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When erature ranging the capsule is intact at the end of cataract removal zombie infection jar purchase generic ciprofloxacin on-line, the pos from 1 antibiotics common buy cheap ciprofloxacin 1000 mg. This complication might require conversion to antimicrobial efficacy testing buy 1000mg ciprofloxacin amex an Intracapsular Cataract Extraction infection 2 bio war simulation buy genuine ciprofloxacin. It can result in marked loss of vision and moderate impairment although sometimes can be treated with no loss of vision. Iridocyclitis rate the clinical picture of Iridocyclitis is practically the same as from literature that of iritis, a sub-type of uveitis. Surgical ma nipulation could result in breakdown of the blood?aqueous barrier, leading to vulnerability in the early postoperative period. Iridocyclitis requires medical control of the intraocular inflammation in both the preoperative and post operative periods. For a clear vision in a healthy cornea, the number of endo thelial cells covering the back surface of the cornea should be sufficient. The mean number of endothelial cells in a young adult is Endothelial cells approximately 3000 cells/mm2, which decreases by 0. The intraocular pressure of the eye is determined by the the rate of elevated balance between the amount of aqueous humor that the eye intraocular pressure makes and the ease with which it leaves the eye. Having eye pressure cataract surgery Elevated Intraoc that is too low or too high can damage vision. It is important to lower high eye pressure before it causes vision loss or damage to the optic nerve. Depending on eye pressure, ophthalmologist may decide for active follow up or to start medical treatment. It can be mild and self-limited, but when persistent and se vere, corneal endothelial decompensation requires corneal transplantation. Most cases resolve but if persis tent, may require medical or surgical treatment. Eye rate from literature surgery could lead to acute (within 1-2 weeks) or chronic ranging from 0. Endophthalmitis is a complication that can result in markedly reduced vision and typically leaves some impairment. It results from the growth and abnormal capsulotomy from Posterior capsule proliferation of lens epithelial cells on the capsule at the time literature ranging opacification; of cataract surgery. The amount of surgically induced astigmatism created dur ing the cataract surgical procedure is measured through keratometry, while magnitude (in diopters) and direction (in degrees) are calculated using vector analysis. Surgically induced astigmatism can reduce the visual acuity achieved after cataract surgery. Increases in central corneal thick ness beyond the expected variance occur after a range of Central corneal intraocular surgeries (cataract operations, penetrating kera Grade I thickness toplasty). A meta-analysis revealed a statistically significant correlation between central corneal thickness and intraocu lar pressure. Cataract surgery setting A Cochrane review has concluded there is no difference in outcome or increased risk of postop erative complications between outpatient and inpatient cataract surgery. The target population of this assessment is adult patients (>18 years) of either sex affected by age-related cataract and for whom the surgical treatment for cataract removal and insertion of intraocular lens could provide a gain in visual acuity and health-related quality of life. A wide range of definitions and study designs are used to describe the prevalence of cataract: population-based studies on the presence of lens opacities with or without visual impairment or studies on previous or current cataract extraction rates. In Europe in 2010, the estimated prevalence of blindness (Visual Acuity Blind < 3/60) or modera te-to-severe vision impairment (Visual Acuity < 6/18,? While British authors reported a prevalence of visual impairing cataract from 16% in Londoners aged 65-69 years to 71% in people aged 85 years or more (112), and 77% in British Indians over age 42 years. Age-Specific Prevalence Rates for Cataract by Age and Race/Ethnicity (113) Age White Black Hispanic Other All 40-49 2. Overall, the 10 trials recruited a total of 648 patients affected by age-related cataract (range: 36-105 patients). Follow-up periods varied among studies and, whenever possible, they have been reported ac cording to length of follow up specified in the project plan. Visual Acuity could be assessed with or without correction with lens (corrected or uncorrected visual acuity). Four studies (Donnenfeld 2018, Kranitz 2012, Mursch Edlmayr 2017, Schargus 2015) (24,29,31,32) reported conflicts of interests (in terms of sponsorship or authors having been consultants for the firm producing the laser system under study). In three out of four studies, no statistically significant difference was found between the two study arms. A low quality of evidence means that further research is likely to change the size and direction of effect and confidence in the estimate is limited. Reasons for this judgement were limitations in blinding of participants in all studies and blinding of outcome assessment in two studies. Two studies (Donnenfeld 2018, Kranitz 2012) (24,29) reported conflicts of interests (in terms of spon sorship, or authors having been consultants for the firm producing the laser system under study). A very low quality of evidence means that any estimate of effect is very uncertain and confidence in the estimate is small. A diopter can be a negative number (which indicates myo pia) or a positive number (which indicates hypermetropia). Of the six studies (Conrad-Hengerer 2015, Donnenfeld 2018, Hida 2014, Mastropasqua 2014b, Nagy 2011, Yu 2015) (23,25,27?30) reporting on refractive outcomes, only two (Mastropasqua 2014b, Yu 2015) (25,28) measured the mean absolute error at one week and one month and were included in the analysis. Risk of bias in the two studies was judged as serious (Figure 15) due to concerns on lack of allo cation concealment in one of the two studies included in the quantitative analysis. Figure 16 Forest Plot Refractive Outcomes (Mean Absolute Error) at 1 week Refractive outcomes (Mean Absolute Error at 1 month after surgery) the two studies assessing mean absolute error at 1 month included a total of 144 patients. Nei ther study found a statistically significant difference between the two study arms. Figure 17 Forest Plot Refractive Outcomes (Mean Absolute Error) at 1 month Overall quality of evidence for refractive outcomes was graded low because of imprecision and serious risk of bias due to allocation concealment not adequately described in both included trials. A low quality of evidence means that further research is likely to change the size and direction of effect and confidence in the estimate is limited. Only one study conducted in Austria was included, (Mursch Edlmayr 2017)(31) which reported data from a non-validated questionnaire on mean pain during surgery (patient-reported outcome) using a scale from 1 (no pain) to 5 (intense pain). Specifically, all patients were asked about their pain level in general during the cataract surgery. After surgery in the second eye, patients were asked to compare the pain level between the 2 types of surgery and which procedure they would recommend. The difference between mean pain during cataract extraction after laser treatment and mean pain during stan dard cataract surgery was not statistically significant, although thirty patients (63. For a detailed description of safety outcomes and consequences of intraoperative and postopera tive complications, see Table 14. Overall, the 15 trials recruited a total of 1215 patients affected by age-related cataract (range: 30 299). In our meta-analyses we did not consider studies generically stating that no complications were observed, without specifying or reporting data on specific complications. Follow-up periods varied among studies and, whenever possible, they have been reported ac cording to length of follow up specified in the project plan. Data for the following safety outcomes were analysed and reported: anterior and posterior capsular tear: 9 studies (Conrad-Hengerer 2013, Conrad-Hengerer 2015, Mursch-Edlmayr 2017, Panthier 2017. Reddy 2013, Roberts 2018, Schargus 2015,Yu 2015, Yu 2016) (28,30?33,42,44,47,50) vitreous loss: 3 studies (Conrad-Hengerer 2015, Roberts 2018, Schargus 2015) (30,32,33) elevated intraocular pressure after one day: 4 studies (Conrad-Hengerer 2013, Conrad Hengerer 2014, Conrad-Hengerer 2015, Schargus 2015) (30,32,47,48) elevated intraocular pressure after one week: 4 studies (Conrad-Hengerer 2013, Conrad Hengerer 2014, Conrad-Hengerer 2015, Yu 2015) (28,30,47,48) endothelial cell loss: 4 studies (Conrad-Hengerer 2013, Mursch-Edlmayr 2017; Schargus 2015, Yu 2015)(28,31,32,47); Iridocyclitis: no study was retrieved Version 1. Intraoperative Complications Anterior and Posterior Capsular Tear Nine studies (Conrad-Hengerer 2013, Conrad-Hengerer 2015, Mursch-Edlmayr 2017, Panthier 2017, Reddy 2013, Roberts 2018, Schargus 2015, Yu 2015, Yu 2016) (28,30?33,42,44,47,50) reported data on anterior and posterior capsular tear. Roberts 2018 reported only posterior capsu lar tears associated with vitreous loss. The risk of bias was judged as not serious (Figure 18), as concerns over allocation concealment and attrition were not considered too relevant for intraoperative outcomes. Six studies (Conrad Hengerer 2013, Conrad-Hengerer 2015, Mursch-Edlmayr 2017, Reddy 2013, Roberts 2018, Schargus 2015) (30?33,42,47) reported conflicts of interests (in terms of sponsorship, grants, lecture fees or authors being an employee or having been a consultant or member of the medical advisory board of the firm producing the laser system under study). Figure 18 Risk of bias summary Anterior and Posterior Capsular Tear the selected studies included a total of 1091 patients. Excluding Roberts 2018 which reported only posterior tears associated with vitreous loss (included in Figure 22), one posterior tear occurred in one study (Schargus 2015)(32).

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Medical Examination Report Form Page 2 the results of the four required tests: vision antibiotic drops for eyes discount ciprofloxacin online, hearing antibiotic wiki discount ciprofloxacin 750 mg with amex, blood pressure/pulse antibiotic ointment packets cheap ciprofloxacin 750 mg without prescription, and urinalysis are recorded on the second page of the Medical Examination Report form bacteria in yogurt buy ciprofloxacin without prescription. Abnormal test results may disqualify a driver or indicate that additional evaluation and/or testing are needed. Drug and alcohol testing are not required for the driver physical examination unless findings indicate they are needed to determine medical fitness for duty. Vision the medical examiner or a licensed ophthalmologist or optometrist can examine and certify vision test results. Page 213 of 260 Visual acuity is measured in each eye individually and both eyes together. Distant visual acuity of at least 20/40 (Snellen) in each eye, with or without corrective lenses. Color vision must be sufficient to recognize and distinguish traffic signals and devices showing the standard red, amber, and green colors. When corrective lenses are used to meet vision qualification requirements, the corrective lenses must be used while driving. A driver with monocular vision, who is otherwise medically qualified, may apply for a Federal vision exemption. You may certify the driver who meets vision qualification requirements, with or without the use of corrective lenses, for up to 2 years. Hearing To qualify, the driver must meet the hearing requirement of either the forced whisper test or the audiometric test in one ear. Forced whisper test is to first perceive a forced whispered voice, in one ear, at not less than five feet. The driver who wears a hearing aid to meet the hearing qualification requirement must wear a hearing aid while driving. Blood Pressure/Pulse Record pulse rate and rhythm on the Medical Examination Report Form. The driver with stage 1 or stage 2 hypertension may be certified in accordance with the cardiovascular recommendations, which take into consideration known hypertension history. The dipstick urinalysis must measure specific Page 214 of 260 gravity and test for protein, blood, and glucose in the urine. Attach copies of additional test results and interpretation reports to the Medical Examination Report form. Medical Examination Report Form Page 3 Record the physical examination and certification status on the third page of the Medical Examination Report form. Physical Examination the physical examination should be as thorough as described in the Medical Examination Report form, at a minimum. Note any abnormal finding, including the safety implication, even if not disqualifying. Inform the driver of any abnormal findings and as needed advise the driver to obtain follow-up evaluation. Physical examination may indicate the need for additional evaluation and/or tests. Specialists, such as cardiologists and endocrinologists, may perform additional medical evaluation, but it is the medical examiner who decides if the driver is medically qualified to drive. Document the certification decision, including the rationale for any decision that does not concur with the recommendations. Certification and Documentation Certification Status Document the certification decision in the space provided for certification status. The driver who must wear corrective lenses, a hearing aid, or have a Skill Performance Evaluation certificate may be certified for up to 2 years when there are no other conditions that require periodic monitoring. Federal exemptions and some Federal Motor Carrier Safety Administration guidelines specify annual medical examinations. Certification and recertification occur only when the medical examiner determines that the driver is medically fit for duty in accordance with Federal qualification requirements for commercial drivers. The expiration date should be consistent with the Medical Examination Report form certification status and cannot exceed 2 years from the date of the examination. The certificate can be the original or a photocopy, and can be reduced in size (usually wallet-sized). The examiner may provide a copy to a prospective or current employing motor carrier who requests it. If the driver was certified as physically qualified, then the medical examiner should also retain the medical certificate as well for at least 3 years from the date the certificate was issued. Provisions of the vision exemption include an annual medical examination and an eye examination by an ophthalmologist or an optometrist. At the annual recertification examination, the driver should present the current vision exemption and a copy of the specialist eye examination report. The motor carrier is responsible for ensuring that the driver has the required documentation before driving a commercial vehicle. At the conclusion of that study, 2,656 drivers received a one time letter confirming participation in the study and granting a continued exemption from the monocular vision requirement, as long as the driver is otherwise medically fit for duty and can meet the vision qualification requirements with the one eye. The driver who was grandfathered must have an annual medical examination and an eye examination by an ophthalmologist or optometrist. At the annual medical examination, the driver should present to the medical examiner the letter identifying the driver as a participant in the vision study program and a copy of the specialist eye examination report. The Federal Diabetes Exemption Program is responsible for determining if the driver meets program requirements and for issuing the diabetes exemption. The driver must provide a quarterly evaluation checklist from his/her endocrinologist throughout the 2-year period or risk losing the exemption. Please direct questions concerning Driver Exemption Programs to medicalexemptions@dot. Are distinguished by a virtual lack of insulin production and often severely compromised counter regulatory mechanisms. Although hypoglycemia can occur in non-insulin-treated diabetes mellitus, it is most often associated with insulin-treated diabetes mellitus. Mild hypoglycemia causes rapid heart rate, sweating, weakness, and hunger, while severe hypoglycemia causes headache and dizziness. The examination is based on information provided by the driver (minimum 5-year history), objective data (physical examination), and additional testing requested by the medical examiner. Your assessment should reflect physical, psychological, and environmental factors. Medical certification depends on a comprehensive medical assessment of overall health and informed medical judgment about the impact of single or multiple conditions on the whole person. Key Points for Examination When the Driver Has Diabetes Mellitus and Uses Insulin this physical examination starts the Federal Diabetes Exemption Program application process. The driver must provide a 5 year medical history for your review before you determine certification status. Additional questions should be asked to supplement information requested on the form. You should ask about and document diabetes mellitus symptoms, blood glucose monitoring, insulin treatment, and history of hypoglycemic episodes. Regulations You must review and discuss with the driver any "yes" answers Does the driver have diabetes mellitus or elevated blood glucose controlled by. Newly started on insulin have documentation of completion of minimum waiting period? Page 220 of 260 Regulations You must evaluate On examination, does the driver have. State-issued Medical Waivers and Exemptions It is important that as a medical examiner you distinguish between intrastate waivers/exemptions and Federal diabetes exemptions for insulin-treated diabetes mellitus. The driver is responsible for ensuring that both certificates are renewed prior to expiration. You should review the report at recertification for any medical changes before determining driver certification status. Follow-up the driver should have at least biennial physical examinations or more frequently when indicated. All proposed changes to the medical standards are subject to public notice-and-comment rulemaking. Yes if: Annual Ultrasound to identify Asymptomatic; Ultrasound for change in change in size. Aneurysms of other Assess for risk of rupture No vessels and for associated cardiovascular diseases.

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Premature atrial or ventricular contractions sufficiently symptomatic to bacteria en la orina discount ciprofloxacin online mastercard require treatment infection behind ear lobe ciprofloxacin 500 mg cheap, or result in physical or psychological impairment infection white blood cell count order ciprofloxacin with mastercard, do not meet the standard antibiotics like amoxicillin buy ciprofloxacin canada. Occasional asymptomatic unifocal premature ventricular contractions are not disqualifying. Current or history of cardiomyopathy (425), including myocarditis (422), or congestive heart failure (428), does not meet the standard. Current or history of pericarditis (420) (acute nonrheumatic), unless the individual is free of all symptoms for 2 years, and has no evidence of cardiac restriction or persistent pericardial effusion, does not meet the standard. Current or history of congenital anomalies of heart and great vessels (746), except for corrected patent ductus arteriosus, do not meet the standard. Current or history of abnormalities of the arteries and blood vessels (447), including, but not limited to aneurysms (442), atherosclerosis (440), or arteritis (446), do not meet the standard. Current or history of hypertensive vascular disease (401) does not meet the standard. Elevated blood pressure defined as the average of three consecutive sitting blood pressure measurements separated by at least 10 minutes, diastolic greater than 90 mmHg or three consecutive systolic pressure measurements greater than 140 mmHg does not meet the standard (796. History of pulmonary (415) or systemic embolization (444) does not meet the standard. Current or history of venous diseases, including but not limited to, recurrent thrombophlebitis (451), thromboph lebitis during the preceding year, or any evidence of venous incompetence, such as large or symptomatic varicose veins, edema, or skin ulceration (454), does not meet the standard. Body build the cause for rejection for appointment, enlistment, and induction is deficient muscular development that would interfere with the completion of required training. Current abnormal elevation of the diaphragm, either side, does not meet the standard. Any nonspecific abnormal findings on radiological and other examination of body structure, such as lung field (793. Current or history of acute infectious processes of the lung, including but not limited to viral pneumonia (480), pneumococcal pneumonia (481), bacterial pneumonia (482), pneumonia other specified (483), pneumonia infectious disease classified elsewhere (484), bronchopneumonia organism unspecified (485), pneumonia organism unspecified (486), do not meet the standard until cured. Asthma (493), including reactive airway disease, exercise-induced bronchospasm or asthmatic bronchitis, reliably diagnosed and symptomatic after the 13th birthday, does not meet the standard. Reliable diagnostic criteria may include any of the following elements: substantiated history of cough, wheeze, chest tightness, and/or dyspnea that persists or recurs over a prolonged period of time, generally more than 12 months. Current bronchitis (490), acute or chronic, symptoms over 3 months occurring at least twice a year (491), does not meet the standard. Current or history of bronchopleural fistula (510) unless resolved with no sequelae does not meet the standard. Current or history of bullous or generalized pulmonary emphysema (492) does not meet the standard. Current chest wall malformation (754), including, but not limited to pectus excavatum (754. Current pulmonary fibrosis (515) from any cause producing respiratory symptoms does not meet the standard. Current foreign body in lung, trachea, or bronchus (934) does not meet the standard. Current or history of pneumothorax (512) occurring during the year preceding examination, if due to trauma or surgery or occurring during the 3 years preceding examination from spontaneous origin, does not meet the standard Recurrent spontaneous pneumothorax (512) does not meet the standard. History of open or laparoscopic thoracic or chest wall (including breasts) surgery during the preceding 6 months (P54) does not meet the standard. Current cleft lip or palate defects (749), not satisfactorily repaired by surgery do not meet the standard. History of allergic rhinitis immunotherapy within the previous year does not meet the standard. Current nasal polyps (471) or history of nasal polyps, unless greater than 12 months has elapsed since nasal polypectomy, does not meet the standard. Such conditions exist when evidenced by chronic purulent nasal discharge, hyperplastic changes of the nasal tissue, symptoms requiring frequent medical attention, or x-ray findings. Current or history of cerebrovascular conditions, including but not limited to subarachnoid (430) or intracerebral (431) hemorrhage, vascular insufficiency, aneurysm, or arteriovenous malformation (437), do not meet the standard. History of congenital or acquired anomalies of the central nervous system (742), or meningocele (741. Current or history of disorders of meninges, including, but not limited to cysts (349. Current or history of degenerative and hereditodegenerative disorders, including, but not limited to those disorders affecting the cerebrum (330), basal ganglia (333), cerebellum (334), spinal cord (335), or peripheral nerves (337), do not meet the standard. After 2 years post-injury, applicants may be qualified if neurological consultation shows no residual dysfunction or complications. Moderate head injuries are defined as unconsciousness, amnesia, or disorientation of person, place, or time alone or in combination, of more than 1 and less than 24-hours duration post-injury, or linear skull fracture. After 1 month post-injury, applicants may be qualified if neurological evaluation shows no residual dysfunction or complications. Mild head injuries are defined as a period of unconsciousness, amnesia, or disorientation of person, place, or time, alone or in combination of 1 hour or less post-injury. Such symptoms include, but are not limited to headache, vomiting, disorientation, spatial disequilibrium, impaired memory, poor mental concentration, shortened attention span, dizziness, or altered sleep patterns. Current or history of paralysis, weakness, lack of coordination, chronic pain, sensory disturbance, or other specified paralytic syndromes (344) does not meet the standard. Chronic nervous system disorders, including but not limited to myasthenia gravis (358. Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (314), or Perceptual/Learning Disorder(s) (315) does not meet the standard, unless applicant can demonstrate passing academic performance and there has been no use of medication(s) in the previous 12 months. Current or history of academic skills or perceptual defects (315) secondary to organic or functional mental disorders, including, but not limited to dyslexia, that interfere with school or employment, do not meet the standard. Applicants demonstrating passing academic and employment performance without utilization or recommendation of academic and/or work accommodations at any time in the previous 12 months may be qualified. Current or history of disorders with psychotic features such as schizophrenia (295), paranoid disorder (297), and other unspecified psychosis (298) does not meet the standard. Current or history of adjustment disorders (309) within the previous 3 months does not meet the standard. Current or history of conduct (312), or behavior (313) disorders does not meet the standard. Recurrent encounters with law enforcement agencies, antisocial attitudes or behaviors are tangible evidence of impaired capacity to adapt to military service and as such do not meet the standard. History (demonstrated by repeated inability to maintain reasonable adjustment in school, with employers or fellow workers, or other social groups), interview, or psychological testing revealing that the degree of immaturity, instability, personality inadequacy, impul siveness, or dependency will likely interfere with adjustment in the Armed Forces does not meet the standard. Current or history of other behavior disorders does not meet the standard, including, but not limited to conditions such as the following: (1) Enuresis (307. Any current receptive or expressive language disorder, including, but not limited to any speech impediment, stammering and stuttering (307. Current or history of dissociative disorders, including, but not limited to hysteria (300. Current or history of somatoform disorders, including, but not limited to hypochondriasis (300. Current or history of psychosexual conditions (302), including, but not limited to transsexualism, exhibitionism, transvestism, voyeurism, and other paraphilias, do not meet the standard. Current or history of alcohol dependence (303), drug dependence (304), alcohol abuse (305), or other drug abuse (305. Current or history of other mental disorders (all 290?319 not listed above) that in the opinion of the civilian or military provider will interfere with, or prevent satisfactory performance of military duty, do not meet the standard. Applicants under treatment with systemic retinoids, including, but not limited to isotretinoin (Accutane(r)) are disqualified until 8 (eight) weeks after completion of therapy. Current or history of atopic dermatitis (691) or eczema (692) after the 9th birthday does not meet the standard. Surgically resected pilonidal cyst that is symptomatic, unhealed, or less than 6 months post-operative does not meet the standard. Current or history of bullous dermatoses (694), including, but not limited to dermatitis herpetiformis, pemphigus, and epidermolysis bullosa, does not meet the standard. Current localized types of fungus infections (117), interfering with the proper wearing of military equipment or the performance of military duties, do not meet the standard. Current or history of furunculosis or carbuncle (680), if extensive, recurrent, or chronic does not meet the standard. Current or history of congenital (757) or acquired (216) anomalies of the skin such as nevi or vascular tumors that interfere with function, or are exposed to constant irritation do not meet the standard.

Motorcycle Accident Cause Factors and Identification of Countermeasures antibiotics with pseudomonas coverage discount ciprofloxacin 250 mg, Volume 1: Technical Report antibiotics for uti and birth control buy generic ciprofloxacin 750mg. Paternalism & its discontents: Motorcycle helmet laws antibiotics pneumonia discount 250 mg ciprofloxacin otc, libertarian values antibiotics dairy generic 750mg ciprofloxacin mastercard, and public health. Effectiveness and Role of Driver Education and Training in a Graduated Licensing System. Impaired Motorcycle Operation, Final Report Volume I: Riders Helping Riders Evaluation. Generalized linear regression analysis of association of universal helmet laws with motorcyclist fatality rates. Traffic Safety Facts, Research Note: Summary of Novelty Helmet Performance Testing. Traffic Safety Facts, Research Note: Motorcycle Helmet Use in 2008 Overall Results. Development and Testing of Techniques for Increasing the Conspicuity of Motorcycles and Motorcycle Drivers. Centennial, Colorado: National Association of State Motorcycle Safety Administrators. Young Drivers Overview Motor vehicle crashes are the leading cause of death for teenagers in the United States. In comparison with adult drivers, young drivers are substantially over-involved in crashes. Between 1996 and 2005, there was a 42% decrease in the fatal crash rate for 16-year-old drivers (from 33 to 19 per 100,000 population). By comparison, fatal crashes rates declined by 15% among adult drivers ages 30-59. There was a similarly large decrease (41%) in police-reported crash involvements among 16-year-old drivers, as well as substantial decreases in nighttime fatal crashes and fatal crashes involving passengers (Ferguson, Teoh, & McCartt, 2007). The reasons for the dramatic reductions in fatal and police-reported crashes among 16-year-olds are not entirely known; however, it is 6 1 noteworthy that most States implemented new, multi-stage licensing systems during this time period. Presently, fatal crashes among 16-year-olds are at a historic low (Ferguson et al. Young drivers have high crash risks for two main reasons, as documented by extensive research (summarized in Hedlund, Shults, & Compton, 2003). The mechanics of driving require much of their attention, so safety considerations frequently are secondary. They do not have experience in recognizing potentially risky situations or in reacting appropriately and controlling their vehicles in these situations. Second, they are immature, sometimes seeking risks for their own sake, often not able or willing to think ahead to the potentially harmful consequences of risky actions. In fact, research on adolescent development suggests that key areas of the brain involved in judgments and decision making are not fully developed until the mid-20s (Dahl, 2008; Keating, 2007; Steinberg, 2007). Inexperience and immaturity combine to make young drivers especially at-risk in four circumstances. At night: Driving is more difficult and dangerous at night for everyone, but particularly for teenagers. Young drivers have less experience driving at night than during the day, and fatigue and alcohol may be more of a factor at night (Lin & Fearn, 2003; Williams, 2003). Driver education was developed to teach both driving skills and safe driving practices. Based on evaluations to date, school-based driver education for beginning drivers does a good job at teaching driving skills, but does not reduce crashes. Rather, some research has suggested that it lowers the age at which teenagers become licensed, and therefore increases exposure, so its overall effect is to increase crashes (Roberts et al. Through their own driving, parents provide role models for good or bad driving practices. At least one driving guide program has successfully encouraged parents to impose more driving restrictions on their teens (Simons Morton, 2007); however, no program has yet been shown to reduce young driver crashes or fatalities. The law enforcement system faces several problems when dealing with young drivers. Once stopped, there may be a tendency for officers in some situations not to make arrests or for prosecutors to dismiss charges because the offender is just a kid. Environmental and vehicular strategies can improve safety for young drivers, as they can for all drivers. In recent years, several new technologies have been developed and applied to young drivers. See also Hedlund, Shults, & Compton (2006) for a summary of much of the research on young driver issues. Effectiveness, cost, and time to implement can vary substantially from State to State and community to community. Costs for many countermeasures are difficult to measure, so the summary terms are very approximate. See individual countermeasure descriptions for information on effectiveness size and how effectiveness is measured. Use: High: more than two-thirds of the States, or a substantial majority of communities Medium: between one-third and two-thirds of States or communities Low: fewer than one-third of the States or communities Unknown: data not available Cost to implement: High: requires extensive new facilities, staff, equipment, or publicity, or makes heavy demands on current resources Medium: requires some additional staff time, equipment, facilities, and/or publicity Low: can be implemented with current staff, perhaps with training; limited costs for equipment or facilities these estimates do not include the costs of enacting legislation or establishing policies. Time to implement: Long: more than one year Medium: more than three months but less than one year Short: three months or less these estimates do not include the time required to enact legislation or establish policies. It helps young drivers avoid dangerous conditions such as late-night driving or driving with teenage passengers in the vehicle during the intermediate phase. During the past year, Arkansas and Kansas each passed legislation enacting an intermediate licensing stage. Time to implement: Licensing changes typically require up to a year to plan, publicize, and implement. Forty-four States and the District of Columbia required some minimum number of supervised driving hours, about half of them requiring 50 hours. Some States reduced or eliminated supervised driving requirements for driver education graduates. This is not recommended, since evidence suggests this practice results in higher crash rates among young drivers (Mayhew, 2007). At night, driving is more difficult, driver fatigue is more common, and alcohol is more likely to be used. For all of these reasons, a night driving restriction helps reduce risk for intermediate level drivers. A starting time earlier than midnight will prevent more crashes, especially since teenage driver crashes occur more frequently before midnight than after (Foss & Goodwin, 2003; Williams, 2003). Use: As of August 2009, 48 States and the District of Columbia restricted intermediate license drivers from driving during specified nighttime hours. Effectiveness: the effectiveness of nighttime driving restrictions in reducing both nighttime driving and nighttime crashes has been demonstrated conclusively (Hedlund et al. In contrast, passengers decrease crash risk for drivers 30 to 59 years old (Williams, 2003; Williams, Ferguson, & McCartt, 2007). The most common passenger restrictions limit teenage drivers to zero or just one passenger. Some restrictions apply to all passengers and some only to passengers younger than a specified age. Some restrictions apply only during the initial months of the intermediate license. Effectiveness: There is growing evidence that passenger restrictions are effective in reducing young driver crashes, though the restrictions sometimes are violated (Goodwin & Foss, 2004; Williams, 2007). California allows no passengers younger than 20 for teenagers who hold an intermediate license. For example, one study showed a 38% decrease in 16-year-old driver crashes in California in which a teen passenger was killed or injured (Williams, 2007). Results showed that 16 year-old-driver crashes were reduced in all three States, as were motor vehicle related injuries among 15 to 17-year-olds (Chaudhary, Williams, & Nissen, 2007).

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