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1.  Children and bicycles: what is really happening? Studies of fatal and non-fatal bicycle injury. 
Injury Prevention  1995;1(2):86-91.
OBJECTIVES: The objectives of the study were to ascertain the causes of accidents, injuries, and deaths in children who ride bicycles. Fatality and injury rates were also studied in order to compare with other studies. METHODS: Two studies of children were undertaken in children aged less than 15 years. In the first (retrospective fatality study), children who died as a result of a bicycle incident during the period 1981-92 were reviewed. In the second (prospective injury study) data were obtained prospectively between April 1991 and June 1992 about children who were injured while riding a bicycle and treated at a public hospital in Brisbane. RESULTS: Study 1: fatality rates for boys were twice those for girls. The rate was highest for boys of 14 years in the metropolitan area at 6.23/100,000. All deaths involved vehicles, and the majority involved head injury or multiple injuries including head injury. Study 2: similar numbers of children were injured at onroad and off-road locations. Faculty riding was described by the rider or caregiver as the cause in 62.5% of cases. The most common time of injury was between 3 and 6 pm on both school and non-school days. Only 5.5% of all incidents involved a moving vehicle. CONCLUSIONS: Bicycle riding by children is a common cause of injury, particularly for boys. Equal numbers of injuries occurred on the road as at other locations. Faulty riding caused most accidents. Injury prevention for bicycle riders should involve not only compulsory wearing of helmets, but should also include education and training about safe riding habits, separation of motorised vehicles from bicycles, modified helmet design to incorporate facial protection, and improved handlebar design.
PMCID: PMC1067558  PMID: 9346002
2.  Non‐fatal horse related injuries treated in emergency departments in the United States, 2001–2003 
Objective
To characterise and provide nationally representative estimates of persons with non‐fatal horse related injuries treated in American emergency departments.
Methods
The National Electronic Injury Surveillance System All Injury Program (NEISS–AIP) is a stratified probability sample comprising 66 hospitals. Data on injuries treated in these emergency departments are collected and reported. NEISS–AIP data on all types (horseback riding and otherwise) of non‐fatal horse related injuries from 2001 to 2003 were analysed.
Results
An estimated 102 904 persons with non‐fatal horse related injuries (35.7 per 100 000 population) were treated in American emergency departments each year from 2001 to 2003 inclusive. Non‐fatal injury rates were higher for females (41.5 per 100 000) than for males (29.8 per 100 000). Most patients were injured while mounted on a horse (66.1%), commonly from falling or being thrown by the horse; while not mounted, injuries most often resulted from being kicked by the horse. The body parts most often injured were the head/neck region (23.2%), lower extremity (22.2%), and upper extremity (21.5%). The most common principal diagnoses were contusions/abrasions (31.4%) and fractures (25.2%). For each year that was studied, an estimated 11 502 people sustained traumatic brain injuries from horse related incidents. Overall, more than 11% of those injured were admitted to hospital.
Conclusions
Horse related injuries are a public health concern not just for riders but for anyone in close contact with horses. Prevention programmes should target horseback riders and horse caregivers to promote helmet use and educate participants about horse behaviour, proper handling of horses, and safe riding practices.
doi:10.1136/bjsm.2006.025858
PMCID: PMC2564310  PMID: 16611723
horse; equestrian; sports and recreation; traumatic brain injury
3.  Predicting ICU admissions from attempted suicide presentations at an Emergency Department in Central Queensland 
The Australasian Medical Journal  2013;6(11):536-541.
Background
Emergency medicine physicians and psychiatric staff face a challenging job in risk stratifying patients presenting with suicide attempts to predict which patients need intensive care unit admission, hospital admission or can be discharged with psychiatry follow up.
Aims
This study aims to analyse patients who were admitted to the intensive care unit or regular ward for suicide attempt, and the methods they employed in a rural Australian base hospital.
Method
We conducted a retrospective analysis of patients who presented with suicide attempts to the Rockhampton Base Hospital Emergency Department, Queensland Australia from 1 September 2007 to 31 August 2009. Multivariate logistic regression was undertaken to identify risk factors for ICU and regular ward admission, and predictors of suicide method.
Results
There were 570 patients presenting with suicide attempts, 74 of which were repeat suicide attempts. There was a 10- fold increase in the odds of intensive care unit or ICU admission (CI 1.45-81.9, p=0.02) for patients who presented with drug overdose. Increased age (OR=1.02, 95 per cent CI 1.00-1.03, p=0.05), drug overdose (OR=2.69, 95 per cent CI 1.37-5.29, p=0.004), and previous suicide attempt (OR=1.53, 95 per cent CI 1.03-2.28, p=0.03) were significantly correlated with hospital admission. Male patients (OR=2.76, 95 per cent CI 1.43-5.30, p=0.002) and Aboriginal patients (OR=3.38, 95 per cent CI 1.42-8.05, p=0.006) were more likely to choose hanging as a suicide method.
Conclusion
We identified drug overdose as a strong predictor of ICU admission, while age, drug overdose and history of previous suicide attempts predict hospital admission. We recommend reviewing physician practices, especially safe medication, in suicide risk patients. Our study also highlights the need for continued close collaboration by acute care and community mental health providers for quality improvement.
doi:10.4066/AMJ.2013.1730
PMCID: PMC3858606  PMID: 24348869
Suicide, Attempted; Drug Overdose; Emergency Care; Intensive Care; Utilisation
4.  Protective and risk factors in amateur equestrians and description of injury patterns: A retrospective data analysis and a case - control survey 
Background
In Switzerland there are about 150,000 equestrians. Horse related injuries, including head and spinal injuries, are frequently treated at our level I trauma centre.
Objectives
To analyse injury patterns, protective factors, and risk factors related to horse riding, and to define groups of safer riders and those at greater risk
Methods
We present a retrospective and a case-control survey at conducted a tertiary trauma centre in Bern, Switzerland.
Injured equestrians from July 2000 - June 2006 were retrospectively classified by injury pattern and neurological symptoms. Injured equestrians from July-December 2008 were prospectively collected using a questionnaire with 17 variables. The same questionnaire was applied in non-injured controls. Multiple logistic regression was performed, and combined risk factors were calculated using inference trees.
Results
Retrospective survey
A total of 528 injuries occured in 365 patients. The injury pattern revealed as follows: extremities (32%: upper 17%, lower 15%), head (24%), spine (14%), thorax (9%), face (9%), pelvis (7%) and abdomen (2%). Two injuries were fatal. One case resulted in quadriplegia, one in paraplegia.
Case-control survey
61 patients and 102 controls (patients: 72% female, 28% male; controls: 63% female, 37% male) were included. Falls were most frequent (65%), followed by horse kicks (19%) and horse bites (2%). Variables statistically significant for the controls were: Older age (p = 0.015), male gender (p = 0.04) and holding a diploma in horse riding (p = 0.004). Inference trees revealed typical groups less and more likely to suffer injury.
Conclusions
Experience with riding and having passed a diploma in horse riding seem to be protective factors. Educational levels and injury risk should be graded within an educational level-injury risk index.
doi:10.1186/1752-2897-5-4
PMCID: PMC3042925  PMID: 21294862
5.  Injuries associated with recreational horse riding and changes over the last 20 years: a review 
JRSM Short Reports  2013;4(5):2042533313476688.
Objective
To assess the incidence and distribution of recreational equestrian injuries seen in the Kent and Sussex region and review the available literature on this subject.
Design
This is a retrospective case series with historical controls.
Setting
Kent and Sussex region, England.
Main outcome measurement
Injuries related to horses in the recreational setting.
Methods
Subjects were selected from our acute injury database. Notes of all patients presenting with horse riding-related injuries between January and December 2010 were reviewed. Skeletal injuries were confirmed using our Picture Archiving and Communications Systems (PACS) system. Data were tabulated and grouped using Microsoft Excel software. Statistics were calculated using Graph Pad software.
Results
During the study period, 155 patients presented with a total of 199 injuries related to horses, accounting for 0.3% of all presentations; 69% were soft tissue injuries. The most commonly affected areas were the extremities (77 patients, 49.7%) followed by injuries to the head (38 patients, 24.5%) and trunk (36 patients, 23.2%). Seventeen patients (11%) were admitted. Patients presenting with head injuries suffered significantly more injuries compared to other groups (1.65 compared to 1.4 injuries, p < 0.0002).
Conclusion
A larger number of persons were riding for a longer period of the year compared to previous studies in the United Kingdom. There was also a shift in the patterns of injury seen in this population over the last two to three decades.
doi:10.1177/2042533313476688
PMCID: PMC3681230  PMID: 23772313
6.  Hazards of horse-riding as a popular sport. 
The increasing incidence of horse-riding accidents, which are often severe in nature, prompted a pilot study of a questionnaire designed to elucidate the cause of such accidents. It was hoped that, on a larger scale, the information gleaned would highlight possible preventative measures which might improve the safety of an important recreational pursuit enjoyed by young and old from many walks of life. A retrospective study of riders sustaining serious spinal injuries admitted to Stoke Mandeville Hospital was compared with riders sustaining minor but significant injuries as the accidents came to the attention of the authors. The detailed analysis paid particular attention to the setting and to the experience and task of horse and rider. It was found that 70% of the 20 accidents could be thought attributable to the behaviour of the horse at the time, and seven of these were in the spinal injuries group. Rider error was a significant contribution in seven cases, and in two instances the rider was under instruction at the time. There was also inadequate experience of the rider in seven cases, of which five were thought to show inadequate supervision. The limited number of cases studied precludes significant observations, but, as the majority of accidents seemed preventable, a larger study has been initiated in collaboration with the British Horse Society.
Images
PMCID: PMC1478823  PMID: 1751891
7.  Spine fractures caused by horse riding 
European Spine Journal  2006;15(4):465-471.
Study Design: Retrospective study and review of literature. Objectives: Study of demographic data concerning spinal fractures caused by horse riding, classification of fractures according to the AO and Load Sharing classifications, evaluation of mid-term radiological results and long-term functional results. Methods: A review of medical reports and radiological examinations of patients presented to our hospital with horse riding-related spine fractures over a 13-year period; long-term functional follow-up is performed using the Roland Morris Disability Questionnaire (RMDQ-24). Results: Thirty-six spine fractures were found in 32 patients. Male to female ratio is 1:7. Average age is 33.7 years (8–58 years). The majority of the fractures (78%) are seen at the thoracolumbar junction Th11–L2. All but two patients have AO type A fractures. The average Load Sharing Classification score is 4.9 (range 3–9). Neurological examinations show ASIA/Frankel E status for all patients. Surgical treatment is performed on ten patients. Mean follow-up for radiological data is 15 months (range 3–63). Functional follow-up times range from 1 to 13 years with an average follow-up of 7.3 years. Mean RMDQ-24 score for all patients is 5.5 (range: 0–19), with significantly different scores for the non-operative and surgical group: 4.6 vs 8.1. Twenty-two percent of the patients have permanent occupational disabilities and there is a significant correlation between occupational disability and RMDQ-24 scores. Conclusions: Not only are short-term effects of spine fractures caused by horse riding substantial but these injuries can also lead to long-term disabilities.
doi:10.1007/s00586-005-1012-5
PMCID: PMC3489311  PMID: 16408237
Sports medicine; Spinal fractures; Horses; Review
8.  Are physiological attributes of jockeys predictors of falls? A pilot study 
BMJ Open  2011;1(1):e000142.
Objectives
This pilot study describes the physiological attributes of jockeys and track-work riders in Tasmania and investigates whether these attributes are associated with falls.
Methods
All jockeys and track-work riders licensed in Tasmania were invited to participate. The study group consisted of eight jockeys (two female, six male) and 20 track-work riders (14 female, six male). Measures of anthropometry, balance, reaction time, isometric strength, vertical jump, glycolytic and aerobic fitness, flexibility and body composition were conducted. Tests were designed to assess specific aspects of rider fitness and performance relevant to horse racing. For a subset of participants (n=14), the authors obtained information on falls and injuries. The authors used Poisson regression to estimate incidence rate ratios.
Results
Jockeys had better balance, a faster mean reaction time, a lower fatigue index and a higher estimated V.O2max than their track-work riding counterparts. Jockeys were also younger and smaller in stature than track-work riders, and when differences in body mass were taken into account, they had a greater muscular strength and muscular (alactic) power. Important factors found to be associated with falls were lower aerobic and anaerobic fitness, greater muscular strength and power, and riding with the full foot in the stirrup irons compared with riding on the ball of the foot.
Conclusion
This pilot study shows that physiological attributes of jockeys and track-work riders can predict their risk of falling and are measurable using methods feasible for large-scale fieldwork.
Article summary
Article focus
Riding racehorses is a physically demanding and hazardous occupation, with most injuries to jockeys caused by falls.
This study aims to investigate the association between physiological attributes and risk of falls for jockeys and track-work riders.
Key messages
Lower anaerobic and aerobic fitness, and higher muscular strength and power were associated with greater risk of falls.
Placement of the foot in the stirrup irons was also found to be associated with falls.
This pilot study has confirmed that it is feasible to measure the physiological attributes of jockeys and track-work riders that are predictive of the risk of falling.
Strengths and limitations of this study
This was the first study to investigate whether physiological attributes are associated with falls to jockeys and track-work rides.
Tests were deliberately restricted to those that could be conducted with robustly constructed and transportable equipment.
We were able to recruit only a small number of participants, but our sample comprised 44% of the jockey population and 24% of the track-work rider population licensed in Tasmania.
Some refinements to the testing methodology are needed.
doi:10.1136/bmjopen-2011-000142
PMCID: PMC3191430  PMID: 22021775
9.  Ten years of major equestrian injury: are we addressing functional outcomes? 
Background
Horseback riding is considered more dangerous than motorcycle riding, skiing, automobile racing, football and rugby. The integral role of rehabilitation therapy in the recovery of patients who have sustained a major horse-related injury is previously not described. The goals of this paper were to (1) define the incidence and pattern of severe equestrian trauma, (2) identify the current level of in-patient rehabilitation services, (3) describe functional outcomes for patients, and (4) discuss methods for increasing rehabilitation therapy in this unique population.
Methods and results
A retrospective review of the trauma registry at a level 1 center (1995–2005) was completed in conjunction with a patient survey outlining formal in-hospital therapy. Forty-nine percent of patients underwent in-patient rehabilitation therapy. Injuries predictive of receiving therapy included musculoskeletal and spinal cord trauma. Previous injury while horseback riding was predictive of not receiving therapy. The majority (55%) of respondents had chronic physical difficulties following their accident.
Conclusion
Rehabilitation therapy is significantly underutilized following severe equestrian trauma. Increased therapy services should target patients with brain, neck and skull injuries. Improvements in the initial provision, and follow-up of rehabilitation therapy could enhance functional outcomes in the treatment resistant Western equestrian population.
doi:10.1186/1752-2897-3-2
PMCID: PMC2653027  PMID: 19228424
10.  Equestrian injuries--a one year prospective study. 
A one year prospective study of equestrian injuries was carried out in an area where horse riding is a popular pursuit. 115 persons suffered injury--eighty females and thirty-five males of whom sixty were under fifteen years of age. No fatalities were recorded and there were 0.2 injuries per 100 rides. Most injuries were minor and to the musculo-skeletal system. Visceral and cerebral injuries were not common but the former were life threatening in all cases. It is concluded that young riders should be supervised.
PMCID: PMC1859746  PMID: 465903
11.  Analytical review of 664 cases of penetrating buttock trauma 
A comprehensive review of data has not yet been provided as penetrating injury to the buttock is not a common condition accounting for 2-3% of all penetrating injuries. The aim of the study is to provide the as yet lacking analytical review of the literature on penetrating trauma to the buttock, with appraisal of characteristics, features, outcomes, and patterns of major injuries. Based on these results we will provide an algorithm. Using a set of terms we searched the databases Pub Med, EMBASE, Cochran, and CINAHL for articles published in English between 1970 and 2010. We analysed cumulative data from prospective and retrospective studies, and case reports. The literature search revealed 36 relevant articles containing data on 664 patients. There was no grade A evidence found. The injury population mostly consists of young males (95.4%) with a high proportion missile injury (75.9%). Bleeding was found to be the key problem which mostly occurs from internal injury and results in shock in 10%. Overall mortality is 2.9% with significant adverse impact of visceral or vascular injury and shock (P < 0.001). The major injury pattern significantly varies between shot and stab injury with small bowel, colon, or rectum injuries leading in shot wounds, whilst vascular injury leads in stab wounds (P < 0.01). Laparotomy was required in 26.9% of patients. Wound infection, sepsis or multiorgan failure, small bowel fistula, ileus, rebleeding, focal neurologic deficit, and urinary tract infection were the most common complications. Sharp differences in injury pattern endorse an algorithm for differential therapy of penetrating buttock trauma. In conclusion, penetrating buttock trauma should be regarded as a life-threatening injury with impact beyond the pelvis until proven otherwise.
doi:10.1186/1749-7922-6-33
PMCID: PMC3205008  PMID: 21995834
buttock injury; penetrating trauma; shot wound; stab wound
12.  Prevalence of Eating Disorder Risk and Body Image Distortion Among National Collegiate Athletic Association Division I Varsity Equestrian Athletes 
Journal of Athletic Training  2011;46(4):431-437.
Context:
Participation in appearance-based sports, particularly at the collegiate level, may place additional pressures on female athletes to be thin, which may increase the likelihood of their resorting to drastic weight control measures, such as disordered eating behaviors.
Objectives:
(1) To estimate the prevalence and sources of eating disorder risk classification by academic status (freshman, sophomore, junior, or senior) and riding discipline (English and Western), (2) to examine riding style and academic status variations in body mass index (BMI) and silhouette type, and (3) to examine these variations across eating disorder risk classification type (eg, body image disturbances).
Design:
Cross-sectional study.
Setting:
Seven universities throughout the United States.
Patients or Other Participants:
A total of 138 participants volunteered (mean age = 19.88 ± 1.29 years). They represented 2 equestrian disciplines: English riding (n = 91) and Western riding (n = 47).
Main Outcome Measure(s):
Participants self-reported menstrual cycle history, height, and weight. We screened for eating disorder risk behaviors with the Eating Attitudes Test and for body disturbance with sex-specific BMI silhouettes.
Results:
Based on the Eating Attitudes Test, estimated eating disorder prevalence was 42.0% in the total sample, 38.5% among English riders, and 48.9% among Western riders. No BMI or silhouette differences were found across academic status or discipline in disordered eating risk. Overall, participants perceived their body images as significantly larger than their actual physical sizes (self-reported BMI) and wanted to be significantly smaller in both normal clothing and competitive uniforms.
Conclusions:
Disordered eating risk prevalence among equestrian athletes was similar to that reported in other aesthetic sports and lower than that in nonaesthetic sports. Athletic trainers working with these athletes should be sensitive to these risks and refer athletes as needed to clinicians knowledgeable about disordered eating. Professionals working with this population should avoid making negative comments about physical size and appearance.
PMCID: PMC3419156  PMID: 21944076
disordered eating behaviors; riding disciplines; aesthetic sports
13.  Enablers of and barriers to making healthy change during pregnancy in overweight and obese women 
The Australasian Medical Journal  2013;6(11):565-577.
Background
High Body Mass Index (BMI) during pregnancy is associated with an increased risk of adverse health outcomes. Making healthy change during pregnancy is beneficial, especially for overweight and obese women.
Aims
The aim of this study was to explore the barriers and enablers identified by overweight and obese women that preclude and facilitate making healthy change during pregnancy.
Method
We conducted a retrospective analysis of patients who presented with suicide attempts to the Rockhampton Base Hospital Emergency Department, Queensland Australia from 1 September 2007 to 31 August 2009. Multivariate logistic regression was undertaken to identify risk factors for ICU and regular ward admission, and predictors of suicide method.
Results
The core concept of “being pregnant” indicated women consider this specific time as both a reason not to make healthy change as well as a motivation for change. Overweight and obese women cited the following barriers to making healthy change during pregnancy: physiological (e.g. pregnancy complications and tiredness); emotional (e.g. preference and mood); cognitive (e.g. lack knowledge); interpersonal (e.g. lack support); and environmental (e.g. availability of healthy choice). Similar enablers were identified by overweight and obese women: physiological (e.g. relief of pregnancy symptoms); emotional (e.g. approval and commitment); cognitive (e.g. knowledge and belief); interpersonal (e.g. family support); and environmental (e.g. help from others). More barriers than enablers were given, indicating that women were more sensitive to barriers than the enablers for making healthy change. Factors viewed by some women as barriers were viewed as enablers by others.
Conclusion
When designing interventions to promote healthy eating and physical activity during pregnancy, individually focused interventions must be implemented in conjunction with environmental-level interventions to facilitate behaviour change.
doi:10.4066/AMJ.2013.1881
PMCID: PMC3858610  PMID: 24348873
Pregnancy; overweight; healthy change
14.  Assessing the impact of human trampling on vegetation: a systematic review and meta-analysis of experimental evidence 
PeerJ  2014;2:e360.
Vegetation trampling resulting from recreation can adversely impact natural habitats, leading to the loss of vegetation and the degradation of plant communities. A considerable primary literature exists on this topic, therefore it is important to assess whether this accumulated evidence can be used to reach general conclusions concerning vegetation vulnerability to inform conservation management decisions. Experimental trampling studies on a global scale were retrieved using a systematic review methodology and synthesised using random effects meta-analysis. The relationships between vegetation recovery and each of initial vegetation resistance, trampling intensity, time for recovery, Raunkiaer life-form (perennating bud position), and habitat were tested using random effects multiple meta-regressions and subgroup analyses. The systematic search yielded 304 studies; of these, nine reported relevant randomized controlled experiments, providing 188 vegetation recovery effect sizes for analysis. The synthesis indicated there was significant heterogeneity in the impact of trampling on vegetation recovery. This was related to resistance and recovery time, and the interactions of these variables with Raunkiaer life-form, but was not strongly dependent on the intensity of the trampling experienced. The available evidence suggests that vegetation dominated by hemicryptophytes and geophytes recovers from trampling to a greater extent than vegetation dominated by other life-forms. Variation in effect within the chamaephyte, hemicryptophyte and geophyte life-form sub-groups was also explained by the initial resistance of vegetation to trampling, but not by trampling intensity. Intrinsic properties of plant communities appear to be the most important factors determining the response of vegetation to trampling disturbance. Specifically, the dominant Raunkiaer life-form of a plant community accounts for more variation in the resilience of communities to trampling than the intensity of the trampling experienced, suggesting that simple assessments based on this trait could guide decisions concerning sustainable access to natural areas. Methodological and reporting limitations must be overcome before more disparate types of evidence can be synthesised; this would enable more reliable extrapolation to non-study situations, and a more comprehensive understanding of how assessments of intrinsic plant traits can be used to underpin conservation management decisions concerning access.
doi:10.7717/peerj.360
PMCID: PMC4017817  PMID: 24860696
Recreation; Relative vegetation cover; Evidence-based management; Plant functional traits; Resilience; Public access; Raunkiaer life-form
15.  Population based case–control study of serious non-fatal motorcycle crashes 
BMC Public Health  2013;13:72.
Background
Motorcycle sales, registration and use are increasing in many countries. The epidemiological literature on risk factors for motorcycle injury is becoming outdated, due to changes in rider demography, licensing regulations, traffic mix and density, road environments, and motorcycle designs and technologies. Further, the potential contribution of road infrastructure and travel speed has not yet been examined.
Methods/design
A population based case–control study together with a nested case-crossover study is planned. Cases will be motorcycle riders who are injured but not killed in a motorcycle crash on a public road within 150 km radius of Melbourne, Australia, and admitted to one of the study hospitals. Controls will be motorcycle riders who ride through the crash site on the same type of day (weekday or weekend) within an hour of the crash time. Data on rider, bike, and trip characteristics will be collected from the participants by questionnaire. Data on crash site characteristics will be collected in a structured site inspection, and travel speed for the cases will be estimated from these data. Travel speed for the controls will be measured prior to recruitment with a radar traffic detection device as they ride through the crash site. Control sites for the case-crossover study will be selected 1 km upstream from the crash site and matched on either intersection status or road curvature (either straight or cornered). If the initial site selected does not match the case site on these characteristics, then the closest matching site on the case route will be selected. Conditional multivariate logistic regression models will be used to compare risk between the matched case and control riders and to examine associations between road infrastructure and road environment characteristics and crash occurrence. Interactions between type of site and speed will be tested to determine if site type is an effect modifier of the relationship between speed and crash risk. The relationship between rider factors and travel speed generally will be assessed by multivariate regression methods.
Discussion
In the context of the changing motorcycling environment, this study will provide evidence on contemporary risk factors for serious non-fatal motorcycle crashes.
doi:10.1186/1471-2458-13-72
PMCID: PMC3599456  PMID: 23351603
Motorcycle; Injury; Case–control; Road infrastructure; Speed
16.  A Comparison of Wakeboard-, Water Skiing-, and Tubing-Related Injuries in The United States, 2000-2007 
The purpose of the study was to compare tubing-related injuries to wakeboarding- and water skiing-related injuries. Data was collected from the 2000-2007 National Electronic Injury Surveillance Survey for 1,761 individuals seeking care at an emergency department due to a tubing-, wakeboarding, or water skiing-related injury. Data included patient age and sex, as well as injury characteristics including body region injured (i.e., head and neck, trunk, shoulder and upper extremity, and hip and lower extremity) and diagnosis of injury (e.g., contusion, laceration, or fracture). Case narratives were reviewed to ensure that a tubing-, wakeboarding-, or water skiing-related injury occurred while the individual was being towed behind a boat. Severe injury (defined as an injury resulting in the individual being hospitalized, transferred, held for observation) was compared among the groups using logistic regression. Wakeboard- and tubing-related injuries more commonly involved the head and neck, while water skiing- related injuries were likely to involve the hip and lower extremity. Tubing-related injuries, compared to water skiing-related injuries, were more likely to be severe (OR 2.31, 95% CI 1.23-4. 33). Like wakeboarding and water skiing, tubing has inherent risks that must be understood by the participant. While tubing is generally considered a safer alternative to wakeboarding and water skiing, the results of the current study suggest otherwise. Both the number and severity of tubing- related injuries could be prevented through means such as advocating the use of protective wear such as helmets while riding a tube or having recommended safe towing speeds prominently placed on inner tubes.
Key pointsIncrease annual injury rate trend in wakeboard injuries.Wakeboard- and tubing-related injuries more often to head and neck, waterskiing-related injuries more often to hip and lower extremity.Tubing-related injuries over 2-times as likely to be severe compared to waterskiing-related injuries.
PMCID: PMC3737970  PMID: 24149391
Water tubing; water skiing; wakeboarding; epidemiology; injury.
17.  A Substantial Proportion of Life-Threatening Injuries are Sport-Related 
Pediatric emergency care  2013;29(5):624-627.
Objective
To assess the proportion of all life-threatening injuries that are sport-related.
Methods
We conducted a cross-sectional study of patients included in the National Hospital Ambulatory Medical Care Survey (NHAMCS) during the years 1999–2008. Life-threatening injuries were defined as International Classification of Diseases 9 codes: skull fracture [800.x–802.xx, 803.x–804.xx], cervical spine fractures [805.xx–806.10], intracranial hemorrhage [852.xx–853.xx], traumatic pneumothorax/hemothorax [860.00–860.05], liver lacerations [864.xx], spleen lacerations [865.xx], aortic rupture [901.0; 902.0], gastric/duodenal rupture [537.89], heat stroke [992.0], and commotio cordis/heart contusion [861.01]. Sport-related was defined by external cause of injury codes, confirmed by text search.
Results
There were 300,394 observed emergency department visits during the study period. An estimated 0.5% (95% CI, 0.5 – 0.6) of all ED visits nationally were for life-threatening injuries. Of life-threatening injuries, 14% (95% CI, 12 – 17) were sport-related, representing 926,805 sport-related, life-threatening injuries nationally. A higher percentage (32%; 95% CI, 27 – 38) of life-threatening injuries sustained by children was sport-related when compared with adults (9%; 95% CI, 7 – 11). For adults aged 19–44 years, 12% (95% CI, 9 – 15) of life-threatening injuries were sport-related. For children aged 6–18 years, 39% (95% CI, 33 – 46) of life-threatening injuries were sport-related. Nearly a quarter (23%; 95% CI, 7 – 55) of pediatric cervical spine fractures was sport-related. The percentage of cervical spine fractures that were sport-related was lower for adults (7%; 95% CI, 4 – 11).
Conclusion
Efforts should be made to prevent the number of sport-related, life-threatening injuries.
doi:10.1097/PEC.0b013e31828e9cea
PMCID: PMC3644356  PMID: 23603654
catastrophic injury; athletics; cervical spine fracture; pediatric; intracranial hematoma
18.  Epidemiology and implications of ocular trauma admitted to hospital in Scotland. 
OBJECTIVES: To describe the current epidemiology of serious ocular trauma which necessitates admission to hospital so that health and safety strategies for the prevention of ocular injuries and their role within the national health strategy, The Health of the Nation, can be better informed. DESIGN: A prospective observational study of all patients with ocular trauma admitted to hospital under the care of a consultant ophthalmologist between 1 November 1991 and 31 October 1992. SETTING: All ophthalmic department in Scotland. SUBJECTS: All patients with ocular trauma admitted to hospital in Scotland. The population of Scotland represented the population at risk of injury. MEASURES AND MAIN RESULTS: Measures included the type and cause of injury, the place where it occurred, and awareness of risk and safety. All ophthalmic departments in Scotland participated and 428 admissions were reported. The home was the most common place for a serious injury to occur (30.2%), followed by the workplace (19.6%) and a sports or leisure facility (15.8%). The home was the single most frequent place of injury for the 0-15 year and 65 year and over age groups. Tools or machinery, either at home (13.9%) or at work (10.3%), were collectively (24.2%) the most frequent cause of injury, followed by assault (21.8%) and sports-related activities (12.5%). The most frequent type of injury was a blunt injury (54.4%). Six per cent (n = 25) of all injuries were bilateral. Only 13.2% of patients were aware of any risk of injury, with 5.6% aware of any risk at home. When applicable, protective eye wear was only available to 48.6% of patients and only 19.4% of these used it. CONCLUSION: Serious ocular trauma frequently occurs at home and the young and the elderly are particularly at risk. This represents a significant change in the epidemiology of serious ocular trauma and has important implications for prevention. Health and safety strategies specifically aimed at preventing eye injury should now include the home as a high risk environment in addition to the work-place and sports/leisure facilities. The target groups for accident prevention in The Health of the Nation strategy include those at risk of serious ocular trauma with potentially sight threatening sequelae. Those involved in implementing the national accident prevention strategy should be aware of this, for in this process it is possible that some serious eye injuries may also be prevented.
Images
PMCID: PMC1060315  PMID: 8882228
19.  G1961E mutant allele in the Stargardt disease gene ABCA4 causes bull’s eye maculopathy 
Experimental eye research  2009;89(1):16-24.
The aim of this study was to characterize the pathological and functional consequences of the G1961E mutant allele in the Stargardt disease gene ABCA4. Data from 15 patients were retrospectively reviewed and all the patients had at least one G1961E mutation. Comprehensive ophthalmic examination, full-field and pattern electroretinograms, and fundus autofluorescence (FAF) imaging were performed on all patients. Microperimetry, spectral-domain optical coherence tomography (OCT), and fluorescein angiography were performed in selected cases. Genetic screening was performed using the ABCR400 micro-array that currently detects 496 disctinct ABCA4 variants. All patients had normal full-field scotopic and photopic electroretinograms (ERGs) and abnormal pattern electroretinograms (PERGs) performed on both eyes, and all the fundi had bull’s eye maculopathy without retinal flecks on FAF. On OCT, one patient had disorganization of photoreceptor outer segment, two had outer nuclear layer (ONL) thinning likely due to photoreceptor atrophy proximal to the foveal center, and three had additional retinal pigment epithelium (RPE) atrophy. On microperimetry, six patients had eccentric superior fixation and amongst this group, five had an absolute scotoma in the foveal area. DNA analysis revealed that three patients were homozygous G1961E/G1961E and the rest were compound heterozygotes for G1961E and other ABCA4 mutations. The G1961E allele in either homozygosity or heterozygosity is associated with anatomical and functional pathologies limited to the parafoveal region and a trend to delayed onset of symptoms, relative to other manifestations of ABCA4 mutations. Our observations support the hypothesis that the G1961E allele contributes to localized macular changes rather than generalized retinal dysfunction, and is a cause of bull’s eye maculopathy in either the homozygosity or heterozygosity state. In addition, genetic testing provides precise diagnosis of the underlying maculopathy, and current non-invasive imaging techniques could be used to detect photoreceptor damage at the earliest clinical onset of the disease.
doi:10.1016/j.exer.2009.02.001
PMCID: PMC2742677  PMID: 19217903
Stargardt; mutation; maculopathy; retinal degeneration; dystrophy
20.  Incidence of sports and recreation related injuries resulting in hospitalization in Wisconsin in 2000 
Injury Prevention  2005;11(2):91-96.
Objective: To describe the incidence and patterns of sports and recreation related injuries resulting in inpatient hospitalization in Wisconsin. Although much sports and recreation related injury research has focused on the emergency department setting, little is known about the scope or characteristics of more severe sports injuries resulting in hospitalization.
Setting: The Wisconsin Bureau of Health Information (BHI) maintains hospital inpatient discharge data through a statewide mandatory reporting system. The database contains demographic and health information on all patients hospitalized in acute care non-federal hospitals in Wisconsin.
Methods: The authors developed a classification scheme based on the International Classification of Diseases External cause of injury code (E code) to identify hospitalizations for sports and recreation related injuries from the BHI data files (2000). Due to the uncertainty within E codes in specifying sports and recreation related injuries, the authors used Bayesian analysis to model the incidence of these types of injuries.
Results: There were 1714 (95% credible interval 1499 to 2022) sports and recreation-related injury hospitalizations in Wisconsin in 2000 (32.0 per 100 000 population). The most common mechanisms of injury were being struck by/against an object in sports (6.4 per 100 000 population) and pedal cycle riding (6.2 per 100 000). Ten to 19 year olds had the highest rate of sports and recreation related injury hospitalization (65.3 per 100 000 population), and males overall had a rate four times higher than females.
Conclusions: Over 1700 sports and recreation related injuries occurred in Wisconsin in 2000 that were treated during an inpatient hospitalization. Sports and recreation activities result in a substantial number of serious, as well as minor injuries. Prevention efforts aimed at reducing injuries while continuing to promote participation in physical activity for all ages are critical.
doi:10.1136/ip.2004.006205
PMCID: PMC1730208  PMID: 15805437
21.  Pediatric farm injuries involving non-working children injured by a farm work hazard: five priorities for primary prevention 
Injury Prevention  2005;11(1):6-11.
Objectives: To describe pediatric farm injuries experienced by children who were not engaged in farm work, but were injured by a farm work hazard and to identify priorities for primary prevention.
Design: Secondary analysis of data from a novel evaluation of an injury control resource using a retrospective case series.
Data sources: Fatal, hospitalized, and restricted activity farm injuries from Canada and the United States.
Subjects: Three hundred and seventy known non-work childhood injuries from a larger case series of 934 injury events covering the full spectrum of pediatric farm injuries.
Methods: Recurrent injury patterns were described by child demographics, external cause of injury, and associated child activities. Factors contributing to pediatric farm injury were described. New priorities for primary prevention were identified.
Results: The children involved were mainly resident members of farm families and 233/370 (63.0%) of the children were under the age of 7 years. Leading mechanisms of injury varied by data source but included: bystander and passenger runovers (fatalities); drowning (fatalities); machinery entanglements (hospitalizations); falls from heights (hospitalizations); and animal trauma (hospitalizations, restricted activity injuries). Common activities leading to injury included playing in the worksite (all data sources); being a bystander to or extra rider on farm machinery (all data sources); recreational horseback riding (restricted activity injuries). Five priorities for prevention programs are proposed.
Conclusions: Substantial proportions of pediatric farm injuries are experienced by children who are not engaged in farm work. These injuries occur because farm children are often exposed to an occupational worksite with known hazards. Study findings could lead to more refined and focused pediatric farm injury prevention initiatives.
doi:10.1136/ip.2004.005769
PMCID: PMC1730186  PMID: 15691981
22.  A review of 187 gunshot wound admissions to a teaching hospital over a 54-month period: training and service implications. 
BACKGROUND: Violence involving the use of firearms has increased in the UK over the past decade. This study assesses the implications of such injuries for service provision and training by reviewing the experience at one hospital. METHODS: Accident and emergency triage data were searched for patients presenting with gunshot wounds over a 54-month period. Case notes were reviewed and patterns of care established. The resources required for clinical management were ascertained, and the financial consequences determined at contemporary full cost. RESULTS: There were 187 attendances with 247 wounds. Mean age was 21 years (range, 8-63 years). Of the attendances, 69% were out of normal working hours. Of the 187 cases, 97 patients were admitted to one hospital (83 of whom required surgery) and 10 patients were transferred to other hospitals (6 for plastic surgery not available at the Manchester Royal Infirmary and 4 due to lack of beds). Of the 80 patients who were not admitted, 4 died in accident and emergency, the rest were either air gun wounds or relatively simple higher calibre injuries. A wide range of surgical specialties was involved (limb injury, 53; thoraco-abdominal and vascular, 28; head and neck, 5; and orbit, 2), and combinations of injuries transgressed specialty and sub-specialty boundaries. The total cost of patient care was pound 267,000. CONCLUSIONS: Gunshot wounds present a heavy demand on the clinical and financial resources of the receiving hospital, and surgeons responsible for unselected acute admissions in "general surgery" should be capable of dealing with these indiscriminate injuries. Current training and service trends towards increasing sub-specialisation may mitigate against them achieving or retaining this capability.
doi:10.1308/003588404322827482
PMCID: PMC1964163  PMID: 15005928
23.  Sport injuries in adolescents 
Orthopedic Reviews  2011;3(2):e18.
In spite of the wide range of injuries in adolescents during sports activities, there are only a few studies investigating the type and frequency of sport injuries in puberty. However, this information may help to prevent, diagnose and treat sports injuries among teens. 4468 injuries in adolescent patients were treated over a ten year period of time: 66,97% were boys and 32.88% girls. The most frequent sports injuries were football (31.13%) followed by handball (8.89%) and sports during school (8.77%). The lower extremity was involved in 68.71% of the cases. Knee problems were seen in 29.79% of the patients; 2.57% spine and 1.99% head injuries. Injuries consisted primarily of distortions (35.34%) and ligament tears (18.76%); 9,00% of all injuries were fractures. We found more skin wounds (6:1) and fractures (7:2) in male patients compared to females. The risk of ligament tears was highest during skiing. Three of four ski injuries led to knee problems. Spine injuries were observed most often during horse riding (1:6). Head injuries were seen in bicycle accidents (1:3). Head injuries were seen in male patients much more often then in female patients (21:1). Fractures were noted during football (1:9), skiing (1:9), inline (2:3), and during school sports (1:11). Many adolescents participate in various sports. Notwithstanding the methodological problems with epidemiological data, there is no doubt about the large number of athletes sustain musculoskeletal injuries, sometimes serious. In most instances, the accident does not happened during professional sports and training. Therefore, school teachers and low league trainer play an important role preventing further accidence based on knowledge of individual risk patterns of different sports.
It is imperative to provide preventive medical check-ups, to monitor the sport-specific needs for each individual sports, to observe the training skills as well as physical fitness needed and to evaluation coaches education.
doi:10.4081/or.2011.e18
PMCID: PMC3257427  PMID: 22355484
epidemiology; sport injury; adolescent.
24.  Making the Message Meaningful: A Qualitative Assessment of Media Promoting All-Terrain Vehicle Safety 
Background
Millions of all-terrain vehicles (ATV) are used around the world for recreation by both adults and youth. This increase in use has led to a substantial increase in the number of injuries and fatalities each year. Effective strategies for reducing this incidence are clearly needed; however, minimal research exists regarding effective educational interventions.
Objective
This study was designed to assess rural ATV riders’ preferences for and assessment of safety messages.
Methods
Thirteen focus group discussions with youth and adult ATV riders were conducted. Eighty-eight formative research participants provided feedback on existing ATV safety materials, which was used to develop more useful ATV safety messages. Sixty evaluative focus group participants critiqued the materials developed for this project.
Results
Existing ATV safety materials are not effective. One reason is because they do not address the content or design needs of the target population. ATV riders want educational and action-oriented safety messages that inform youth and adult riders about their responsibilities to learn, educate, and implement safety behaviors (e.g., appropriate-sized ATV, safety gear, solo riding, speed limits, riding locations). Additionally, messages should be clear, realistic, visually appealing, and easily accessible. Newly designed ATV safety materials using the acronym TRIPSS (Training, Ride Off-Road, Impairment, Plan Ahead, Safety Gear, Single Rider) meets ATV riders’ safety messaging needs.
Conclusions
To best reach a target population, it is crucial to include them in the development and assessment of safety messages. Germane to this particular study, ATV riders provided essential information for creating useful ATV safety materials.
doi:10.1136/injuryprev-2011-040132
PMCID: PMC3704218  PMID: 22101098
25.  Acute injuries from mountain biking. 
Western Journal of Medicine  1993;159(2):145-148.
We questioned members of 2 southern California off-road bicycling organizations about injuries associated with the use of all-terrain bicycles. Cyclists were asked about riding and safety habits, the kind(s) of injury sustained with their most recent accident and whether they sought medical treatment, and the circumstances of the accident. Of 459 mailed surveys, 268 (58.4%) were returned. Respondents (82.8% of whom were male) ranged in age from 14 to 68 years. Of these, 225 (84%) had been injured while riding all-terrain bicycles, 51% in the past year. Although most injuries were characterized as minor, 26% required professional medical care, and 4.4% of those injured were admitted to hospital. Extremity injuries--abrasions, lacerations, contusions--occurred in 201 (90%) cyclists with 27 (12%) sustaining a fracture or dislocation. High levels of helmet use (88%) may explain the low occurrence of head and neck trauma (12%). Frequent riding and riding on paved terrain were associated with increased severity of injury, although most accidents--197 (87.6%)--occurred off paved roads. These results suggest that, compared with regular bicyclists, all-terrain cyclists have more, but not necessarily more severe, injuries. Clinicians and emergency medical personnel should be aware that the increasing popularity of off-road cycling may change the frequency and nature of bicycling injuries.
PMCID: PMC1022220  PMID: 8212679

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