists. • These barriers were more likely to be reported by females compared to males. • Females were more likely to report positive attitudes towards cyclists and improved cycling infrastructure, as the main facilitators of cycling.

Buehler R., Pucher J.

The COVID-19 pandemic has had an enormous impact on travel behaviour in most of the world. This editorial examines the available evidence about the impact of the pandemic on cycling in various citi...

Poulton A., Shaw J.F., Nguyen F., Wong C., Lampron J., Tran A., Lalu M.M., McIsaac D.I.

Frailty strongly predicts adverse outcomes in a variety of clinical settings; however, frailty-related trauma outcomes have not been systematically reviewed and quantitatively synthesized. Our objective was to systematically review and meta-analyze the association between frailty and outcomes (mortality-primary; complications, health resource use, and patient experience-secondary) after multisystem trauma.After registration (CRD42018104116), we applied a peer-reviewed search strategy to MEDLINE, EMBASE, and Comprehensive Index to Nursing and Allied Health Literature (CINAHL) from inception to May 22, 2019, to identify studies that described: (1) multisystem trauma; (2) participants ≥18 years of age; (3) explicit frailty instrument application; and (4) relevant outcomes. Excluded studies included those that: (1) lacked a comparator group; (2) reported isolated injuries; and (3) reported mixed trauma and nontrauma populations. Criteria were applied independently, in duplicate to title/abstract and full-text articles. Risk of bias was assessed using the Risk of Bias in Nonrandomized Studies-of Interventions (ROBINS-I) tool. Effect measures (adjusted for prespecified confounders) were pooled using random-effects models; otherwise, narrative synthesis was used.Sixteen studies were included that represented 5198 participants; 9.9% of people with frailty died compared to 4.2% of people without frailty. Frailty was associated with increased mortality (adjusted odds ratio [OR], 1.53; 95% confidence interval [CI], 1.37-1.71), complications (adjusted OR, 2.32; 95% CI, 1.72-3.15), and adverse discharge (adjusted OR, 1.78; 95% CI, 1.29-2.45). Patient function, experience, and resource use outcomes were rarely reported.The presence of frailty is significantly associated with mortality, complications, and adverse discharge disposition after multisystem trauma. This provides important prognostic information to inform discussions with patients and families and highlights the need for trauma system optimization to meet the complex needs of older patients.

Scholes S., Wardlaw M., Anciaes P., Heydecker B., Mindell J.S.

Fatality rates based on deaths only to the drivers themselves do not accurately portray the impact of driving on road traffic deaths. We characterised more fully the impact of driving and cycling on road traffic fatalities by including deaths to all the other road users in fatal car or cycle crashes. We used crash data from the Great Britain National Road Accident Database (STATS19) and exposure data from the National Travel Survey. Rates were estimated as the ratio of fatalities to the amount of time travelled: fatalities per million hours’ use (f/mhu). Rates in 2005-07, 2008-10, and 2011-13 were calculated based on deaths to: (1) the drivers or cyclists themselves (persons ‘in charge’ of vehicles), (2) other, i.e. ‘third-party’, road users (e.g. passengers, drivers or riders of other vehicles, and pedestrians), and (3) both of these groups combined, i.e. all road users. Rates were stratified by the sex and age of the drivers or cyclists involved in the fatal crashes. Rates based on deaths to persons in charge of vehicles were higher for cyclists than for drivers, whereas those based on deaths to third-party road users showed the opposite. The inclusion of third-party deaths increased the overall rates considerably more for drivers than for cyclists. Nevertheless, the overall rate for male cyclists (2011-13: 0.425 f/mhu; 95% Confidence Interval (CI): 0.377–0.478) exceeded that for male drivers (0.257 f/mhu; 95% CI: 0.248–0.267). A similar pattern was observed for females (cycling: 0.216 f/mhu; 95% CI: 0.158–0.287; driving: 0.127 f/mhu; 95% CI: 0.120–0.135). These differences between cars and cycles were overestimated as the safer travel on motorways could not be disaggregated in the estimates for driving. The higher rates for cycling - mainly borne by the cyclists themselves - need to be balanced against the substantially lower risks to other road users.

Konda S.R., Lott A., Saleh H., Schubl S., Chan J., Egol K.A.

Introduction: Frailty in elderly trauma populations has been correlated with an increased risk of morbidity and mortality. The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated mortality risk score that evaluates 4 major physiologic criteria: age, comorbidities, vital signs, and anatomic injuries. The aim of this study was to investigate whether the addition of additional frailty variables to the STTGMA tool would improve risk stratification of a middle-aged and elderly trauma population. Methods: A total of 1486 patients aged 55 years and older who met the American College of Surgeons Tier 1 to 3 criteria and/or who had orthopedic or neurosurgical traumatic consultations in the emergency department between September 2014 and September 2016 were included. The STTGMAORIGINAL and STTGMAFRAILTY scores were calculated. Additional “frailty variables” included preinjury assistive device use (disability), independent ambulatory status (functional independence), and albumin level (nutrition). The ability of the STTGMAORIGINAL and the STTGMAFRAILTY models to predict inpatient mortality was compared using area under the receiver operating characteristic curves (AUROCs). Results: There were 23 high-energy inpatient mortalities (4.7%) and 20 low-energy inpatient mortalities (2.0%). When the STTGMAORIGINAL model was used, the AUROC in the high-energy and low-energy cohorts was 0.926 and 0.896, respectively. The AUROC for STTGMAFRAILTY for the high-energy and low-energy cohorts was 0.905 and 0.937, respectively. There was no significant difference in predictive capacity for inpatient mortality between STTGMAORIGINAL and STTGMAFRAILTY for both the high-energy and low-energy cohorts. Conclusion: The original STTGMA tool accounts for important frailty factors including cognition and general health status. These variables combined with other major physiologic variables such as age and anatomic injuries appear to be sufficient to adequately and accurately quantify inpatient mortality risk. The addition of other common frailty factors that account for does not enhance the STTGMA tool’s predictive capabilities.

Drendel A.L., Gray M.P., Lerner E.B.

Hospital trauma activation criteria are intended to identify children who are likely to require aggressive resuscitation or specific surgical interventions that are time sensitive and require the resources of a trauma team at the bedside. Evidence to support criteria is limited, and no prior publication has provided historical or current perspectives on hospital practices toward informing best practice. This study aimed to describe the published variation in (1) highest level of hospital trauma team activation criteria for pediatric patients and (2) hospital trauma team membership and (3) compare these finding to the current ACS recommendations.Using an Ovid MEDLINE In-Process & Other Non-Indexed Citations search, any published description of hospital trauma team activation criteria for children that used information captured in the prehospital setting was identified. Only studies of children were included. If the study included both adults and children, it was included if the number of children assessed with the criteria was included.Eighteen studies spanning 20 years and 13,184 children were included. Hospital trauma team activation and trauma team membership were variable. Nearly all (92%) of the trauma criteria used physiologic factors. Penetrating trauma (83%) was frequently included in the trauma team activation criteria. Mechanisms of injury (52%) were least likely to be included in the highest level of activation. No predictable pattern of criterion adoption was found. Only 2 of the published criteria and 1 of published trauma team membership are consistent with the current American College of Surgeons recommendations.Published hospital trauma team activation criteria and trauma team membership for children were variable. Future prospective studies are needed to define the optimal hospital trauma team activation criteria and trauma team membership and assess its impact on improving outcomes for children.

Celis-Morales C., Livingstone K.M., Marsaux C.F., Macready A.L., Fallaize R., O’Donovan C.B., Woolhead C., Forster H., Walsh M.C., Navas-Carretero S., San-Cristobal R., Tsirigoti L., Lambrinou C.P., Mavrogianni C., Moschonis G., et. al.

Optimal nutritional choices are linked with better health, but many current interventions to improve diet have limited effect. We tested the hypothesis that providing personalized nutrition (PN) advice based on information on individual diet and lifestyle, phenotype and/or genotype would promote larger, more appropriate, and sustained changes in dietary behaviour.: Adults from seven European countries were recruited to an internet-delivered intervention (Food4Me) and randomized to: (i) conventional dietary advice (control) or to PN advice based on: (ii) individual baseline diet; (iii) individual baseline diet plus phenotype (anthropometry and blood biomarkers); or (iv) individual baseline diet plus phenotype plus genotype (five diet-responsive genetic variants). Outcomes were dietary intake, anthropometry and blood biomarkers measured at baseline and after 3 and 6 months' intervention.At baseline, mean age of participants was 39.8 years (range 18-79), 59% of participants were female and mean body mass index (BMI) was 25.5 kg/m 2 . From the enrolled participants, 1269 completed the study. Following a 6-month intervention, participants randomized to PN consumed less red meat [-5.48 g, (95% confidence interval:-10.8,-0.09), P = 0.046], salt [-0.65 g, (-1.1,-0.25), P = 0.002] and saturated fat [-1.14 % of energy, (-1.6,-0.67), P < 0.0001], increased folate [29.6 µg, (0.21,59.0), P = 0.048] intake and had higher Healthy Eating Index scores [1.27, (0.30, 2.25), P = 0.010) than those randomized to the control arm. There was no evidence that including phenotypic and phenotypic plus genotypic information enhanced the effectiveness of the PN advice.Among European adults, PN advice via internet-delivered intervention produced larger and more appropriate changes in dietary behaviour than a conventional approach.

Bouaoun L., Sonkin D., Ardin M., Hollstein M., Byrnes G., Zavadil J., Olivier M.

TP53 gene mutations are one of the most frequent somatic events in cancer. The IARC TP53 Database (http://p53.iarc.fr) is a popular resource that compiles occurrence and phenotype data on TP53 germline and somatic variations linked to human cancer. The deluge of data coming from cancer genomic studies generates new data on TP53 variations and attracts a growing number of database users for the interpretation of TP53 variants. Here, we present the current contents and functionalities of the IARC TP53 Database and perform a systematic analysis of TP53 somatic mutation data extracted from this database and from genomic data repositories. This analysis showed that IARC has more TP53 somatic mutation data than genomic repositories (29,000 vs. 4,000). However, the more complete screening achieved by genomic studies highlighted some overlooked facts about TP53 mutations, such as the presence of a significant number of mutations occurring outside the DNA-binding domain in specific cancer types. We also provide an update on TP53 inherited variants including the ones that should be considered as neutral frequent variations. We thus provide an update of current knowledge on TP53 variations in human cancer as well as inform users on the efficient use of the IARC TP53 Database.

Teyhan A., Cornish R., Boyd A., Sissons Joshi M., Macleod J.

Cycle accidents are a common cause of physical injury in children and adolescents. Education is one strategy to reduce cycle-related injuries. In the UK, some children undertake National Cycle Proficiency Scheme [NCPS] training (now known as Bikeability) in their final years of primary school. It aims to promote cycling and safe cycling behaviours but there has been little scientific evaluation of its effectiveness. The sample (n = 5415) were participants in the Avon Longitudinal Study of Parents and Children who reported whether or not they had received NCPS training. Outcomes were self-reported at 14 and 16 years: cycling to school, ownership of cycle helmet, use of cycle helmet and high-visibility clothing on last cycle, and involvement in a cycle accident. An additional outcome, hospital admittance due to a cycle accident from 11 to 16 years, was also included for a subsample (n = 2222) who have been linked to Hospital Episode Statistics (HES) data. Approximately 40 % of the sample had received NCPS training. Trained children were more likely to cycle to school and to own a cycle helmet at both 14 and 16 years, to have worn a helmet on their last cycle at age 14, and to have worn high-visibility clothing at age 16, than those who had not attended a course. NCPS training was not associated with self-reported involvement in a cycle accident, and only six of those with HES data had been admitted to hospital due to a cycle accident. Irrespective of training, results indicate very low use of high-visibility clothing, very few girls cycling as part of their school commute, and less than half of helmet owners wearing one on their last cycle. Our results suggest cycle training courses for children can have benefits that persist into adolescence. However, the low use of cycle helmets, very low use of high-visibility clothing, and low levels of cycling to school for girls, indicate the further potential for interventions to encourage cycling, and safe cycling behaviours, in young people.

Liu Y., De A.

Missing data commonly occur in large epidemiologic studies. Ignoring incompleteness or handling the data inappropriately may bias study results, reduce power and efficiency, and alter important risk/benefit relationships. Standard ways of dealing with missing values, such as complete case analysis (CCA), are generally inappropriate due to the loss of precision and risk of bias. Multiple imputation by fully conditional specification (FCS MI) is a powerful and statistically valid method for creating imputations in large data sets which include both categorical and continuous variables. It specifies the multivariate imputation model on a variable-by-variable basis and offers a principled yet flexible method of addressing missing data, which is particularly useful for large data sets with complex data structures. However, FCS MI is still rarely used in epidemiology, and few practical resources exist to guide researchers in the implementation of this technique. We demonstrate the application of FCS MI in support of a large epidemiologic study evaluating national blood utilization patterns in a sub-Saharan African country. A number of practical tips and guidelines for implementing FCS MI based on this experience are described.