Mandatory Helmet Use Research Articles

Unveiling the Surge: A Comprehensive Analysis of E-Scooter-Related Injuries at an Urban Level 1 Trauma Center in Vilnius, Lithuania (2018-2021).

Background The surge in electric scooter (e-scooter) adoption in 2019 fueled by sharing platforms has raised safety concerns, leading to an increased incidence of e-scooter-related injuries. Despite regulatory efforts, there has been a notable rise in accidents, prompting a comprehensive investigation. This study conducted at the Republican Vilnius University Hospital (RVUH), a level 1 trauma center, is one of thefirst in the Baltic States aiming to analyze the causes, severity, and frequency of e-scooter injuries from 2018 to 2021. This research addresses a critical gap in understanding e-scooter safety in the Baltic States, providing valuable insights for informed policy and preventive measures. Methodology This retrospective study analyzed e-scooter-related injuries in Vilnius, Lithuania, from April to September during 2018-2021. Data from the RVUH emergency department were examined. Using keywords such as "scooter" and "electric," relevant cases were extracted from the RVUH electronic health system. Included were individuals, both riders and pedestrians, with clear e-scooter involvement, excluding duplicates, those under 18, and users of other types of scooters. Extracted medical records provided data on demographics, injury specifics, helmet use, alcohol consumption, and more. Trauma severity was assessed through the New Injury Severity Score (NISS) and Abbreviated Injury Scale (AIS). Statistical analysis utilized GraphPad Prism software and Excel, adhering to ethical guidelines with RVUH Bioethics Committee approval. Results Over four years, 1,036 e-scooter-related injuries at RVUH revealed a gender-based shift, with males sustaining more injuries. The introduction of rentals in 2019 triggered a 334% surge in injuries compared to 2018. Despite an annual 208% increase from 2018 to 2021, 2021 saw a 710.93% rise. Trauma severity remained consistent, with AIS scores 1 and 2 being prevalent. Non-helmet wearers constituted 97.97%, and soft tissue damage was predominant. Ownership patterns shifted toward rentals (81.15%), reflecting the popularity of sharing platforms. Alcohol influence showed no significant change, but intoxicated patients had a higher surgery rate during four years. Mechanism analysis highlighted tripping as the primary cause. Injury characteristics revealed fractures in 34.56% of cases, primarily affecting upper limbs (53.35%). Soft tissue trauma was prominent (65.44%), with lower limbs being significantly impacted. Conclusions The surge in e-scooter injuries demands urgent preventive action. While most injuries are mild, a significant proportion is moderate to severe, even fatal. Inadequate education, lax enforcement, and uneven infrastructure contribute to the risk. Urgent measures, including road maintenance, speed reduction, and mandatory helmet use, are crucial. Clarity in government directives for designated e-scooter areas is vital. Further research is needed to understand the broader impact of informed policymaking and safer urban mobility. Expanding research to other Lithuanian regions would enhance the current study.

Quad bike related trauma in Ireland

IntroductionA quad bike or an all-terrain vehicle is a four-wheeled powered vehicle generally designed for off-road use. They are widely used for farm-related work and more recently for recreational purposes. The potential for serious injury and death with quad bike use is a growing public health concern. There is an inherent instability in their design and they are typically used on rugged terrain characterised by dangerous driving surfaces. This study examines quad bike related trauma in Ireland using a national trauma registry to identify patient demographics, injury mechanism and type, treatments received and outcomes. MethodsAll quad bike related trauma cases recorded on the Major Trauma Audit (MTA), National Office of Clinical Audit in Ireland for the period 2014–2019 were gathered and analysed. ResultsThere were 69 cases identified and 63 (91 %) of these were male. The median (IQR) age was 27 (19 - 49.1). There were 25 % (n = 17) aged 0–18 years, 64 % (n = 44) aged 19–65 and 12 % (n = 8) aged greater than 65 years. The median injury severity score (ISS) was 10 (IQR 9–22). The most severely injured body region was the head (n = 21, 30 %). No helmet use was recorded in 50 % (n = 34) of cases.October recorded the highest number of cases (n = 9, 13 %), and Sunday was the most common day (n = 17, 25 %). The median length of hospital stay was five days (IQR 3–9). One patient died after arrival to hospital. ConclusionQuad bike related trauma predominantly affects a young male cohort with serious injury characteristics. A sizeable proportion of patients are under 18 years of age. This data can better inform national policies and public awareness campaigns targeting this trauma subset. The head was the most common severely injured body region, highlighting the potential need for legislative intervention regarding mandatory helmet use. A large cohort of patients required transfer for definitive care which has implications for trauma care pathways and advocates for the development of an integrated trauma system in Ireland.

Computer vision-based helmet use registration for e-scooter riders – The impact of the mandatory helmet law in Copenhagen

Problem: E-scooters are a new form of mobility used more frequently in urban environments worldwide. As there is evidence of an increased risk of head injuries, helmets are recommended and (less frequently) legislated. Denmark has enacted mandatory e-scooter helmet use legislation from January 1, 2022. So far, it is unclear how this newly implemented law influenced helmet use of e-scooter riders in Denmark immediately after its implementation. Method: In this observational study, we register and compare e-scooter helmet use before the mandatory helmet use legislation (December 2021) and after (February 2022). As observational survey data collection in the field can be highly time-consuming, we conducted a video-based observation survey. We trained and applied a computer vision algorithm to automatically register e-scooter helmet use in the video data. Results: The trained algorithm produces accurate helmet use data, which does not differ significantly from human-registered helmet use. In applying the algorithm to video data collected in December 2021 and February 2022, we register an overall e-scooter helmet use of 4.4% in n = 1054 riders. Splitting the observation between the time before and after the implementation of the helmet use law reveals a significant increase in helmet use from 1.80% to 5.56%. Discussion: In this study, we successfully train and apply an object detection algorithm to register accurate helmet use data in videos collected in Copenhagen, Denmark. Using this algorithm, we find a significant impact of a new mandatory e-scooter helmet use law on e-scooter riders’ helmet use behavior. Limitations of the study as well as future research needs, are discussed. Practical Applications: Computer vision algorithms can be used for accurate e-scooter helmet assessments. Implementing a mandatory helmet use law can increase helmet use of e-scooters at specific observation sites.

Bivariate-Logit-Based Severity Analysis for Motorcycle Crashes in Texas, 2017–2021

Due to the number of severe traffic collisions involving motorcycles, a comprehensive investigation is required to determine their causes. This study analyzed Texas crash data from 2017 to 2021 to determine who was at fault and how various factors affect the frequency and severity of motorcycle collisions. Moreover, the study tried to identify high-risk sites for motorcycle crashes. Utilizing bivariate analysis and logistic regression models, the study investigated the individual and combined effects of several variables. Heat maps and hotspot analyses were used to identify locations with a high incidence of both minor and severe motorcycle crashes. The survey showed that dangerous speed, inattention, lane departure, and failing to surrender the right-of-way at a stop sign or during a left turn were the leading causes of motorcycle crashes. When a motorcyclist was at fault, the likelihood of severe collisions was much higher. The study revealed numerous elements as strong predictors of catastrophic motorcycle crashes, including higher speed limits, poor illumination, darkness during the weekend, dividers or designated lanes as the principal road traffic control, an increased age of the primary crash victim, and the lack of a helmet. The concentration of motorcycle collisions was found to be relatively high in city cores, whereas clusters of severe motorcycle collisions were detected on road segments beyond city limits. This study recommends implementing reduced speed limits on high-risk segments, mandating helmet use, prioritizing resource allocation to high-risk locations, launching educational campaigns to promote safer driving practices and the use of protective gear, and inspecting existing conditions as well as the road geometry of high-risk locations to reduce the incidence and severity of motorcycle crashes.

Investigating the trend of road traffic fatalities in Malawi using Mann-Kendall statistic

Fatalities due to road accidents remain a major challenge worldwide. In the recent years, Malawi, one of the developing African countries with a total population of about 19 million has also been witnessing a very high fatality rate [of about 31 crash deaths per 100,000 population in 2016] compared to most of its neighbours in the region. This seems to be continuously increasing even with several intervention measures, such as, speed and alcohol impairment laws, and laws for mandatory seatbelt and helmet use. In view of this, the study attempted to investigate the trend of road fatalities in Malawi, such that effectiveness of the existing measures can be established. For this, archived crash data of road fatalities between years 2000–2021 were used to undertake intervention and trend analyses. The method of Cumulative Summation was used to identify intervention points in the series, followed by the Mann-Kendall statistic (τ) to determine the trend during the intervened period using the non-parametric Rank-Sum test to support the findings. The results showed that the trend has been decreasing in the early years of legislating policy measures [2000–2012] and, thereafter [2013–2021], increased significantly [τ = 0.8333]. This suggests that there was acceptance of the measures by the motorists/public in the early years of implementation [2000–2012], which might have been overshadowed by vehicle population growth and weak enforcement mechanism that have seen the trend increasing lately. The study therefore suggests that there is still a scope to review the intervention measures in their effective implementation as well as regular monitoring.

Which sports have a higher risk of maxillofacial injuries?

ObjectivesSports etiology is one of the most common causes of maxillofacial injuries. This work aimed to provide an up-to-date review of sports-related maxillofacial injuries. MethodsAn updated review was conducted on Pubmed and Google Scholar. No publication year and language restrictions were applied. Two different search strategies were performed, the first addressed which sports, generally associated with maxillofacial injuries, and the second search was conducted to determine the frequency of maxillofacial injuries associated with each sport individually. ResultsThe first search returned 26 articles distributed across different sports, from different countries, and with varied age distribution. The second search displayed 85 articles on individual sports group. Papers were rated and categorized according by the sport associated to the reported injury. A useful sports risk scale for maxillofacial injuries has been developed. Peculiar themes from all participating sports were evaluated. The use of protective equipment and other preventive measures were highlighted. ConclusionsSome sports with ball and cycling can be considered riskier sports for maxillofacial injuries. Athlete education and the mandatory use of mouthguards, helmets, and eye protection, among other things, are crucial to prevent these injuries. Tailor-made mouthguards and protective masks, which are becoming cheaper, are in vogue. The Sports-related Maxillofacial Injuries Risk scale can be useful for athletes, athletic coaches, and maxillofacial surgeons.

Is the Use of Segways or E-Scooters in Urban Areas a Potential Health Risk? A Comparison of Trauma Consequences.

Background and objectives: Electromobility has become increasingly popular. In 2001, Segway personal transporters (Segway) were established for tourists, and e-scooters have been in use since their approval in 2019. The aim of this study was to analyze and compare the types of injuries directly related to the use of Segways and e-scooters, respectively, in a German city and to phrase potential safety advice. Materials and Methods: All patients presenting to our emergency department after Segway incidents were retrospectively analyzed and compared with the prospectively collected cohort of patients following e-scooter incidents. Presented injuries were analyzed by body region and injury severity score (ISS). Epidemiological data were collected. Results: Overall, 171 patients were enrolled. The Segway group included 56 patients (mean age 48 years), and the e-scooter group consisted of 115 patients (mean age 33.9 years). Head injuries (HI) occurred in 34% in the Segway group compared to 52% in the e-scooter group. The ISS was approximately equal for both groups (mean ISS Segway group: 6.9/e-scooter group: 5.6). Conclusions: Since the e-scooter group presented a high number of HI along with a higher likelihood and greater severity of HI, mandatory use of helmets is suggested.

A retrospective registry analysis of the transport‐related health burden of wheeled recreational devices in Queensland, Australia

ObjectiveEvaluate injury patterns from wheeled recreational devices (WRD) in the public space and explore risk factors for hospital admission. MethodA cross‐sectional analysis of WRD injury prevalence and risk factors for hospital admissions was conducted using data from the Queensland Injury Surveillance Unit (QISU) database for 2007 to 2017. Descriptive statistics and a log‐binomial regression model were used to calculate adjusted relative risk for hospital admission. ResultsMost WRD injury in the public space was related to stand‐alone WRD injury events such as falls, with few reported WRD users being hit by vehicles from 2007 to 2017. Stand‐alone WRD injury events had a higher independent risk of hospital admissions when injured in the head/neck/face (RR 2.08, 95%CI 1.6 to 2.8, p<0.001), and when the injury was a fracture (RR 2.57, 95%CI 2.1 to 3.3, p<0.001) or a brain injury (RR 3.19, 95%CI 2.5 to 4.1, p<0.001). ConclusionHead, brain and facial injuries and fractures are leading preventable factors for hospital admissions due to WRD injury. These types of injuries generate a preventable burden to the health system. Implications for public healthThe results support the need to consider legislation regarding mandatory helmet use for non‐motorised WRD when used on public roads and footpaths, while further research is conducted. This strategy could reduce the long‐term health outcomes associated with head, face and brain injury in young commuters.

Analysis of Bicycle-Motor Vehicle Crashes in San Antonio, Texas.

Bicycling is inexpensive, environmentally friendly, and healthful; however, bicyclist safety is a rising concern. This study investigates bicycle crash-related key variables that might substantially differ in terms of the party at fault and bicycle facility presence. Employing 5 year (2014–2018) data from the Texas Crash Record and Information System database, the effect of these variables on bicyclist injury severity was assessed for San Antonio, Texas, using bivariate analysis and binary logistic regression. Severe injury risk based on the party at fault and bicycle facility presence varied significantly for different crash-related variables. The strongest predictors of severe bicycle injury include bicyclist age and ethnicity, lighting condition, road class, time of occurrence, and period of week. Driver inattention and disregard of stop sign/light were the primary contributing factors to bicycle-vehicle crashes. Crash density heatmap and hotspot analyses were used to identify high-risk locations. The downtown area experienced the highest crash density, while severity hotspots were located at intersections outside of the downtown area. This study recommends the introduction of more dedicated/protected bicycle lanes, separation of bicycle lanes from the roadway, mandatory helmet use ordinance, reduction in speed limit, prioritization of resources at high-risk locations, and implementation of bike-activated signal detection at signalized intersections.

A Yaounde – Kigali Experience Sharing for Harmonious City Biking Culture in Sub-Saharan Africa

Salvaging motorbike calamities and urban chaos would not only safeguard lives but achieve urban tranquility in Yaounde and Cameroon. The disorder in this transport sector observed in Yaounde can be uncurled and riders called to order as solution to the chaos accrued. This article exposes the shortcomings of biking transport as inadequate training and reckless riding have led to the urban chaos and calamities observed. If it does not occur from high speed, perhaps it would be a mentality problem. Some 140 questionnaires were administered to motor bike riders, clients, and transport authorities in Yaounde. Field observation and interview sessions were organized to have first-hand information on calamities in the city. Hotbed neighbourhoods of accidents were captured through a GPS and transformed into maps and tables. An in-depth documentary research at the Ministry of Transport and its delegations as well as the national institute of statistics was done to have data for analysis. Findings adhere to the fact that total identification of riders, mandatory use of helmets for rider and passenger as well as stringent speed limits with unadorned sanctions can be used to address the situation. This paper advocates that the Kigali experience in the management and control of motor bike transport be shared in Yaounde so as to reduce, if not curb urban mayhem and wanton accidents.

Prevalence and distribution of maxillofacial trauma in tertiary care centers before/ after motorcycle helmet use law in Sullia, India-A retrospective study.

In India, motorcycles are commonly involved in accidents and traffic rules negligence, most of which include some type of maxillofacial trauma. In September 2019, the rules for motorcycle and helmet use were modified to compulsory use in the state of Karnataka. The aim of this study was to assess the impact of mandatory helmet use on maxillofacial fractures and injuries in Sullia Taluk, Karnataka. The study was based on the information obtained from clinical records in the K.V.G Dental College and the K.V.G Medical College from February 2019 to February 2020. The inclusion criteria were subjects who met with two-wheeler accidents with complete case records and radiological investigations. A total of 78 individuals reported with maxillofacial trauma from February 2019 to February 2020. The mean age was 31±14years. There were 74 (94%) males and 4 (6%) females. Forty-nine cases reported before the mandatory helmet use rule and 29 cases reported after the helmet use rule. There was a 36.3% decrease in the incidence of maxillofacial trauma, 23.5% decrease in fractures, and an 89% reduction in the number of victims who underwent open reduction and internal fixation during the post-law period. There was a significant reduction in the incidence and severity of maxillofacial trauma after the implementation of the helmet rule.

Disparity of motorcycle helmet use in Nepal – Weak law enforcement or riders' reluctance?

Like many low- and middle-income countries, Nepal is experiencing a massive motorization, predominantly from increased use of motorcycles which is driving a surge in road-related injuries and fatalities. Motorcycles and their riders have been identified as a focal point for road traffic injury prevention measures. While helmet use is mandatory for both motorcycle drivers and passengers, fines for helmet non-use are only levied on drivers, not on passengers, and it is unclear how this unequal enforcement translates to helmet use rates in Nepal. Hence, a video-based observation on motorcyclists’ helmet use was conducted alongside a questionnaire survey on fatalism, perceived police enforcement, risk-taking personality, and perceived usefulness of helmets. For the observation and questionnaire survey, seven rural and urban sites were selected from all seven provinces of Nepal, representing varied populations, road environments, and elevations. The observation of the helmet use behavior of 2548 motorcycle riders revealed an alarming picture of helmet use in Nepal. While more than 98% of observed motorcycle drivers in Nepal used a motorcycle helmet, less than 1% of observed passengers did so. Interviews of 220 riders show that the absence of a fine for helmet non-use by passengers is accompanied by an unawareness of the traffic law, where only 11.8% of respondents knew about the mandatory helmet use law for passengers. Unhelmeted riders had a significantly higher attribution of road related crashes to fate, compared with riders that used a helmet. Results of this study can serve as an evidence base for revisions of Nepal’s Vehicle and Transportation Management Act in regard to traffic rule enforcement and fines. They further show the global importance of comprehensive regulation on safety related behaviors of road users. The feasibility of more comprehensive enforcement is discussed against the background of helmet availability for passengers.

Mandatory Helmet Use and the Severity of Motorcycle Accidents: No Brainer?

We study the impact of mandatory motorcycle helmet use laws on the severity and volume of road accidents in Uruguay by exploiting a change in the enforcement of the traffic law. Using a difference-in-differences design based on an unexpected change in policy, we report a sharp increase in helmet use and a five percentage point reduction in the incidence of serious or fatal motorcyclist accidents from a baseline of 11 percent. The benefits of helmet use are disproportionately borne by groups more likely to experience serious injuries, such as males or young drivers. We find no evidence of other responses in terms of either the volume or type of accident, suggesting that motorcyclists’ behavior did not respond to differences in risk. We show that additional costs of enforcement for the relevant government agencies were negligible and estimate the health benefits of the policy.

Workplace safety regulations and worker well-being: the impact of mandatory helmet use on career length in the national hockey league

ABSTRACT The long-term health problems resulting from professional careers in contact sports such as hockey and football have recently received lots of attention. The lawsuits initiated by NFL- and NHL-veterans suffering from repetitive concussions of the brain that eventually lead to chronic traumatic encephalopathy are two particularly prominent examples. The question, whether these long-term health problems could have been avoided, remains a highly contested issue. Using detailed career information on every single player drafted in the ten seasons before (1969 thru 1978) and the ten seasons after (1979 thru 1988) the implementation of mandatory helmets, we find that career length in professional hockey has increased by about two years, suggesting that adequate protective equipment contributes to player health and fitness. This positive effect, however, is somewhat reduced by specific forms of ‘offsetting behaviour’.

Burden of motorcyclists without helmets in a state without a universal helmet law: a propensity score analysis

BackgroundAlthough helmets are associated with reduction in mortality from motorcycle collisions, many states have failed to adopt universal helmet laws for motorcyclists, in part on the grounds that prior research...

Managing head injury risks in competitive skateboarding: what do we know?

ObjectivesThe broad objective of this paper is to inform policy, practice and research regarding the management of head injury risks in competitive skateboarding. The main motivation for the current study...

Kajian Yuridis Terhadap Ketentuan Wajib Helm Bagi Pengendara Sepeda Motor Berdasarkan Undang-Undang RI No. 22 Tahun 2009 Tentang Lalu Lintas Dan Angkutan Jalan

This research is entitled, "Juridical Study of Mandatory Helmet Provisionsfor Motorcycle Riders Under Ri No. Law. 22 of 2009 Regarding Road Traffic andTransportation. "Problems discussed in this study are the Regulations and Criteria forthe mandatory use of Helmets for motorcyclists according to Law No. 22 of 2009concerning Road Traffic and Transportation and the constraints of mandatory helmetusers for cyclists excluded motorcycles. The writing method used in this study isNormative research. One of the fundamental changes in provisions in Law No. 22 of 2009concerning Traffic is obligatory for every motorcycle rider to wear a helmet with anIndonesian national standard (SNI). From the results of a study conducted by the authorabout the obligation of motorcyclists to be obliged to use helmets as regulated in article106 paragraph 8 of Act No. 22 of 2009 concerning Road Traffic and Transportationwhich is not effective where it should require all motorcyclists to use helmets . But it isindeed different for the Province of Bali because of the Governor's Decree of the Head ofthe Bali Region Number 217 of 1986 concerning the Requirement of the Use of a Helmetfor Motorbike Drivers and the person sitting behind him or on a bicycle in the BaliProvince I tolerate drivers motorbikes that use traditional Balinese clothing.

Cost-effectiveness of mandatory bicycle helmet use to prevent traumatic brain injuries and death

BackgroundTraumatic brain injury (TBI) is the main cause of mortality and severe morbidity in cyclists admitted to Dutch emergency departments (EDs). Although the use of bicycle helmets is an effective way of preventing TBI, this is uncommon in the Netherlands. An option to increase its use is through a legal enforcement. However, little is known about the cost-effectiveness of such mandatory use of helmets in the Dutch context.The current study aimed to assess the cost-effectiveness of a law that enforces helmet use to reduce TBI and TBI-related mortality.MethodsThe cost-effectiveness was estimated through decision tree modelling. In this study, wearing bicycle helmets enforced by law was compared with the current situation of infrequent voluntary helmet use. The total Dutch cycling population, consisting of 13.5 million people, was included in the model. Model data and parameters were obtained from Statistics Netherlands, the National Road Traffic Database, Dutch Injury Surveillance System, and literature. Effects included were numbers of TBI, death, and disability-adjusted life years (DALY). Costs included were healthcare costs, costs of productivity losses, and helmet costs. Sensitivity analysis was performed to assess which parameter had the largest influence on the incremental cost-effectiveness ratio (ICER).ResultsThe intervention would lead to an estimated reduction of 2942 cases of TBI and 46 deaths.Overall, the incremental costs per 1) death averted, 2) per TBI averted, and 3) per DALY averted were estimated at 1) € 2,002,766, 2) € 31,028 and 3) € 28,465, respectively. Most favorable were the incremental costs per DALY in the 65+ age group: € 17,775.ConclusionsThe overall costs per DALY averted surpassed the Dutch willingness to pay threshold value of € 20,000 for cost-effectiveness of preventive interventions. However, the cost per DALY averted for the elderly was below this threshold, indicating that in this age group largest effects can be reached. If the price of a helmet would reduce by 20%, which is non-hypothetical in a situation of large-scale purchases and use of these helmets, the introduction of this regulation would result in an intervention that is almost cost-effective in all age groups.

Adoption of municipal bylaw legislating mandatory helmet use for cyclists under the age of 18: impact on cycling and helmet use.

Bicycle helmet use is recognized as an effective way to prevent head injuries in cyclists. A number of countries have introduced legislation to make helmets mandatory, but many object to this type of measure for fear that it could discourage people, particularly teenagers, from cycling. In 2011, the City of Sherbrooke adopted a bylaw requiring minors to wear a bicycle helmet. The objective of this study was to assess the impact of this bylaw on cycling and bicycle helmet use. The impact of the bylaw was measured by comparing the evolution of bicycle helmet use among youth aged 12 to 17 years in the Sherbrooke area (n = 248) and in three control regions (n = 767), through the use of logistic regression analyses. Cycling rates remained stable in the Sherbrooke area (going from 49.9% to 53.8%) but decreased in the control regions (going from 59.1% to 46.3%). This difference in evolution shows that cycling rates increased in the Sherbrooke area after the adoption of the bylaw, compared to the control regions (odds ratio [OR] of the interaction term: 2.32; 95% confidence interval [CI]: 1.01-5.35). With respect to helmet use, a non-statistically significant upward trend was observed in the Sherbrooke area (going from 43.5% to 60.6%). This figure remained stable in the control regions (going from 41.5% to 41.9%). No significant difference was observed in the evolution of helmet use between the two groups (OR of the interaction term of 2.70; 95% CI: 0.67-10.83). After the bylaw was adopted, bicycle use among youth aged 12 to 17 years in the Sherbrooke area remained stable and helmet used increased, though not significantly.

Road safety risk factors for non-motorised vehicle users in a Chinese city: an observational study

ObjectiveThe objective of this study is to describe and analyse the prevalence of speeding, helmet use and red-light running among riders of non-motorised vehicles (NMVs) in Shanghai, China, with a...