Emergency. 2017; 5 (1): e21 OR I G I N A L RE S E A RC H Predictive factors of poor outcome in road traffic injures; a retrospective cohort study Hamid Reza Hatamabadi1, Majid Shojaee2, Parvin Kashani2, Mohammad Mehdi Forouzanfar2, Dorrin Aghajani Nargesi2, Mohammad Reza Amini Esfahani3 ∗ 1. Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Department of Emergency Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Received: June 2016; Accepted: August 2016; Published online: 9 January 2017 Abstract: Introduction: Road traffic injuries (RTI) are among the most important health problems worldwide as they cause more than 1.2 million deaths and 50 million injuries each year. The present study aims to evaluate the outcome and aftermath of RTI in those who were injured and hospitalized due to traffic accidents. Methods: In the present retrospective cohort study with a one-year follow-up, data were extracted from the profiles of the RTI hospitalized patients. Outcome of the patients was evaluated at the time of discharge and 1-year later including their living state, presence of a disability or complete recovery. Results: 1471 patients were studied (mean age of 32.8±17.0; 80.3% male). 571 (38.8%) had mild disability, 684 (46.5%) moderate disability, and 85 (5.8%) had severe disability at the time of discharge. In the end, 53 (3.6%) died. In the 1-year follow-up, 194 (13.2%) had mild disability, 43 (2.9%) had moderate disability, 9 (0.6%) had severe disability, and 7 (0.5%) were in a vegetative state. Presence of an underlying disease (p=0.03), loss of consciousness for more than 24 hours (p=0.04), spinal injury (p=0.002), presence of multiple trauma (p=0.01), increased ISS (p<0.001), need for ventilator (p<0.001), and organ injuries during hospitalization (p<0.001) are independent factors that increase the risk of poor outcome in RTI patients. Conclusion: Based on the results of the present study, underlying illnesses, loss of consciousness for more than 24 hours, spinal injury, multiple trauma, increased ISS, need for ventilator, and organ injuries during hospitalization were independent factors that increased the probability of poor outcome in RTI injuries. Keywords: Accidents, traffic; hospitalization; patient outcome assessment; epidemiology © Copyright (2017) Shahid Beheshti University of Medical Sciences Cite this article as: Hatamabadi H, Shojaee M, Kashani P, Forouzanfar M, Aghajani Nargesi D, Amini Esfahani M. Predictive factors of poor outcome in road traffic injures; a retrospective cohort study. Emergency. 2017; 5 (1): e21. 1. Introduction Road traffic injuries (RTI) are among the most important health problems worldwide as they cause more than 1.2 mil- lion deaths and 50 million injuries each year. More than 90% of mortalities due to RTI occur in low and middle income countries (1, 2). It is predicted that in the next 5 years RTI will lead to 6 million deaths and 60 million injuries, only in de- veloping countries. In 1990, RTI ranked 9t h in the most im- portant factors determining population health and it is pre- ∗Corresponding Author: Mohammad Reza Amini Esfahani; Namazi Hospi- tal; Namazi Square; Shiraz University of Medical Sciences, Shiraz, Iran. Tel: +989171529761; E-mail: dr.amini94@yahoo.com dicted to become the 3r d cause of mortality and disability by 2020. The reports also show that 50% of the dead were 15-43 years old, who are the most effective population in a society’s financial development (3). In Iran RTI rate is very high and fatal RTI rate is 33 in 100000 people, which empha- sizes the need for more research and taking preventive mea- sures and efficient treatment in managing RTI (4-6). The high social and financial costs of RTI and its physical and men- tal aftermaths on people and societies are the major prob- lem that transportation managers and health providers must face. This challenge is many times more in developing coun- tries, where RTI rate is increasing and its direct and indirect costs are more than the developed countries. World Bank re- port shows that the number of people who die of RTI in Iran has increased by 10%, which is higher than most developing This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com H. Hatamabadi et al. 2 Panel 1: Glasgow outcome scale Database Search terms 1. Death Severe injury or death without recovery of consciousness 2. Persistent vegetative state Severe damage with prolonged state of unresponsiveness and a lack of higher mental functions 3. Severe disability Severe injury with permanent need for help with daily living 4. Moderate disability No need for assistance in everyday life, employment is possible but may require special equipment. 5. mild disability Light damage with minor neurological and psychological deficits. 6. Good recovery Resumption of normal activities, however there may be minor neurological or psychological deficits. countries and is very undesirable and worrisome compared to world standards (2). In its last report, World Health Organi- zation has expressed the need for more research on the epi- demiologic pattern of RTI in low and middle income coun- tries to determine the dimensions of the problem and iden- tify those who are most susceptible to RTI, since no accurate estimation exists regarding the social and economic effects of RTI in these countries. Although valuable efforts have been made to identify the effects and outcomes of RTI in Iran in recent years, there is still a shortage of available data in this regard (7-9). Therefore, the present study aims to retrospec- tively evaluate the outcome and aftermath of RTI in those who were injured and hospitalized due to a traffic accident. 2. Methods 2.1. Study design The present study is a retrospective cohort one, with a one- year follow-up, carried out in two educational hospitals in Tehran, Iran. Patients referred to the hospitals from April 2012 to March 2013 were included and Ethics Committee of Shahid Beheshti University of Medical Sciences approved the study. Data collection forms were anonymous and patient data remained confidential. 2.2. Participants The studied population consisted of all the patients injured in RTI during the course of the study, who had an accident with at least 1 vehicle. Patients with incomplete or unreach- able data were excluded. There was no age and sex limitation. 2.3. Data collection Data collection was done using a checklist that consisted of demographic data (age, sex, level of education), trauma mechanism, type and location of injury, type of vehicle in accident, route of transportation to emergency department (ED) (by ambulance, taxi, or personal vehicle), pre-hospital clinical measures taken, hospitalization status, hospitaliza- tion duration, intensive care unit admission, injury severity score (ISS), need for ventilator, organ failure, and outcome (death, disability, or complete recovery at the time and one year after discharge). Data were gathered by trained emer- gency medicine residents. Their trainings consisted of re- search tool management (how to fill a checklist, data record- ing) and summarizing medical data. Data were extracted from the patients’ profiles and quality of data collection was evaluated by the head researcher of each hospital every 24 hours. In addition, at the end of each week, some checklists were randomly chosen and their quality was controlled by the chief researcher to ensure the quality of data collection. In this study, injury severity was classified into 4 groups: mild (ISS < 9), moderate (ISS 9-15), severe (ISS 16-25), and pro- found (ISS > 25). 2.4. Outcomes Living status (dead or alive), and disability or complete recov- ery at the time of discharge were appraised, and in-hospital complications such as embolism, deep vein thrombosis, in- fection, organ failure, need for ventilator, infection, high or low blood pressure, hypothermia, hypoxia, seizure, sepsis and shock were evaluated. Death and severe disability were considered as poor outcome. Glasgow outcome scale (GOS) was used for the 1-year follow-up outcome evaluation (panel 1). GOS divides patients into 2 groups based on desirable and undesirable outcome: poor consisting of GOS score 1-3 and desirable with the score of 4-6. In the 1-year follow-up, the patients or their relatives were contacted by phone. Cases that could not be contacted after calling 3 times (due to not responding, wrong number or the phone number being sold) were considered as loss to follow-up. 2.5. Statistical analyses Data were analyzed using STATA 11.0. Quantitative data were reported as mean and standard deviation, and quali- tative ones as frequency and percentage. Outcome (death, disability, complete recovery) and complications were as- sessed based on demographic data, baseline characteristics and clinical information. The association of each variable with 1-year outcome was then determined using indepen- dent t-test, chi square and exact Fisher’s test. Finally, to as- sess the independent predictive factors of patient outcome, stepwise multivariate logistic regression analysis was used. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2017; 5 (1): e21 Table 1: Relationship between demographic data and baseline characteristics of patients and their 1-year outcome Factors Desirable outcome Poor outcome Total P Age(mean ± SD) 32.0 ± 16.5 40.0 ± 21.5 32.8 ± 17.0 < 0.001 Sex(n, %) Male 1126 (80.3) 55 (79.7) 1181 (80.3) 0.90 Female 276 (19.7) 14 (20.3) 290 (19.7) Reference by(n, %) Ambulance 1003 (71.5) 45 (65.2) 1048 (71.2) 0.001 Personal vehicle 199 (14.2) 4 (5.8) 203 (13.8) Referral from another hospital 200 (14.3) 20 (29.0) 220 (15.0) Time before arrival (mean ± SD) 32.9 ± 20.3 33.5 ± 16.0 33.1 0.85 Trauma mechanism(n, %) Automobile 1024 (73.0) 39 (56.5) 1063 (72.3) 0.03 Motorcycle 153 (10.9) 11 (16.0) 154 (10.5) Collision with a stationary ob- ject 187 (13.3) 16 (23.2) 203 (13.8) Bicycle 2 (0.1) 0 (0.0) 12 (0.7) Unknown 36 (2.6) 3 (4.3) 39 (2.7) History of illness(n, %) NO 1263 (90.1) 0 (0.0) 1263 (85.9) Diabetes 41 (3.0) 4 (5.8) 45 (3.1) 0.11 High blood pressure 59 (4.1) 58 (84.1) 117 (7.9) 0.11 Ischemic heart disease or stroke 37 (2.7) 4 (5.8) 41 (2.8) 0.08 Myocardial infarction 2 (0.1) 2 (2.9) 4 (0.3) 0.009 Cerebrovascular Accident 0 (0.0) 1 (1.4) 1 (0.1) 0.04 History of drug use(n, %) No 1278 (90.9) 49 (71.0) 1327 (90.2) < 0.001 Yes 127 (9.1) 20 (29.0) 144 (9.8) Drug abuse(n, %) No 1134 (80.9) 53 (76.8) 1187 (80.7) 0.43 Cigarette 129 (9.3) 9 (14.8) 138 (9.4) 0.16 Alcohol 23 (1.7) 0 (0.0) 23 (1.6) 0.62 Drugs 103 (7.4) 6 (9.8) 109 (7.4) 0.49 Hookah 3 (0.2) 0 (0.0) 3 (0.2) 0.72 Psychotropic drugs 10 (0.7) 0 (0.0) 10 (0.7) 0.99 In all analyses, p < 0.05 was considered as significance level. 3. Results: 3.1. Baseline characteristics of the patients 1941 patients were included in this study, 206 (10.6%) of which were discharged against medical advice and there were 264 (15.2%) cases of loss to 1-year follow-up. Therefore no data was available regarding their outcome. Analyses were done on the remaining 1471 patients. Their mean age was 32.8 ± 17.0 years ranging from 1 to 91 years (80.3% male). Tables 1 and 2 show the patients’ demographic data, base- line characteristics and patients’ clinical variables. The 18-29 years age group had the most frequency with 657 (37.9%) pa- tients. Most of the patients (71.2%) were referred to the hos- pital by an ambulance. Trauma mechanism was car accident in 1063 (72.3%) patients. Urban areas were the most common location with 43.5%. Glasgow coma scale (GCS) was between 14 and 15 in 1372 (93.3%) of the patients, 9-13 in 57 (3.9%), and < 9 in 42 (2.8%) cases. This loss of consciousness lasted less than 6 hours in 54 (3.9%), 6-24 hours in 1 (0.1%) and more than 24 hours in 16 (1.1%) patients. Lower extremities injury (53.4%) was the most common injury. 3.2. Patient outcomes Mean length of stay was 8.7 ± 8.3 days ranging from 1 to 96 days. 38 (2.6%) patients were hospitalized in the intensive care unit (ICU). Mean hospitalization duration in ICU was 7.7 ± 9.1 days (ranged 1-52 days). 17 (1.2%) of the patients were affected with wound infection, 6 (0.4%) with pulmonary em- bolism 8 (0.6%) with fat embolism, and 2 (0.2%) had deep vein thrombosis. In evaluating in-hospital organ failure, 6 (0.4%) cases of respiratory diseases, 6 (0.4%) cases of coag- ulation abnormalities, 1 (0.1) patient with liver problem, 8 This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com H. Hatamabadi et al. 4 Table 2: Relationship between clinical factors of patients and their 1-year outcome Factor Desirable outcome Poor outcome Total P Life-threatening signs on ad- mission(n, %) No 1286 (91.7) 65 (94.2) 1351 (91.8) 0.43 Airway obstruction 10 (0.7) 0 (0.0) 10 (0.7) 0.99 Respiratory problems 35 (2.5) 0 (0.0) 35 (2.4) 0.41 Circulation problems 71 (5.1) 4 (6.8) 75 (5.1) 0.99 Pupil(n, %) Normal 1120 (98.9) 51 (96.2) 1171 (98.7) 0.22 Single-sided pupil dilation 8 (0.7) 1 (1.9) 9 (0.8) Double-sided mydriasis pupil dilation 5 (0.4) 1 (1.9) 6 (0.5) Glasgow coma scale(n, %) 14-15 1309 (93.4) 63 (91.3) 1372 (93.3) 0.34 9-13 55 (3.9) 2 (2.9) 57 (3.9) > 9 38 (2.7) 4 (5.8) 42 (2.8) Head trauma(n, %) No 1085 (77.4) 39 (54.5) 1124 (76.4) < 0.001 Yes 317 (22.6) 30 (43.5) 347 (23.6) Loss of consciousness dura- tion(n, %) No 1274 (95.5) 47 (81.0) 1321 (94.9) < 0.001 < 6 hours 53 (4.0) 1 (1.7) 54 (3.9) 6-24 hours 1 (0.1) 0 (0.0) 1 (0.1) > 24 hours 6 (0.4) 10 (17.3) 16 (1.1) Amnesia(n, %) No 1218 (92.4) 47 (83.0) 1265 (91.9) < 0.001 < 6 hours 92 (7.0) 3 (5.2) 95 (6.9) 6-24 hours 2 (0.2) 0 (0.0) 2 (0.2) >24 hours 6 (0.4) 8 (13.8) 14 (1.0) Site of injury(n, %) Neck 56 (4.0) 5 (7.2) 61 (4.4) 0.1 Face 16 (1.1) 0 (0.0) 16 (1.1) 0.99 Chest 111 (7.9) 12 (17.4) 123 (8.8) < 0.001 Abdomen and hip 112 (8.0) 12 (17.4) 124 (8.9) < 0.001 Spine 61 (4.4) 10 (14.5) 71 (5.1) < 0.001 Upper extremities 247 (17.6) 8 (11.6) 255 (18.3) 0.20 Lower extremities 724 (51.6) 22 (31.9) 746 (53.4) 0.001 Multiple trauma(n, %) No 1180 (84.2) 40 (58.0) 1220 (82.9) < 0.001 Yes 222 (15.8) 29 (42.0) 251 (17.1) Injury severity score(n, %) < 9 (Mild) 628 (52.4) 3 (4.5) 631 (49.9) < 0.001 9-15 (Moderate) 338 (28.2) 5 (7.6) 343 (27.1) 16-25 (Severe) 160 (13.4) 24 (36.4) 184 (14.6) > 25 (profound) 72 (6.0) 34 (51.5) 106 (8.4) (0.6%) patients with cardiovascular diseases, 8 (0.6%) with kidney diseases, and 5 (0.3%) with sepsis were observed (Fig- ure 1A-B and Table 3). Out of the 1471 studied patients, 312 (21.2%) were discharged with full recovery, while 571 (38.8%) had mild disability, 684 (46.5%) had moderate disability, and 85 (5.8%) had severe disability at the time of discharge. In the end, 53 (3.6%) patients died (Figure 1C). After 1 year, 1165 (79.2%) patients had fully recovered, 194 (13.2%) had mild disability, 43 (2.9%) had moderate disability, 9 (0.6%) had se- vere disability, and 7 (0.5%) were in a vegetative state. No cases of death were reported during this time (Figure 1D). 4. Predictive factors of 1-year outcome: 4.1. Univariate analyses Higher ages (p < 0.001); being referred from another hospital (p = 0.001); high energy trauma mechanism (p = 0.03); having a history of myocardial infarction (p = 0.009), cerebral vascu- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 5 Emergency. 2017; 5 (1): e21 Table 3: Relationship of therapeutic measures and side effects during hospitalization with patients’ 1-year outcome Variable* Desirable outcome Poor outcome Total P Pre- hospital emergency measures(n, %) Serum therapy 1037 (74.5) 50 (72.5) 1087 (73.9) 0.71 Intubation 1 (0.06) 0 (0.0) 1 (0.1) 0.99 Oxygen therapy 765 (55.0) 46 (66.7) 811 (55.1) 0.06 Neck collar 443 (31.9) 33 (47.8) 476 (32.4) 0.006 Back board 326 (23.5) 31 (44.9) 357 (28.2) < 0.001 Splinting 571 (41.1) 26 (37.7) 597 (40.6) 0.57 In- hospital emergency mea- sures(n, %) Blood transfusion 149 (10.6) 40 (57.0) 189 (12.8) < 0.001 Cardiopulmonary resuscita- tion 2 (0.14) 51 (73.9) 53 (3.6) < 0.001 Chest tube 50 (3.6) 19 (27.5) 69 (4.7) < 0.001 Diagnostic peritoneal lavage 19 (1.4) 23 (33.3) 42 (2.8) < 0.001 Need for ventilator 48 (3.4) 50 (77.5) 98 (6.7) < 0.001 Organ injury(n, %) No 1355 (96.5) 35 (50.1) 1390 (94.5) < 0.001 Respiratory 1 (0.07) 5 (7.4) 6 (0.4) < 0.001 Coagulation abnormality 1 (0.07) 5 (7.4) 6 (0.4) < 0.001 Liver 0 (0.0) 1 (1.5) 1 (0.1) 0.05 Cardiovascular 2 (0.1) 6 (8.8) 8 (0.6) < 0.001 Kidney 4 (0.3) 4 (5.9) 8 (0.6) < 0.001 Sepsis 1 (0.07) 4 (5.9) 5 (0.3) < 0.001 Infection 26 (1.9) 8 (11.6) 34 (2.3) < 0.001 Embolism 10 (0.7) 1 (1.5) 11 (7.5) 0.41 Deep vein thrombosis 2 (0.1) 0 (0.0) 2 (0.2) 0.99 *, Some patients have more than one injury or underwent more than one procedure. Table 4: Independent effective factors on 1-year outcome of RTI patients Variable Regression coefficient 95% confidence interval P Underlying illness 1.15 0.11 – 2.34 0.03 Loss of consciousness > 24 hours 0.62 0.02 – 1.22 0.04 Abdominal trauma -2.62 -4.49– -0.74 0.006 Spinal trauma 1.98 0.75 – 3.21 0.002 Multiple trauma 1.02 0.10 – 2.14 0.01 Increased injury severity score 0.17 0.10 – 0.25 < 0.001 Intensive care unit hospitalization 1.98 -3.81 – 0.19 0.03 Need for ventilator 3.22 2.0 – 4.45 < 0.001 Organ injuries during hospitalization 3.69 2.16 – 5.21 < 0.001 lar accident (p = 0.04), drug use (p < 0.001); using neck collar (p = 0.006) and back board (p < 0.001) at pre-hospital setting; having head trauma (p< 0.001); the longer duration of loss of consciousness (p <0.001); need for ventilator (p < 0.001); hos- pitalization in ICU (p < 0.001); and higher ISS (p < 0.001) were the factors that had a significant association with patient out- come (table 1-3). 4.2. Multivariate analyses Presence of an underlying illness (p = 0.03), loss of conscious- ness for more than 24 hours (p = 0.04), spinal injury (p = 0.002), presence of multiple trauma (p = 0.01), increased ISS (p < 0.001), need for ventilator (p < 0.001), and organ failure during hospitalization (p < 0.001) were independent factors that increased the risk of poor outcome in RTI patients. In contrast, a single abdominal trauma (p = 0.006) and hospital- ization in ICU were associated with improved outcome (Ta- ble 4). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com H. Hatamabadi et al. 6 Figure 1: Patient outcomes. A) In-hospital complication; B) Organ injuries during hospitalization; C) Outcome of the patients at the time of discharge; D) 1-year outcome of the patients. 5. Discussion: The present study showed that young males are most fre- quently affected with RTI and motorcycle is the most impor- tant cause, which is in line with previous studies. For in- stance, Yousefzadeh et al. showed that the number of men in- volved in RTI was 3.6 times the women, and about 50% of the patients were 20-44 years old. Most injuries were due to mo- torcycle accidents and 5.2% died in the end (10). Torabi et al. also revealed that 89.9% of the injured were male and mostly (56.8%) 16-25 years old (11). In another cross-sectional study in Tehran, most of those injured in RTI were 21-30 years old (22.3%), and mainly pedestrians (54.6%) (12). Hatam- abadi et al. also expressed that majority of those who were killed in traffic accidents were male, most of which were 21- 40 years old and uneducated (13). These researchers, in an- other study, reported 7.0% mortality rate due to RTI. 78.5% male and the majority aged 20-30 years old and most used personal cars (52.9%) (14). This higher mortality rate was due to the nature of the road they studied. Abali-Tehran is an inter-city road in Iran that has steep slopes and can be very slippery especially in rainy seasons. In addition, driving speed is much higher compared to urban streets and there are fewer motorcycles, which might justify the low rate of mo- torcycle accidents. In the present study, mortality due to RTI was 3.05%. Akbari et al. studied RTI in 10 provinces of Iran and concluded that mortality rate in unintentional accidents was 4% which is in line with this study. Traffic accidents with 7.51% were the most frequent cause of death (15). In addi- tion, Yousefzadeh et al. epidemiologically evaluated effec- tive factors in trauma patients in Rasht, Iran, and showed that 5.17% of RTI injuries result in death (10). Torabi et al. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 7 Emergency. 2017; 5 (1): e21 assessed motorcycle accidents and revealed 4% mortality in these patients. Their most important cause of death being head and neck trauma (11). A study by Kadivar et al. also showed that RTI was the major cause of death in uninten- tional accidents (16). Despite RTI being the third most im- portant cause of death, since it targets the younger popula- tion (mean age was about 34 years in 2001), it ranks first in the list of causes for years of potential life lost (6, 17). Control- ling and decreasing RTI is not the responsibility of health care providers but informing the responsible organizations on the importance of this problem and cooperating with them to control and reduce this major cause of death can be. The statistics of this study reveal the necessity of paying more at- tention to emergency services and providing trauma centers and equipping them. The reason for high mortality rate of RTI and its increase might be industrialization and broader usage of motor vehicles in recent years without improving standards for this new way of life. Reducing drug abuse, safety education, improving protective measures in working environment, rapid first aid in the location of accident, elim- inating causing factors (reducing speed, putting appropri- ate signs on the road, etc), enforcing more restricted traffic rules, and providing rehabilitation services are among the useful measures, which can aid in prevention of accidents and therefore decrease mortality. The findings of logistic re- gression analysis showed that presence of an underlying ill- ness, loss of consciousness for more than 24 hours, spinal injury, presence of multiple trauma, increased ISS, need for ventilator, and organ injuries during hospitalization were in- dependent factors that increased the risk of poor outcome in RTI patients, while a single abdominal trauma and hospital- ization in ICU led to improved final outcome. These results emphasize the importance of careful evaluation of these pa- tients in ED, so that no injury goes unnoticed, because if the injuries are rapidly diagnosed and properly treated outcome can improve (18, 19). This is confirmed by the result of this study that states hospitalization in ICU leads to improved outcome. Therefore, paying attention to these patients and maintaining proper tissue perfusion during hospitalization can prevent organ disabilities and therefore poor outcome. 6. Conclusion: Based on the results of present study, underlying illnesses, loss of consciousness for more than 24 hours, spinal injury, multiple trauma, increased ISS, need for ventilator, and or- gan injuries during hospitalization were independent factors that increased the probability of poor outcome in RTI in- juries. 7. Appendix 7.1. Acknowledgements This research has been supported by Shahid Beheshti Uni- versity of Medical Sciences & health Services. 7.2. Authors contribution All authors passed the four criteria for authorship contribu- tion based on recommendations of the International Com- mittee of Medical Journal Editors. 7.3. Conflict of interest None. 7.4. Funding None declared. References 1. Toroyan T. Global status report on road safety: time for action2009. 2. Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention. World Health Organization Geneva; 2004. 3. Organization WH. World health statistics 2009: World Health Organization; 2009. 4. 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