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Fall from ladders is increasingly identified as a significant cause of injury and mortality, yet large-scale research into ladder fall outcomes and trends is limited.To explore the nature and severity of injuries resulting from ladder falls and to determine predictors of Injury Severity Score (ISS) and 6-month mortality.Data were obtained from the New South Wales (NSW) Trauma Registry, Admitted Patient Data Collection and Registry of Births, Deaths, and Marriages on patients aged 15 and over who had major trauma from a ladder fall and were admitted to hospital between January 1st, 2012, and July 31st, 2019. Data linkage and descriptive statistics were carried out alongside bivariate and multivariable regression analysis.963 patients injured after ladder falls were identified. The mean age was 61.9 years (SD 14.2), 91.0% were male, and 489 (50.8%) were born in Australia. The height of fall was between one and five meters in 827 (86.2%) patients, and the place of fall was home and residential places in 27.5%. The most common body areas injured were the head (26.5%), spine (21.2%) and thorax (20.6%), and the median injury severity score was 17. The median length of stay of patients' in-hospital and intensive care unit was six days and two days, respectively. Six months post-discharge mortality was 6.4%. The unadjusted association between the presence of comorbidities or socio-economic class and ISS or mortality was not statistically significant. Increasing ISS was found to be associated with increasing age (Estimate (Est), 15.2; 95% Confidence Interval (CI), 12.3-18.1) and a fall height greater than five metres (Est, 5.8; CI, 3.2-8.4). Mortality was found to be associated with increasing age (Odds ratio (OR), 1.06; CI, 1.03-1.08) and increasing ISS (OR, 1.19; CI, 1.15-1.24).People presenting to the hospital after falling from a ladder were predominately male, aged over 60 and had fallen in a residential setting. Increasing age and fall height are associated with more severe injuries.

Summary Background Women with unexplained infertility are often offered intrauterine insemination (IUI) with ovarian stimulation as an alternative to in-vitro fertilisation (IVF). However, little evidence exists that IUI is an effective treatment. In 2013, the UK National Institute for Health and Care Excellence recommended that IUI should not be routinely offered for couples with unexplained infertility. Methods For this pragmatic, open-label, randomised, controlled, two-centre study, we enrolled women attending two fertility clinics in New Zealand with unexplained infertility and an unfavourable prognosis of natural conception. Participants were randomly assigned (1:1) using a computer-generated randomisation sequence, prepared by an independent statistician, to either three cycles of IUI with ovarian stimulation (with either oral clomifene citrate [50–150 mg, days 2–6] or oral letrozole [2·5–7·5 mg, days 2–6], with choice of ovarian stimulation made by the clinic) or three cycles of expectant management (couples advised to be sexually active around the likely time of ovulation and provided with a diary to record the first day of each menstrual cycle and dates of sexual activity) in blocks of four, six, and ten, without stratification. The participating couple and the clinicians were informed of treatment allocation. The primary outcome was cumulative livebirth rate in the intention-to-treat population. The safety analyses were done in the intention-to-treat population. This study was prospectively registered with the Australian and New Zealand Clinical Trials Register, number ACTRN12612001025820. Findings Between March 12, 2013, and May 12, 2016, we randomly assigned 101 women to IUI with ovarian stimulation and 100 to expectant management, all of whom were included in the primary efficacy analysis and safety analyses. Women assigned to IUI had a higher cumulative livebirth rate than women assigned to expectant management (31 [31%] livebirths among 101 women vs nine [9%] livebirths among 100 women; risk ratio [RR] 3·41, 95% CI 1·71–6·79; p=0·0003). Of 31 livebirths in the IUI group, 23 resulted from IUI cycles and eight were conceived without assistance before or between IUI cycles. Of nine livebirths in the expectant management group, one patient was pregnant from IUI with ovarian stimulation at study entry and one had received off-protocol treatment (IVF). Two sets of twins were born, both in the IUI group (one from a cancelled cycle for over-response). Interpretation IUI with ovarian stimulation is a safe and effective treatment for women with unexplained infertility and an unfavourable prognosis for natural conception. Funding Auckland Medical Research Foundation, Evelyn Bond Fund of Auckland District Health Board, Mercia Barnes Trust of Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Maurice and Phyllis Paykel Trust, and The Nurture Foundation for Reproductive Research.

In many road crashes the human body is exposed to high forces, commonly resulting in multiple injuries. This study of linked road crash data aimed to identify co-occurring injuries in multiple injured road users by using a novel application of a data mining technique commonly used in Market Basket Analysis. We expected that some injuries are statistically associated with each other and form Individual-Based Injury Patterns (IBIPs) and further that specific road users are associated with certain IBIPs. First, a new injury taxonomy was developed through a four-step process to allow the use of injury data recorded from either of the two major dictionaries used to document anatomical injury. Then data from the Swedish Traffic Accident Data Acquisition, which includes crash circumstances from the police and injury information from hospitals, was analysed for the years 2011 to 2017. The injury data was analysed using the Apriori algorithm to identify statistical association between injuries (IBIP). Each IBIP were then used as the outcome variable in logistic regression modelling to identify associations between specific road user types and IBIPs. A total of 48,544 individuals were included in the analysis of which 36,480 (75.1%) had a single injury category recorded and 12,064 (24.9%) were considered multiply injured. The data mining analysis identified 77 IBIPs in the multiply injured sample and 16 of these were associated with only one road user type. IBIPs and their relation to road user type are one step on the journey towards developing a tool to better understand and quantify injury severity and thereby improve the evidence-base supporting prioritisation of road safety countermeasures.

The importance and safety of non-operative management (NOM) of Blunt Splenic Injury (BSI) has been established in children and adults over recent decades. However, studies have shown higher operation rates in adults. There is international evidence that when children are managed in adult centres, operation rates are higher while adolescents in paediatric centres, are operated on in line with paediatric guidelines. This difference between children and young adults, and the factors responsible, have not been examined in New South Wales (NSW).To use NSW hospital and mortality data to compare the characteristics of BSI in patients aged 0-16 to those aged 17-25, and determine factors related to operative management (OM) and splenic salvage in each group.Patients age 0-25 between July 2000 and December 2011, with a diagnosis of BSI, were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages and Bureau of Statistics. Operation rate was compared between the two groups. Univariable analysis was used to determine factors associated with OM. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of OM according to age group, adjusting for potential confounders.1986 cases were identified, with 422 (21.2%) managed operatively - 101/907 children (11.1%) and321/1079 (29.7%)young adults(p0.001). Of these, 59 (58%) children underwent splenectomy compared with 233 (73%) young adults (p0.001). OM increased significantly after the age of 12 (p=0.03), and the percentage almost tripled in the teenage years, coinciding with a higher proportion admitted to adult centres. OM doubled again in young adults(p0.001), all of whom were managed away from paediatric centres. On multivariable analysis, factors significantly associated with operation included age over 16 (OR 2.82, 95%CI 2.10-3.81), splenic injury severity, associated thoracic, liver, pancreatic and hollow viscus injury, and blood transfusion.While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, it is possible children and young people in NSW are undergoing operation unnecessarily. Further evaluation of the surgeon attitudes and institutional factors involved in the management of injured children and young people within the broad NSW trauma system is required.

Introduction While an association between road crashes and health impairments is well documented, few studies have analysed impairments in relation to crash parameters. The aim of this paper is to describe a novel approach for studying the full complexity of road crashes which allows an analysis of the relationship between crash factors and longer-term health consequences. Methods A multidisciplinary team investigated road crashes sampled in a Swedish region. The course of events, road environment and crash configuration were studied at the scene and telephone interviews were conducted with drivers. Road users were queried about their health status 1, 6, and 12 months after the crash. To illustrate a potential use of the collected data, the relationship between crash factors and impairments for car occupants after one month was explored using multiple logistic regression. Results The sampled data included 176 crashes, 310 vehicles and 430 people. The most common crash characteristics were: multiple vehicle crashes (62%); posted speed limit of ≥ 70 km/h (65%); passenger cars (88%); driver age 25–54 years (60%); male drivers/riders (70%). The example analysis of passenger car occupants showed that having an injury with ISS ≥ 1 at the time of crash was a statistically significant predictor for impairment at one month (p Conclusions The methodology described in this paper provides information about the full spectrum of road crashes and enables novel analyses of unexplored research questions. Based on the data collected so far and the example analysis presented in the paper, recommendations have been made about future data collection. The proposed data collection methodology enables characterisation of crash factors that are associated with long-term health consequences. The ability to timely identify those at risk provides important opportunities for early intervention to reduce long-term health outcomes also from low severity crashes.

The data presented in this article are related to the research manuscript “Predictors of older drivers’ involvement in rapid deceleration events”, which investigates potential predictors of older drivers’ involvement in rapid deceleration events including measures of vision, cognitive function and driving confidence (A. Chevalier et al., 2016) [1]. In naturalistic driving studies such as this, when sample size is not large enough to allow crashes to be used to investigate driver safety, rapid deceleration events may be used as a surrogate safety measure. Naturalistic driving data were collected for up to 52 weeks from 182 volunteer drivers aged 75–94 years (median 80 years, 52% male) living in the suburban outskirts of Sydney. Driving data were collected using an in-vehicle monitoring device. Accelerometer data were recorded 32 times per second and Global Positioning System (GPS) data each second. To measure rapid deceleration behavior, rapid deceleration events (RDEs) were defined as having at least one data point at or above the deceleration threshold of 750milli-g (7.35m/s2). All events were constrained to a maximum 5s duration. The dataset provided with this article contains 473 events, with a row per RDE. This article also contains information about data processing, treatment and quality control. The methods and data presented here may assist with planning and analysis of future studies into rapid deceleration behaviour using in-vehicle monitoring.

Objective This study examined the relationship between restraint design features and comfort, posture and seat belt position of children in booster seats during a driving trial. The relationship between comfort and errors introduced by a child throughout a trip were also explored. Method Fifteen children were recruited in this study. Due to technical issues affecting video capture of three participants, the comfort, belt fit, errors and posture of twelve Australian children aged 4–8 years were analysed during two, one hour on-road drives in an instrumented study vehicle fitted with in-vehicle video monitoring equipment. Each child sat in two different types of booster seats, which varied markedly in design. Restraint 1 featured an adjustable headrest, sash belt guide and side wings, whilst Restraint 2 had a longer cushion length (R1: 29 cm, R2: 34 cm), no sash belt guide or side wings. Three five-minute video segments were analysed per seating condition; at the beginning, middle and end of the trip. The Discomfort Avoidance Behaviour (DAB) rate, DAB time, errors and average participant trip time observed in shoulder belt, sagittal torso and head positions were quantified. Results The average DAB rate was higher in R2 than R1 (R2 = 2.79 vs. R1 = 1.85, p = 0.009) and the average number of errors across time points was greater in R2 than R1 (R2 = 0.81 vs. R1 = 0.38, p = 0.01). The DAB rate was associated with increases in the number of child induced errors (log (errors in use) = −2.07 + 0.57 × DAB, p Conclusions The design of a restraint and its influence on comfort, errors, shoulder belt fit and posture may provide an effective avenue to enhance the correct use of child restraints throughout a trip.

Children that are unrestrained while travelling in a motor vehicle are more vulnerable to serious injury and death. The greatest levels of crash protection are achieved when children use the most age or size appropriate form of restraint. In this study, we aimed to examine the effectiveness of the introduction of age-appropriate child restraint legislation on serious and fatal injury in five Australian states and territories. For this interrupted time series analysis, we used a segmented regression method to assess the association between the implementation of child-restraint legislation and motor-vehicle related serious injuries and fatalities using data obtained from transport authorities in each jurisdiction. We estimated the change in annual rates after the implementation of legislation with the number of motor-vehicle accidents resulting in fatalities or serious injuries as the outcome, and the total number of injuries (minor, serious and fatal) as an offset in the model. We identified 10882 motor-vehicle related crashes resulting in fatalities (n = 188), serious injuries (n = 1730) and minor injuries (n = 8964). In NSW and VIC, the rate ratio was statistically significant and positive, indicating an increase in the rate of serious injuries and fatalities in the period post-legislation compared to the period prior to legislation. In all other states and territories, we did not find a statistically significant effect of legislation Road safety programs incorporating interventions targeted at increasing awareness of optimal restraint practices, strengthened enforcement and measures to improve the affordability of restraints are needed to support legislation.

Background: Children that are unrestrained while travelling in a motor vehicle are more vulnerable to serious injury and death. The greatest levels of crash protection are achieved when children use the most age or size appropriate form of restraint. In this study, we aimed to examine the effectiveness of the introduction of age-appropriate child restraint legislation on serious and fatal injury in five Australian states and territories. Methods: For this interrupted time series analysis, we used a segmented regression method to assess the association between the implementation of child-restraint legislation and motor-vehicle related serious injuries and fatalities using data obtained from transport authorities in each jurisdiction. We estimated the change in annual rates after the implementation of legislation with the number of motor-vehicle accidents resulting in fatalities or serious injuries as the outcome, and the total number of injuries (minor, serious and fatal) as an offset in the model. Findings: We identified 10882 motor-vehicle related crashes resulting in fatalities (n=188), serious injuries (n=1730) and minor injuries (n=8964). In NSW and VIC, the rate ratio was statistically significant and positive, indicating an increase in the rate of serious injuries and fatalities in the period post-legislation compared to the period prior to legislation. In all other states and territories, we did not find a statistically significant effect of legislation. Interpretation: Road safety programs incorporating interventions targeted at increasing awareness of optimal restraint practices, strengthened enforcement and measures to improve the affordability of restraints are needed to support legislation. Funding Statement: The George Institute for Global Health. Declaration of Interests: The authors state: "None declared." Ethics Approval Statement: The authors declare: "Ethics committee approval was not needed as the data was de-identified, publicly accessible government data."

In recent years, increases in motorcycle registrations have led to increases in the numbers of motorcycle casualties. Abrasion injuries are the most common injury to crashed motorcyclists and can still occur when the skin is fully protected by motorcycle specific clothing. This study investigated abrasion injuries and whether the type of material and the dynamic coefficient of friction (COF) of that material against skin could predict injury. This investigation was performed on a sample of riders who were involved in crashes (n = 92). The dynamic COF of the materials worn by the riders against an artificial skin substitute, Lorica® Soft, was determined using a biaxial materials testing machine. The occurrence of abrasion injuries for each of the riders was recorded and the injury outcome was compared to the type of material and the COF of these materials. Riders wearing heavy cotton and fleecy cotton knit sustained significantly more abrasion injuries than riders who wore other materials. No relationship was found between the dynamic COF of the materials and the likelihood of abrasion injuries to crashed motorcyclists. These results suggest that some materials are associated with higher levels of abrasion injuries, yet the COF may not be used to predict abrasion injury.

Objectives : To examine changes in child car restraint practices in low socioeconomic areas following the introduction of mandatory child car restraint legislation in New South Wales (NSW), Australia. Methods : Data from two cross-sectional studies of child car restraint use at pre-schools, early childhood centres and primary schools before and after the introduction of legislating mandatory age-appropriate car restraint use for children up to the age of seven years was used in this analysis. All included observations were from local government areas with socioeconomic status in the lowest 30% of urban Sydney. Children aged 2–5 years were observed in their vehicles as they arrived at observation sites (107 pre-legislation, 360 post-legislation). Multilevel logistic regression was used to examine changes in observed age-appropriate and correct use of car restraints. Results : Age-appropriate car restraint use was higher post-legislation than pre-legislation. After controlling for child's age, parental income, language spoken at home and adjusting for clustering, the odds of children being appropriately restrained post-legislation were 2.3 times higher than in the pre-legislation sample, and the odds of them being correctly restrained were 1.6 times greater. Conclusions : Results indicate an improvement in car restraint practices among children aged 2–5 in low socioeconomic areas after introduction of child restraint laws. Implications : Despite improvements observed with enhanced legislation, further efforts are required to increase optimal child car restraint use.

Competence and skills in overcoming clinical inertia for diabetes treatment, and actually supporting and assisting the patient through adherence and compliance (as opposed to just reiterating what they “should” be doing and then assigning them the blame if they fail) is a key component to success in addressing diabetes, and to date it is a component that has received little formal attention. To improve and systematize diabetes care, it is critical to move beyond the “traditional” continuing medical education (CME) model of imparting knowledge as the entirety of the educational effort, and move toward a focus on Performance Improvement CME. This new approach does not just teach new information but also provides support for improvements where needed most within practice systems based on targeted data—based on self-assessments for the entire system of care. Joslin data conclude that this new approach will benefit support, clinical, and office teams as well as the specialist. In short, the Performance Improvement CME structure reflects the needed components of the successful practice today, particularly for chronic conditions such as diabetes, including the focus on interdisciplinary team care and on quality improvement, which is becoming more and more aligned with reimbursement schemes, public and private, in the U.S.

To determine knowledge, competence, and attitudinal issues among primary care providers (PCPs) and diabetes specialists regarding the use and application of evidence-based clinical guidelines and the coordination of care between PCPs and diabetes specialists specifically related to referral practices for patients with diabetes.A survey tool was completed by 491 PCPs and 249 diabetes specialists. Data were collected from specialists online and from PCP attendees at live symposia across the United States. Results were analyzed for frequency of response and evaluation of significant relationships among the variables.Suboptimal practice patterns and interprofessional communication as well as gaps in diabetes-related knowledge and processes were identified. PCPs reported a lack of clarity about who, PCP or specialist, should assume clinical responsibility for the management of diabetes after a specialty referral. PCPs were most likely to refer patients to diabetes specialists for management issues relating to insulin therapy and use of advanced treatment strategies, such as insulin pens and continuous glucose monitoring. A minority of PCPs and even fewer specialists reported the routine use of clinical guidelines in practice.This research-based assessment identified critical educational needs and gaps related to coordinated care for patients with diabetes as well as the need for quality- and performance-based educational interventions.

To determine knowledge, competence, and attitudinal issues among diabetes specialists and primary care providers (PCPs) regarding the use of insulin delivery devices such as insulin pens and insulin pumps and the role of glucose monitoring devices and systems in the care of patients with diabetes.A quantitative survey tool was developed that contained 51 questions directed to diabetes specialists and 49 questions directed to PCPs. A 5-point, Likert-type scale or multiple-choice format was used. Data were collected from attendees at live symposia across the United States. Results were analyzed for frequency of response and significant relationships among the variables.The survey was completed by 136 specialists and 418 PCPs. There were higher usage rates for insulin pens among specialists than PCPs, although there were higher usage rates among more experienced PCPs. Regarding glucose monitoring, most specialists and PCPs did not recommend "block checking," which has been commonly thought of as a reasonable compromise checking schedule for patients with type 2 diabetes not using insulin. PCPs who were more experienced and used outside educational resources, such as a certified diabetes educator, and specialists who saw more patients on a weekly basis were more likely to prescribe the use of continuous glucose monitoring. There was a general underuse of continuous glucose monitoring in eligible patients.These findings underscore the discordance between PCPs and specialists with regard to advanced knowledge and confidence required for the use of newer technologies for glucose monitoring and insulin replacement. We have identified important remedial opportunities for quality- and performance-based educational interventions.

Accessory child safety harnesses are available in some countries as alternative restraints for young children or as an accessory restraint used with booster seats. Their use, in Australia at least, is becoming more common. There have been concerns that the risk of misuse of these restraints outweighs any potential benefit this system might have over a retractable lap-shoulder belt system used with a booster seat. However to date there is no evidence to confirm or deny this. This study used laboratory simulated frontal crash tests to examine the performance of accessory child safety harness systems compared to the lap-shoulder belt when used alone and when used with two common designs of Australian booster seat. The performance of the child safety harness system when misused was also investigated. The results demonstrate that the correctly used child safety harness system performed no better than the lap-shoulder system, and in fact allows for a greater risk of submarining. Furthermore, one common form of child safety harness misuse, where the harness is over-tightened causing the lap belt to be positioned high over the abdomen, allowed extremely undesirable dummy motion. This involved gross submarining and direct contact between the harness system and the dummy's neck. These findings suggest that the risks associated with accessory child safety harness systems most likely outweigh any potential benefits, in frontal impacts at least.

Advanced practice nurses (APNs) have been a critical component of the rural health care system for many years. This study describes the impact of APNs on primary care in Wyoming, a predominantly rural and frontier state, and illustrates a typical practice day for APNs. Wyoming APNs are experienced nurses, in their late 40s on average, and are quite independent in their practices. The APNs provided a significant amount of health care, with an average of 15 client visits per day. These APNs were heavy prescribers and performed a number of office procedures. Implications for health policy are discussed.

Purpose: To compare the measured radiographic entrance surface dose with thatobtained by calculation based on routine quality assurance (QA) measurements. To devise a computer-based system by which radiographers can determine patient doses from exposure factors recorded at the time of examination and compare the results with national reference levels. Methods: Patient doses were measured using thermoluminescent dosemeters(TLD) and the results compared with those obtained by calculation for the same patients. A computer program was written to enable dose calculation to be performed by radiographers using a departmental personal computer (PC). Results: The agreement between doses determined by the two methods iswithin ± 20% except for chest examinations. The computer program has been successfully used by radiographers to survey patient doses. Conclusion: Calculation, based on QA measurements, is a viable alternative todirect patient measurement. Once installed, the computer program can be used for routine dose audit for large numbers of patients.

MHC class I genes are potently repressed by HIV Tat, which transactivates the HIV LTR. Tat represses class I transcription by binding to complexes associated with a novel promoter element, consisting of Spi-like DNA binding sites. Transcription by other Sp1-dependent promoters, such as MDR1 and the minimal SV40 promoters, is also repressed by Tat, whereas the human β-actin promoter is neither activated by Sp1 nor repressed by Tat. Tat repression can be overcome by a strong enhancer element. Thus, the SV40 72 by enhancer element confers protection from Tat-mediated repression on both the minimal SV40 promoter and the class I promoter. Surprisingly, Tat can activate the class I promoter In the presence of both the HIV TAR element and a strong upstream enhancer. These data demonstrate that Tat differentially affects Sp1-responsive promoters, depending on promoter architecture.