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OBJECTIVE: To quantify the prevalence and effects of distracting activities while driving. DESIGN: Cross sectional driver survey. SETTING: New South Wales and Western Australia, Australia. PARTICIPANTS: 1347 licensed drivers aged between 18 and 65 years. Data were weighted to reflect the corresponding driving population. MAIN OUTCOME MEASURES: Prevalence of distracting activities while driving; perceived risks and adverse outcomes due to distractions. RESULTS: The most common distracting activities during the most recent driving trip were lack of concentration (weighted percentage (standard error, SE) 71.8% (1.4%) of drivers); adjusting in-vehicle equipment (68.7% (1.5%)); outside people, objects or events (57.8% (1.6%)); and talking to passengers (39.8% (1.6%)). On average, a driver engaged in a distracting activity once every six minutes. One in five crashes (21%) during the last three years, involving one in 20 drivers (5.0% (0.7%)), was attributed to driver distraction based on self-report. In the population under study, this equated to 242,188 (SE 34,417) drivers. Younger drivers (18-30 years) were significantly more likely to report distracting activities, to perceive distracting activities as less dangerous, and to have crashed as a result. CONCLUSIONS: Distracting activities while driving are common and can result in driving errors. Driver distraction is an important cause of crashes. Further research is needed to estimate the risk conferred by different distracting activities and the circumstances during which activities pose greatest risk. These results suggest that a strategy to minimize distracting activities while driving, with a focus on young drivers, is indicated. [ABSTRACT FROM AUTHOR]

Objective: To describe the trends in recreational sports injury in Perth, Western Australia.Design: A prospective cohort study of sports injuries during the 1997 winter season (May to September).Setting: Sample of Australian football, field hockey, basketball, and netball players from the Perth metropolitan area, Western Australia.Methods: A cohort of sports participants was followed over the five month winter sports season. Before the season, participants completed a baseline questionnaire and during the season were interviewed every four weeks by telephone.Results: Overall, 92% of participants (n = 1391) who completed a baseline questionnaire completed at least one follow up telephone interview. About half (51%) of the cohort sustained one or more injuries during the winter season accounting for a total of 1034 injuries. Most injuries were of moderate (58%, n = 598) or minor (40%, n = 412) severity, with only 3% (n = 24) requiring emergency department treatment or a hospital stay. The injury incidence rate was greatest for football (20.3/1000 hours of participation), similar for field hockey and basketball (15.2/1000 hours and 15.1/1000 hours respectively), and lowest for netball (12.1/1000 hours). The incidence of injury was greatest in the first four weeks of the season, and participants aged between 26 and 30 years had about a 55% greater risk of injury than those aged less than 18 years.Conclusions: This is one of the first studies to show that recreational sports are safe. Although the likelihood of injury was greatest in the first month of the season, few injuries required admission to hospital or emergency department treatment. A greater emphasis on prevention in the early part of the season should help to reduce the elevated incidence of injury found at this time. [ABSTRACT FROM AUTHOR]

Investigates the influence of dental to facial midline discrepancies on dental attractiveness rating. Components of functional occlusion; Treatment of malocclusion; Establishment of buccal inter-digitation; Impact of symmetrical dental arrangement on smile.

This study reports the time to sustain a mild traumatic brain injury (mTBI) among a cohort of community rugby union players. Demographic and player characteristics were collected and players followed up for between one and three playing seasons. 7% of the cohort sustained an mTBI within 10 h of game time, increasing twofold to 14% within 20 h. The mean time to first mTBI was 8 h with an SD of 6.2 (median 6.8 h; IQR: 2.9-11.7 h). Players reporting a recent history of concussion were 20% more likely to sustain an mTBI after 20 h of game time compared with those with no recent history of concussion. Players were likely to sustain an mTBI in shorter time if they trained for <3 h/week (HR=1.48, p=0.03) or had a body mass index <27 (HR=1.77, p=0.007). The findings highlight modifiable characteristics to reduce the likelihood of shortened time to mTBI. [ABSTRACT FROM AUTHOR]

Australia, the United States, and other developed countries, offer elementary school programs that heighten childrens' awareness about the possibility of abduction. To examine the effectiveness of such programs, an investigation was conducted of the proportion of elementary school children previously taught about 'stranger' abduction and who detected they were being followed. Fifteen children were observed on four separate occasions during a seven-month period. Only 3% of the observations were detected by children. Several reasons are proposed for the poor detection rate, and recommendations for elementary school programs are made. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To investigate the causes of child drowning and determine the need for changes in the legislation as well as improvements to the inspection and enforcement of current legislation related to barriers surrounding private swimming pools. METHODS: There were 3 stages to the study: a retrospective review of coroner's data, an audit of swimming pool inspections, and in-depth interviews with swimming pool inspectors in Western Australia. The incidence of childhood drowning (per population) and compliance rates of swimming pools (per 1000 swimming pools) to the legislation were measured. RESULTS: During the 12-year observational period (1988-2000) 50 children younger than 5 years drowned in private swimming pools in Western Australia with an overall incidence of drowning of 4.4 per 100 000 children per year. Sixty-eight percent of drownings occurred in pools that did not have 4-sided fencing with an almost 2-fold increased risk (incidence rate ratio: 1.78; 95% confidence interval: 1.40-1.79) of a child's drowning in a swimming pool with 3-sided versus 4-sided fencing. The compliance rate of swimming pools (compliance to the current legislation) at first inspection was approximately 400 per 1000 swimming pools. CONCLUSIONS: Almost two thirds of the swimming pools in which children drowned had only 3-sided fencing. With a combination of a change in legislation, enhanced inspection processes, and public education, the incidence of drowning in private swimming pools in Western Australia could be reduced in the coming years. [ABSTRACT FROM AUTHOR]

Introduction: Self-harm and suicide are leading causes of morbidity and death for young people, worldwide. Previous research has identified self-harm is a risk factor for vehicle crashes, however, there is a lack of long-term crash data post licensing that investigates this relationship. We aimed to determine whether adolescent self-harm persists as crash risk factor in adulthood., Methods: We followed 20 806 newly licensed adolescent and young adult drivers in the DRIVE prospective cohort for 13 years to examine whether self-harm was a risk factor for vehicle crashes. The association between self-harm and crash was analysed using cumulative incidence curves investigating time to first crash and quantified using negative binominal regression models adjusted for driver demographics and conventional crash risk factors., Results: Adolescents who reported self-harm at baseline were at increased risk of crashes 13 years later than those reporting no self-harm (relative risk (RR) 1.29: 95% CI 1.14 to 1.47). This risk remained after controlling for driver experience, demographic characteristics and known risk factors for crashes, including alcohol use and risk taking behaviour (RR 1.23: 95% CI 1.08 to 1.39). Sensation seeking had an additive effect on the association between self-harm and single-vehicle crashes (relative excess risk due to interaction 0.87: 95% CI 0.07 to 1.67), but not for other types of crashes., Discussion: Our findings add to the growing body of evidence that self-harm during adolescence predicts a range of poorer health outcomes, including motor vehicle crash risks that warrant further investigation and consideration in road safety interventions. Complex interventions addressing self-harm in adolescence, as well as road safety and substance use, are critical for preventing health harming behaviours across the life course., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The study examines changes over time in crash risk differences between young Australian drivers born in Asia and those born in Australia.Data from the 2003 baseline survey of the DRIVE cohort of 20 806 young drivers aged 17-24 years were linked to police, hospital and death data up until 2016. The association between country of birth and crash was investigated using flexible parametric survival models adjusted for confounders.Six months after baseline, the crash risk in Asian-born drivers was less than half that of their Australian-born counterparts (mean HR, MHR 0.41; 95% CI 0.29 to 0.57), only to increase steadily over time to resemble that of Australian-born drivers 13 years later (MHR 0.94; 95% CI 0.66 to 1.36).This is likely to be associated with acculturation and the adoption by young Asian-born Australian drivers of driving behaviour patterns akin to those born locally. This needs to be considered in future road safety campaigns., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The efficacy and safety of primary re-irradiation for MSCC are not known. Our aim was to establish the efficacy and safety of biologically effective dose-based re-irradiation., Methods: Patients presenting with MSCC at a previously irradiated spine segment, and not proceeding with surgical decompression, were eligible. A 3 Gray per fraction experimental schedule (minimum 18 Gy/6 fractions, maximum 30 Gy/10 fractions) was used, delivering a maximum cumulative spinal dose of 100 Gy 2 if the interval since the last radiotherapy was within 6 months, or 130 Gy 2 if longer. The primary outcome was a change in mobility from week 1 to week 5 post-treatment, as assessed by the Tomita score. The RTOG SOMA score was used to screen for spinal toxicity, and an MRI performed to assess for radiation-induced myelopathy (RIM)., Results: Twenty-two patients were enroled, of whom eleven were evaluable for the primary outcome. Nine of eleven (81.8%) had stable or improved Tomita scores at 5 weeks. One of eight (12.5%) evaluable for late toxicity developed RIM., Conclusions: Re-irradiation is an efficacious treatment for MSCC. There is a risk of RIM with a cumulative dose of 120 Gy 2 ., Clinical Trial Registration: Cancer Trials Ireland (ICORG 07-11); NCT00974168., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: The optimal EBRT schedule for MSCC is undetermined. Our aim was to determine whether a single fraction (SF) was non-inferior to five daily fractions (5Fx), for functional motor outcome., Methods: Patients not proceeding with surgical decompression in this multicentre non-inferiority, Phase 3 trial were randomised to 10 Gy/SF or 20 Gy/5Fx. A change in mobility from baseline to 5 weeks for each patient, was evaluated by a Modified Tomita score: 1 = 'Walk unaided', 2 = 'With walking aid' and 3 = 'Bed-bound'. The margin used to establish non-inferiority was a detrimental change of -0.4 in the mean difference between arms., Results: One-hundred and twelve eligible patients were enrolled. Seventy-three patients aged 30-87 were evaluated for the primary analysis. The 95% CI for the difference in the mean change in mobility scores between arms was -0.12 to 0.6. Since -0.4 is not included in the interval, there is evidence that 10 Gy/SF is non-inferior to 20 Gy/5Fx. One grade 3 AE was reported in the 5Fx arm. Twelve (26%) patients in the 5Fx arm had a Grade 2-3 AE compared with six (11%) patients in the SF arm (p = 0.093)., Conclusion: For mobility preservation, one 10-Gy fraction is non-inferior to 20 Gy in five fractions, in patients with MSCC not proceeding with surgical decompression., Clinical Trial Registration: Cancer Trials Ireland ICORG 05-03; NCT00968643; EU-20952.

The safety in numbers (SiN) effect for cyclists is widely observed but remains poorly understood. Although most studies investigating the SiN phenomenon have focused on behavioural adaptation to 'numbers' of cyclists in the road network, previous work in simulated environments has suggested SiN may instead be driven by increases in local cyclist spatial density, which prevents drivers from attempting to move through groups of oncoming cyclists. This study therefore set out to validate the results of prior simulation studies in a real-world environment. Time-gap analysis of cyclists passing through an intersection was conducted using 5 hours of video observation of a single intersection in the city of Melbourne, Australia, where motorists were required to 'yield' to oncoming cyclists. Results demonstrated that potential collisions between motor vehicles and cyclists reduced with increasing cyclists per minute passing through the intersection. These results successfully validate those observed under simulated conditions, supporting evidence of a proposed causal mechanism related to safety in density rather than SiN, per se. Implications of these results for transportation planners, cyclists and transportation safety researchers are discussed, suggesting that increased cyclist safety could be achieved through directing cyclists towards focused, strategic corridors rather than dispersed across a network., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Compared with crashes with motor vehicles, single-bicycle crashes are an under-recognised contributor to cycling injury and the aetiology is poorly understood. Using an in-depth crash investigation technique, this study describes the crash characteristics and patient outcomes of a sample of cyclists admitted to hospital following on-road bicycle crashes. Enrolled cyclists completed a structured interview, and injury details and patient outcomes were extracted from trauma registries. Single-bicycle crashes (n=62) accounted for 48% of on-road crashes and commonly involved experienced cyclists. Common single-bicycle crash types included loss-of-control events, interactions with tram tracks, striking potholes or objects or resulting from mechanical issues with the bicycle. To address single-bicycle crashes, targeted countermeasures are required for each of these specific crash types., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Use of mobile phones and portable audio equipment and alcohol are known to negatively affect cycling ability. Evidence suggests that cyclists may be less likely to engage in these behaviours while riding in a group; however, it is unknown whether group riders are also at reduced risk when participating in non-group riding., Objective: To examine the association between group riding participation and the use of mobile phones and portable audio equipment and alcohol while non-group riding in Perth, Western Australia., Methods: A cross-sectional analysis of an online questionnaire was undertaken. Group and exclusive non-group riders were compared and separate binary logistic regression models were used to examine the association between group riding participation and the use of mobile phones and portable audio equipment and alcohol while non-group riding, controlling for gender, age, education and frequency of non-group riding., Results: Participants included 365 cyclists: 187 exclusive non-group riders (51.2%) and 178 group riders (48.8%). Group riders were less likely to have possibly cycled while over the legal blood alcohol limit in the past 12 months (OR: 0.56, 95% CI 0.34 to 0.92) and were less likely to ever use portable audio equipment (OR: 0.57, 95% CI 0.34 to 0.94) than exclusive non-group riders, while participating in non-group riding. Group riding status was not associated with mobile phone use., Conclusions: This study provides early evidence that there may be differences between group and non-group riders that impact on their safety behaviours while participating in non-group riding., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To examine determinants of firefighting simulation test performance., Methods: Sixty-eight (63 male; 5 female) firefighters completed a firefighting simulation (eg, equipment carry, casualty evacuation) previously validated to test occupational fitness among UK firefighters. Multiple linear regression methods were used to determine physiological and physical attributes that best predicted completion time., Results: Mean (±SD) time taken to complete the simulation was 610 (±79) seconds. The prediction model combining absolute cardiorespiratory capacity (L min) and fat mass explained the greatest variance in performance and elicited the least random error (R = 0.765, R = 0.585, standard error of the estimate [SEE]: ±52 seconds). Higher fitness and lower fat mass were associated with faster performance., Conclusions: Firefighter simulation test performance is associated with absolute cardiorespiratory fitness and fat mass. Fitter and leaner individuals perform the task more quickly. Work-based interventions should enhance these attributes to promote safe and effective operational performance.

Purpose: To describe the photoreceptor-retinal pigment epithelium (RPE) interface changes and to analyze the relationships between these features and hyperreflective material (HRM) with scarring and atrophy at the macula of patients with neovascular age-related macular degeneration (nAMD)., Design: Retrospective single-center observational study., Participants: A total of 150 eyes from 144 patients with naive nAMD were included., Methods: All patients had OCT (HRA-OCT Spectralis, Heidelberg Engineering, Heidelberg, Germany) at baseline and at 1, 3, 6, and 12 months. Macular scar and macular atrophy (MA) were determined on multimodal imaging, including color fundus (CF) and near-infrared imaging at baseline and month 12 (M12)., Main Outcome Measures: Change in HRM type (undefined and well-defined) and location, development of fibrotic or nonfibrotic macular scar, MA, and best-corrected visual acuity (BCVA) at M12., Results: At baseline, eyes with fibrin on CF had thicker and wider HRM on OCT that correlated strongly with presence of undefined HRM. The proportion of eyes with undefined HRM fell dramatically by month 1 but well-defined HRM increased. At M12 defined HRM was strongly associated with macular scar (chi-square, 82.1; P < 0.001). Ordinal regression showed that both the thickness and the width of HRM were significant risk factors for development of fibrotic scar (P < 0.001 and P = 0.02) but not nonfibrotic scars (P = 0.67 and P = 0.65). Fibrotic macular scar (P = 0.001) but not nonfibrotic scar (P = 0.129) negatively affected visual acuity at M12. Ordinal regression showed that the risk factors for progression to MA were reticular pseudodrusen and thinner HRM (P = 0.017 and P = 0.028, respectively). MA negatively affected BCVA at M12 (P < 0.001)., Conclusion: Our study supports the role of HRM as an important biomarker for the evolution of macular scar and atrophy in patients with nAMD undergoing treatment with anti-VEGF therapies. Undefined HRM can resolve with treatment, whereas well-defined HRM likely contains vascular complexes and fibrotic elements., (Copyright © 2017 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study is to describe key risks related to dooring collisions on roads in mixed function activity centers by examining video footage recorded onboard the bicycles of cyclists riding through this road environment. The study aims to enhance our understanding of the risk associated with cyclist door collisions on these roads and to provide a focus for future studies that aim to identify measures that enhance cyclist safety., Method: The study measured 4 key risk exposures (per hour and kilometer), namely, on-street parked cars and 3 conditions associated with parked cars being accessed or egressed: door opened (a) after the cyclist passes (give-way event); (b) in the path of the cyclist without collision (obstruction event); and (c) in the path of the cyclist with collision (collision event). Exposure to the risk factors was measured using video footage recorded onboard the bicycles of adult cyclists (n = 25) as they rode through this road environment. The average speed of cyclists was also estimated from these video data and related to the measures of exposure., Results: The cycling experiences of the participants were observed over 3 h 58 min and 84.0 km. On average, the sample was exposed to 1,166 parked car events per hour (55 per kilometer), 6.9 give-way events per hour (0.3 per kilometer), 2.3 obstruction events per hour (0.1 per kilometer), and no collision events. There were 9 instances of obstruction events. In most cases, the cyclist was clearly visible (n = 7; 77.8%) and modified his or her position to avoid the door (n = 8; 88.9%). Moreover, the door was opened by the driver in nearly all cases (n = 8; 88.9%), primarily to exit the vehicle (n = 4; 44.4%) or enter the vehicle (n = 3; 33.3%). The average speed of cyclists was 22.7 km/h (SD = 4.1 km/h), and average speed tended to reduce as exposure to parked car events increased., Conclusion: Cyclists seldom interact with a vehicle occupant accessing or egressing a parked car, yet a concerning proportion of these interactions involve the occupant opening the door in the path of the cyclist, rather than waiting for the cyclist to pass. This suggests that there is still considerable need to identify measures that increase the likelihood that a vehicle occupant will look for cyclists before opening the car door, particularly in road environments where longer-term solutions such as physical separation are not readily achieved.

Objective: To determine the association between a heavy vehicle driver's work environment, including fatigue-related characteristics, and the risk of a crash in Western Australia., Methods: This case-control study included 100 long-haul heavy vehicle drivers who were involved in a police-reported crash in WA and 100 long-haul heavy vehicle drivers recruited from WA truck stops, who were not involved in a crash in the previous 12 months. Driver demographics and driving details, work environment, vehicle and sleep-related characteristics were obtained using an interviewer-administered questionnaire. Drivers were tested for obstructive sleep apnoea using an overnight diagnostic device. Conditional multiple logistic regression analysis was undertaken to determine work environment-related factors associated with crash involvement., Results: After accounting for potential confounders, driving a heavy vehicle with an empty load was associated with almost a three-fold increased crash risk compared to carrying general freight (adjusted OR: 2.93, 95% CI: 1.17-7.34). Driving a rigid heavy vehicle was associated with a four-fold increased risk of crashing compared to articulated heavy vehicles (adjusted OR: 4.08, 95% CI: 1.13-14.68). The risk of crashing was almost five times higher when driving more than 50% of the trip between midnight and 5.59am (adjusted OR: 4.86, 95% CI: 1.47-16.07). Furthermore, the risk of crashing significantly increased if the time since the last break on the index trip was greater than 2h (adjusted OR: 2.18, 95% CI: 1.14-4.17). Drivers with more than 10 years driving experience were 52% less likely to be involved in a crash (adjusted OR: 0.48, 95% CI: 0.23-0.99)., Conclusion: The results provide support for an association between a driver's work environment, fatigue-related factors, and the risk of heavy vehicle crash involvement. Greater attention needs to be paid to the creation of a safer work environment for long distance heavy vehicle drivers., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Postembryonic frog development requires a thyroid hormone (TH)-dependent metamorphic transition from an aquatic larva to a terrestrial frog. Such change in environment involves lung maturation in preparation for breathing air. However, little is known regarding the underlying molecular events and the role of THs in this process. Using quantitative real-time polymerase chain reaction, we evaluated Rana (Lithobates) catesbeiana lung mRNA transcripts representing key elements of TH and oxidative stress signaling pathways during natural and TH-induced precocious metamorphosis. TH induction was evaluated in two ways: 1) in vivo through interperitoneal injection of 10pmol/g body weight of 3,3', 5-triiodothyronine (T3) into premetamorphic tadpoles and analysis after 48h, and 2) in serum-free organ culture in the presence of 10nM T3 after 48h. Abundance of transcripts encoding the transcriptional regulators TH receptors α and β, TH-induced bZip protein, and CCAAT/enhancer binding protein 1 was increased during postembryonic development and following administration of exogenous THs to premetamorphic tadpoles in vivo and culture. In contrast, mRNA representing Krüppel-like factor 9 and cold-inducible RNA binding protein revealed differential effects between natural and precocious metamorphosis. Elevated levels of catalase and Cu/Zn superoxide dismutase mRNA were observed at the end of metamorphosis with transcript levels displaying minimal TH-dependency. No change in stress-responsive heat shock protein 30 mRNA abundance was noted. The results support a role for TH-dependent reprogramming of the lung transcriptome during frog development and reveal a requirement for increased antioxidant capacity following anuran metamorphosis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Identifying new and more robust assessments of proficiency/expertise (finding new "biomarkers of expertise") in histopathology is desirable for many reasons. Advances in digital pathology permit new and innovative tests such as flash viewing tests and eye tracking and slide navigation analyses that would not be possible with a traditional microscope. The main purpose of this study was to examine the usefulness of time-restricted testing of expertise in histopathology using digital images., Methods: 19 novices (undergraduate medical students), 18 intermediates (trainees), and 19 experts (consultants) were invited to give their opinion on 20 general histopathology cases after 1 s and 10 s viewing times. Differences in performance between groups were measured and the internal reliability of the test was calculated., Results: There were highly significant differences in performance between the groups using the Fisher's least significant difference method for multiple comparisons. Differences between groups were consistently greater in the 10-s than the 1-s test. The Kuder-Richardson 20 internal reliability coefficients were very high for both tests: 0.905 for the 1-s test and 0.926 for the 10-s test. Consultants had levels of diagnostic accuracy of 72% at 1 s and 83% at 10 s., Conclusions: Time-restricted tests using digital images have the potential to be extremely reliable tests of diagnostic proficiency in histopathology. A 10-s viewing test may be more reliable than a 1-s test. Over-reliance on "at a glance" diagnoses in histopathology is a potential source of medical error due to over-confidence bias and premature closure.

Study Objectives: To determine the association between obstructive sleep apnea (OSA), health-related factors and the likelihood of heavy vehicle crashes in Western Australia (WA)., Methods: This case-control study included 100 long-haul heavy vehicle drivers who were involved in a police-reported crash in WA during the study period (cases) and 100 long-haul heavy vehicle drivers recruited from WA truck stops, who were not involved in a crash during the past year (controls). Driver demographics, health, and fatigue-related characteristics were obtained using an interviewer administered questionnaire. Drivers were tested for OSA using a diagnostic Flow Wizard. Logistic regression was used to determine health-related factors associated with crash involvement among long distance heavy vehicle drivers., Results: Heavy vehicle drivers diagnosed with OSA through the use of the FlowWizard were over three times more likely to be involved in a crash than drivers without OSA (adjusted OR: 3.42, 95% CI: 1.34-8.72). The risk of crash was significantly increased if heavy vehicle drivers reported a diagnosis of depression (adjusted OR: 6.59, 95% CI: 1.30-33.24) or had not completed fatigue management training (adjusted OR: 6.05, 95% CI: 1.80-20.24). Crash risk was 74% lower among older drivers (> 35 years) than younger drivers (adjusted OR: 0.25, 95% CI: 0.08-0.82)., Conclusion: The results suggest that more rigorous screening and subsequent treatment of OSA and depression by clinicians as well as compulsory fatigue management training may reduce crashes among heavy vehicle drivers., Commentary: A commentary on this article appears in this issue on page 409., (© 2015 American Academy of Sleep Medicine.)

Hyperglycemia accentuates the injury produced by anoxia both in the central and peripheral nervous system. To understand whether this is a consequence of changes in metabolic pathways produced by anoxia, the effect of the metabolic substrate used by the rat peripheral nerve on the nerve action potential (NAP) was studied in the presence and absence of anoxia. In the continuously oxygenated state, the NAP was well preserved with glucose, lactate, as well as with high concentrations of sorbitol and fructose but not β-hydroxybutyrate, acetate or galactose. With intermittent anoxia, the pattern of substrate effects on the NAP changed markedly so that low concentrations of fructose became able to support neurophysiologic activity but not high concentrations of glucose. These alterations occurred gradually with repeated episodes of anoxia as reflected by the progressive increase in the time needed for the NAP to disappear during anoxia when using glucose as substrate. This "preconditioning" effect was not seen with other substrates and an opposite effect was seen with lactate. In fact, the rate at which the NAP disappeared during anoxia was not simply related to degree of recovery after anoxia. These are distinct phenomena. For example, the NAP persisted longest during anoxia in the setting of hyperglycemia but this was the state in which the anoxic damage was most severe. Correlating the results with existing literature on the metabolic functions of Schwann cells and axons generates testable hypotheses for the mechanism of hyperglycemic damage during anoxia and lead to discussions of the role for a metabolic shuttle between Schwann cells and axons as well as a potential important role of glycogen., (Copyright © 2014 IBRO. Published by Elsevier Ltd. All rights reserved.)

Objective: This study applied geospatial analysis to explore spatial trends in cycling-related injury in Melbourne, Australia, in order to identify an area where injury density was reducing against expectation. The crash characteristics and cycling environment of the identified area were examined to better understand factors related to cycling safety., Method: Two methods were used to examine spatial trends in cycling-related injury. Firstly, cycling injury density was calculated using a kernel density estimation method for the years 2000 to 2011. This was used to examine patterns in injury density across Melbourne over an extended time period. Secondly, absolute change in injury density was calculated between 2005 and 2011. From this, a geographical area presenting a reduced injury density was selected for a case study, and crash characteristics of the area were obtained for the observational period. This led to discussion on which changes to the cycling environment, if any, may be associated with the reduced injury rate., Results: Injury density in Melbourne had been progressively increasing between 2000 and 2011, with a nearly 3-fold increase in the peak injury density over that period. Decreases were observed in some locations between 2005 and 2011, and a geographical area to the southeast of Melbourne experienced a more significant decrease than others. This appeared to be associated with a combination of behavior and road infrastructure change, although a lack of data to verify change in cycling exposure prevented more definitive associations from being established., Conclusion: The apparent positive response of the injury rate to behavior and road infrastructure interventions is promising, yet the injury rate is unlikely to achieve the government's road safety target of 30% reduction in serious injuries by 2022. Moreover, the number of injuries sustained at the most common crash location appears to be increasing. Further research is necessary to discern which specific features of the urban road infrastructure have an effect on the risk of injury to a cyclist and which combination of features is consistent with a safe cycling environment.

Background: Although road traffic injury is reported as the leading cause of work-related death in Australia, it is not clear, due to limitations in previous methods used, just how large a burden it is. Many organisations are unaware of the extent of work-related road traffic injury and, importantly, what can be done to reduce the burden. The proposed research will (i) estimate the prevalence of work-related road traffic injury and (ii) identify the organisational determinants associated with work-related road traffic injury., Methods and Design: The current study is designed to enumerate the problem and identify the individual driver-level, the supervisor-level and organisational-level factors associated with work-related road traffic injury. The multilevel systems protocol will involve a series of cross-sectional surveys administered to drivers of fleet vehicles (n=1200), supervisors of the drivers (n=1200) and senior managers (n=300) within the same organisation., Discussion: The novel use of the multilevel systems protocol is critical to be able to accurately assess the specific determinants of driving safety within each context of an organisation., Results: The results are expected to highlight that reducing injury in the workplace requires more than just individual compliance with safety procedures. It will also establish, for the first time, an occupational translation taskforce to ensure that the research findings are adopted into work-place practice and thereby directly contribute to reductions in work-related road traffic injury., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

With increases in active mining and continued discharge associated with former mine operations, evaluating the health of watersheds in the Canadian Yukon Territory is warranted. Current environmental assessment approaches often employ guidelines established using sentinel species not relevant to Arctic monitoring programs. The present study focused on the successful development of a quantitative real-time polymerase chain reaction (qPCR) assay directed towards the indigenous Arctic grayling (Thymallus arcticus) and examines the feasibility of using non-lethal sampling from the caudal fin as a means for evaluation of mRNA abundance profiles reflective of environmental conditions. In a proof of concept study performed blind, qPCR results from animals in an area with elevated water concentrations of cadmium (Cd) and zinc (Zn) and higher body burdens of Cd, Zn, and lead (Pb) were compared to a reference location in the Yukon Territory. Lower condition factor and a higher abundance of hepatic and caudal fin gene transcripts encoding the metallothionein isoforms (mta/mtb), in addition to elevated heat shock protein 70 (hsp70) and catalase (cat) mRNAs in liver, were observed in fish from the test site. The strong positive correlation between metal body burden and caudal fin mta/mtb mRNA abundance demonstrates a high potential for use of the Arctic grayling assay in non-lethal environmental monitoring programs., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Heavy-vehicle driving involves a challenging work environment and a high crash rate. We investigated the associations of sleepiness, sleep disorders, and work environment (including truck characteristics) with the risk of crashing between 2008 and 2011 in the Australian states of New South Wales and Western Australia. We conducted a case-control study of 530 heavy-vehicle drivers who had recently crashed and 517 heavy-vehicle drivers who had not. Drivers' crash histories, truck details, driving schedules, payment rates, sleep patterns, and measures of health were collected. Subjects wore a nasal flow monitor for 1 night to assess for obstructive sleep apnea. Driving schedules that included the period between midnight and 5:59 am were associated with increased likelihood of crashing (odds ratio = 3.42, 95% confidence interval: 2.04, 5.74), as were having an empty load (odds ratio = 2.61, 95% confidence interval: 1.72, 3.97) and being a less experienced driver (odds ratio = 3.25, 95% confidence interval: 2.37, 4.46). Not taking regular breaks and the lack of vehicle safety devices were also associated with increased crash risk. Despite the high prevalence of obstructive sleep apnea, it was not associated with the risk of a heavy-vehicle nonfatal, nonsevere crash. Scheduling of driving to avoid midnight-to-dawn driving and the use of more frequent rest breaks are likely to reduce the risk of heavy-vehicle nonfatal, nonsevere crashes by 2-3 times.

An increasing number of anthropogenic chemicals have demonstrated potential for disruption of biological processes critical to normal growth and development of wildlife species. Both anadromous and freshwater salmon species are at risk of exposure to environmental chemical contaminants that may affect migratory behavior, environmental fitness, and reproductive success. A sensitive metric in determination of the presence and impact of such environmental chemical contaminants is through detection of changes in the status of gene transcript levels using a targeted quantitative real-time polymerase chain reaction assay. Ideally, the wildlife assessment strategy would incorporate conservation-centered non-lethal practices. Herein, we describe the development of such an assay for rainbow trout, Oncorhynchus mykiss, following an acute 96 h exposure to increasing concentrations of either 17α-ethinyl estradiol or cadmium. The estrogenic screen included measurement of mRNA encoding estrogen receptor α and β isoforms, vitellogenin, vitelline envelope protein γ, cytochrome p450 family 19 subfamily A, aryl hydrocarbon receptor, and the stress indicator, catalase. The metal exposure screen included evaluation of the latter two mRNA transcripts along with those encoding the metallothionein A and B isoforms. Exposure-dependent transcript abundance profiles were detected in both liver and caudal fin supporting the use of the caudal fin as a non-lethally obtained tissue source. The potential for both transcriptome profiling and genotypic sex determination from fin biopsy was extended, in principle, to field-captured Chinook salmon (Oncorhynchus tshawytscha)., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Purpose: To report the secondary outcomes in the Carotenoids with Coantioxidants in Age-Related Maculopathy trial., Design: Randomized double-masked placebo-controlled clinical trial (registered as ISRCTN 94557601)., Participants: Participants included 433 adults 55 years of age or older with early age-related macular degeneration (AMD) in 1 eye and late-stage disease in the fellow eye (group 1) or early AMD in both eyes (group 2)., Intervention: An oral preparation containing lutein (L), zeaxanthin (Z), vitamin C, vitamin E, copper, and zinc or placebo. Best-corrected visual acuity (BCVA), contrast sensitivity (CS), Raman spectroscopy, stereoscopic colour fundus photography, and serum sampling were performed every 6 months with a minimum follow-up time of 12 months., Main Outcome Measures: Secondary outcomes included differences in BCVA (at 24 and 36 months), CS, Raman counts, serum antioxidant levels, and progression along the AMD severity scale (at 12, 24, and 36 months)., Results: The differential between active and placebo groups increased steadily, with average BCVA in the former being approximately 4.8 letters better than the latter for those who had 36 months of follow-up, and this difference was statistically significant (P = 0.04). In the longitudinal analysis, for a 1-log-unit increase in serum L, visual acuity was better by 1.4 letters (95% confidence interval, 0.3-2.5; P = 0.01), and a slower progression along a morphologic severity scale (P = 0.014) was observed., Conclusions: Functional and morphologic benefits were observed in key secondary outcomes after supplementation with L, Z, and coantioxidants in persons with early AMD., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Despite the fact that the A6 mortality reporting system has been operating for almost 20 years in Vietnam, there has been no systematic evaluation of the system. This study assesses the completeness, sensitivity and positive predictive value of the system in relation to injury related mortality., Methods: Evaluation of the A6 system was undertaken in three (geographically distributed) provinces in Vietnam. Deaths identified in the A6 system were compared with deaths identified by an independent consensus panel to determine the per cent completeness of the A6 system. Verbal autopsies (VA) were conducted for all identified deaths from the consensus panels, and the sensitivity and positive predictive value of the A6 system were assessed using the VAs as the reference., Results: 5273 deaths were identified from the A6 system with a further 340 cases identified by the independent consensus panel (total n=5613). Injury related deaths accounted for 13.6% (n=763) of all deaths with an overall injury mortality rate of 55.3 per 100 000 person years. The per cent completeness of the A6 system in relation to injury deaths was 93.9% with a sensitivity of 75.4%, specificity of 98.4% and positive predictive value of 88.4%., Conclusions: The A6 mortality reporting system is embedded within the commune health system and is the lead mortality reporting system for the Ministry of Health. The system performs well in relation to its completeness and classification of injury related deaths. With further enhancements and ongoing support from government and donor agencies, the A6 system will be a valuable resource for identifying and planning preventive strategies targeting the leading causes of injury related deaths in Vietnam.

Background: There is a risk of concussion when playing rugby union. Appropriate management of concussion includes compliance with the return-to-play regulations of the sports body for reducing the likelihood of premature return-to-play by injured players., Purpose: To describe the proportion of rugby union players who comply with the sports body's regulations on returning to play postconcussion., Study Design: Prospective cohort study., Methods: 1958 community rugby union players (aged 15-48 years) in Sydney (Australia) were recruited from schoolboy, grade and suburban competitions and followed over ≥1 playing seasons. Club doctors/physiotherapists/coaches or trained injury recorders who attended the game reported players who sustained a concussion. Concussed players were followed up over a 3-month period and the dates when they returned to play (including either a game or training session) were recorded, as well as any return-to-play advice they received., Results: 187 players sustained ≥1 concussion throughout the follow-up. The median number of days before players returned to play (competition game play or training) following concussion was 3 (range 1-84). Most players (78%) did not receive return-to-play advice postconcussion, and of those who received correct advice, all failed to comply with the 3-week stand-down regulation., Conclusions: The paucity of return-to-play advice received by community rugby union players postconcussion and the high level of non-compliance with return-to-play regulations highlight the need for better dissemination and implementation of the return-to-play regulations and improved understanding of the underlying causes of why players do not adhere to return-to-play practices.

Background: The aim of this pilot retrospective study was to investigate the immunohistochemical expression of Cathepsin S (CatS) in three cohorts of colorectal cancer (CRC) patients (n=560)., Methods: Prevalence and association with histopathological variables were assessed across all cohorts. Association with clinical outcomes was investigated in the Northern Ireland Adjuvant Chemotherapy Trial cohort (n=211), where stage II/III CRC patients were randomised between surgery-alone or surgery with adjuvant fluorouracil/folinic acid (FU/FA) treatment., Results: Greater than 95% of tumours had detectable CatS expression with significantly increased staining in tumours compared with matched normal colon (P>0.001). Increasing CatS was associated with reduced recurrence-free survival (RFS; P=0.03) among patients treated with surgery alone. Adjuvant FU/FA significantly improved RFS (hazard ratio (HR), 0.33; 95% CI, 0.12-0.89) and overall survival (OS; HR, 0.25; 95% CI, 0.08-0.81) among 36 patients with high CatS. Treatment did not benefit the 66 patients with low CatS, with a RFS HR of 1.34 (95% CI, 0.60-3.19) and OS HR of 1.33 (95% CI, 0.56-3.15). Interaction between CatS and treatment status was significant for RFS (P=0.02) and OS (P=0.04) in a multivariate model adjusted for known prognostic markers., Conclusion: These results signify that CatS may be an important prognostic biomarker and predictive of response to adjuvant FU/FA in CRC., (2011 Cancer Research UK)

Aim: The aim of the study was to evaluate the effect of topical phenytoin on healing in diabetic foot ulcers. A randomized, controlled, double-blind, clinical trial was conducted., Methods: A phenytoin dressing and a control dressing were manufactured. Individuals who were ≥ 18 years of age with peripheral neuropathy, an ankle brachial pressure index > 0.5 and a diabetic foot ulcer ≥ 4 weeks' duration were independently randomized to the phenytoin group (31 participants) or the control group (34 participants). Participants with renal disease, ankle brachial pressure index < 0.5, necrosis or osteomyelitis were excluded. Subjects received standard wound care and dressing application. Primary endpoint analysis (diabetic foot ulcer closed or not at 16 weeks) was calculated by survival analysis., Results: Participants (n = 65, 52 with Type 2 diabetes) were treated for a maximum of 16 weeks. Sixty per cent of the diabetic foot ulcers closed overall (18 in the phenytoin group, 20 in the control group) with no statistically significant differences in complete healing or in diabetic foot ulcer area over time between the two groups. At 24-weeks follow-up, one diabetic foot ulcer had recurred., Conclusions: There were no differences in diabetic foot ulcer closure rates or in diabetic foot ulcer area over time between the two groups. This study does not support the use of phenytoin in the treatment of diabetic foot ulcers., (© 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.)

Purpose: The loss of vision is associated with the impairment of functional ability, including a reduced ability to move around and to utilise all forms of transport. Walking in unfamiliar environments is challenging and driving becomes a legal prohibition. This article explores mobility and access to transport issues of urban and rural dwelling people with vision impairment in Ireland., Methods: Fourteen focus groups took place consisting of 121 people with vision impairment resident in both urban and rural Ireland. Participant selection was representative of the vision impaired community. Data were recorded, transcribed and analysed using thematic analysis., Results: Poor access to public transport and a perceived absence of public awareness about vision impairment are evident from this study. Customised disability awareness training is deemed essential for both the public and transport staff. Difficulties with access issues within the physical environment are highlighted., Conclusion: The lack of availability of accessible transport creates an increased dependency on friends and family, and restricts access to medical, social and rehabilitative services. This study highlights issues concerning inequality of access to appropriate transport for rural vision impaired persons. These issues need to be brought to the attention of social planners and local government.

Background: Riding a motorcycle (a two-wheeled vehicle that is powered by a motor and has no pedals) is associated with a high risk of fatal crashes, particularly in new riders. Motorcycle rider training has therefore been suggested as an important means of reducing the number of crashes, and the severity of injuries., Objectives: To quantify the effectiveness of pre- and post-licence motorcycle rider training on the reduction of traffic offences, traffic crash involvement, injuries and deaths of motorcycle riders., Search Strategy: We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 3), TRANSPORT, MEDLINE, EMBASE, CINAHL, WHOLIS (World Health Organization Library Information System), PsycInfo, LILACS (Latin American and Caribbean Health Sciences), ISI Web of Science: Social Sciences Citation Index (SSCI), ERIC, ZETOC and SIGLE. Database searches covered all available dates up to October 2008. We also checked reference lists of relevant papers and contacted study authors in an effort to identify published, unpublished and ongoing trials related to motorcycle rider training., Selection Criteria: We included all relevant intervention studies such as randomised and non-randomised controlled trials, interrupted time-series and observational studies such as cohort and case-control studies., Data Collection and Analysis: Two review authors independently analysed data about the study population, study design and methods, interventions and outcome measures as well as data quality from each included study, and compared the findings. We resolved differences by discussion with a third review author., Main Results: We reviewed 23 studies: three randomised trials, two non-randomised trials, 14 cohort studies and four case-control studies. Five examined mandatory pre-licence training, 14 assessed non-mandatory training, three of the case-control studies assessed 'any' type of rider training, and one case-control study assessed mandatory pre-licence training and non-mandatory training. The types of assessed rider training varied in duration and content.Most studies suffered from serious methodological weaknesses. Most studies were non-randomised and controlled poorly for confounders. Most studies also suffered from detection bias due to the poor use of outcome measurement tools such as the sole reliance upon police records or self-reported data. Small sample sizes and short follow-up time after training were also common., Authors' Conclusions: Due to the poor quality of studies identified, we were unable to draw any conclusions about the effectiveness of rider training on crash, injury, or offence rates. The findings suggest that mandatory pre-licence training may be an impediment to completing a motorcycle licensing process, possibly indirectly reducing crashes through a reduction in exposure. It is not clear if training (or what type) reduces the risk of crashes, injuries or offences in motorcyclists, and a best rider training practice can therefore not be recommended. As some type of rider training is likely to be necessary to teach motorcyclists to ride a motorcycle safely, rigorous research is needed.

This article presents an affirmative paradigm for understanding the leadership of sexual minorities-that is, lesbian, gay, bisexual, and transgender (LGBT) people. Although research on LGBT issues in leadership to date is almost nonexistent, there are several bodies of literature that can contribute to an understanding of the unique leadership challenges faced by sexual minority people. These include the literatures on stigma and marginalization, leadership in particular status groups (e.g., college students, women), and LGBT vocational issues (especially workplace climate and identity disclosure). We propose a new, multidimensional model of LGBT leadership enactment that incorporates sexual orientation (particularly regarding identity disclosure), gender orientation (including leader gender), and the situation (conceptualized here as group composition); the model also is embedded in context, the most relevant factors that affect the enactment of leadership being stigma and marginalization. We explicate this model with findings and concepts from relevant literatures, and we conclude the article with recommendations for building a scholarly literature in LGBT leadership., ((PsycINFO Database Record (c) 2010 APA, all rights reserved).)

Background: Mild traumatic brain injury (mTBI) is an emerging public health issue in high-contact sports. Understanding the incidence along with the risk and protective factors of mTBI in high-contact sports such as rugby is paramount if appropriate preventive strategies are to be developed., Purpose: To estimate the incidence and identify the risk and protective factors of mTBI in Australian nonprofessional rugby players., Study Design: Cohort study; Level of evidence, 2., Methods: A cohort of 3207 male nonprofessional rugby players from Sydney, Australia, was recruited and followed over 1 or more playing seasons. Demographic information, history of recent concussion, and information on risk and protective factors were collected. The incidence of mTBI was estimated and the putative risk and protective factors were modeled in relation to mTBI., Results: The incidence of mTBI was 7.97 per 1000 player game hours, with 313 players (9.8%) sustaining 1 or more mTBIs during the study. Players who reported always wearing protective headgear during games were at a reduced risk (incident rate ratio [IRR], 0.57; 95% confidence interval [CI], 0.40-0.82) of sustaining an mTBI. In contrast, the likelihood of mTBI was almost 2 times higher among players who reported having sustained either 1 (IRR, 1.75; 95% CI, 1.11-2.76) or more mTBIs (IRR, 1.65; 95% CI, 1.11-2.45) within the 12 months before recruitment., Conclusion: Nonprofessional rugby has a high incidence of mTBI, with the absence of headgear and a recent history of mTBI associated with an increased risk of subsequent mTBI. These findings highlight that both use of headgear and the management of prior concussion would likely be beneficial in reducing the likelihood of mTBI among nonprofessional rugby players, who compose more than 99% of rugby union players in Australia.

Age-related macular degeneration (AMD), is the leading cause of blind registration in the Western World among individuals 65 years or older. Early AMD, a clinical state without overt functional loss, is said to be present clinically when yellowish deposits known as drusen and/or alterations of fundus pigmentation are seen in the macular retina. Although the etiopathogenesis of AMD remains uncertain, there is a growing body of evidence in support of the view that cumulative oxidative damage plays a causal role. Appropriate dietary antioxidant supplementation is likely to be beneficial in maintaining visual function in patients with AMD, and preventing or delaying the progression of early AMD to late AMD. The Carotenoids in Age-Related Maculopathy (CARMA) Study is a randomized and double-masked clinical trial of antioxidant supplementation versus placebo in 433 participants with either early AMD features of sufficient severity in at least one eye or any level of AMD in one eye with late AMD (neovascular AMD or central geographic atrophy) in the fellow eye. The aim of the CARMA Study is to investigate whether lutein and zeaxanthin, in combination with co-antioxidants (vitamin C, E, and zinc), has a beneficial effect on visual function and/or prevention of progression from early to late stages of disease. The primary outcome is improved or preserved distance visual acuity at 12 months. Secondary outcomes include improved or preserved interferometric acuity, contrast sensitivity, shape discrimination ability, and change in AMD severity as monitored by fundus photography. This article outlines the CARMA Study design and methodology, including its rationale.

Background: Little is known about the burden or causes of injury in rural villages in India., Objective: To examine injury-related mortality and morbidity in villages in the state of Andhra Pradesh, India., Methods: A verbal-autopsy-based mortality surveillance study was used to collect mortality data on all ages from residents in 45 villages in 2003-2004. In early 2005, a morbidity survey in adults was carried out using stratified random sampling in 20 villages. Participants were asked about injuries sustained in the preceding 12 months. Both fatal and non-fatal injuries were coded using classification methods derived from ICD-10., Results: Response rates for the mortality surveillance and morbidity survey were 98% and 81%, respectively. Injury was the second leading cause of death for all ages, responsible for 13% (95% CI 11% to 15%) of all deaths. The leading causes of fatal injury were self-harm (36%), falls (20%), and road traffic crashes (13%). Non-fatal injury was reported by 6.7% of survey participants, with the leading causes of injury being falls (38%), road traffic crashes (25%), and mechanical forces (16.1%). Falls were more common in women, with most (72.3%) attributable to slipping and tripping. Road traffic injuries were sustained mainly by men and were primarily the result of motorcycle crashes (48.8%)., Discussion: Injury is an important contributor to disease burden in rural India. The leading causes of injury-falls, road traffic crashes, and suicides-are all preventable. It is important that effective interventions are developed and implemented to minimize the impact of injury in this region.

This study investigated barriers to, and factors associated with, observed motorcycle helmet use among motorcyclists in Hai Duong Province, Vietnam. The findings highlighted an array of factors associated with observed helmet use namely, support for universal helmet legislation and a positive attitude towards what might be perceived as negative attributes of helmet use such as inconvenience and discomfort in hot weather. As well, older age (greater than 25 years in age), riding on a compulsory road, being a driver, trips of greater than 10 km, higher levels of education (having a university degree and higher) were found to be key determinants of helmet use. Despite over 95% of motorcyclists disagreeing with the statement that wearing a helmet does not reduce the severity of head injury in a crash, most motorcyclists believed that helmets did not need to be worn for a short trip. Overall, only 23% of motorcyclists were observed wearing a helmet. The authors conclude that efforts to increase helmet use need to focus on the necessity for universal helmet legislation in association with identifying solutions to reduce the negative attitudes towards helmet use.