Endoscopic management of ingested toothpick resulting in duodeno-ureteric fistula.

Toothpicks are commonly used but rarely ingested. Unlike most foreign bodies, if accidentally swallowed these rarely spontaneously pass. The duodenum has been reported as the most common site of toothpick foreign body lodgement in the upper gastrointestinal tract. We report the case of a 57-year-old presenting with recurrent urosepsis after non recognition of a toothpick impaction in the duodenum with fistulisation into the right renal pelvis. Endoscopic removal of the foreign body was successful in management of the urosepsis.

Injuries and Health Issues Occurring During Offshore Transoceanic Sailing: A Survey of Recreational Sailors and Cruisers.

INTRODUCTION: Most of the literature on sailing injuries is centered on competitive sailing, often involving a single regatta. The aims of this study were to provide a description of the types of injuries and illnesses sustained during amateur offshore cruising events, estimate their incidence, and investigate potential risk factors for injuries. METHODS: We conducted a cross-sectional survey of self-reported sailing-related injuries and health issues during 4 different events organized by the World Cruising Club between 2014 and 2015. Prior to departure, sailors received an injury or health issue report form to complete during their sailing event. Questionnaires were then collected at the end of each event. Bivariable (Student's t tests and χ2 tests) and mutilvariable logistic regression were used to study the associations among injuries, health issues, and the characteristics of sailors or sailboats. RESULTS: The incidence of injuries and health issues among the respondents was 1.08 and 1.01 per 10,000 nautical miles, respectively. Smaller boats (P<0.001) and crews with less experience with the current boat (P<0.001) were associated with reporting of more injuries. Most of the injuries were reported during favorable weather conditions. Health issues were more frequent on smaller boats and with women (P=0.008), who reported significantly more seasickness (P<0.001), anxiety (P=0.037), and skin rash/fungal infection (P=0.021). CONCLUSIONS: Injuries and health issues are relatively common among amateur offshore recreational sailors, but severe injuries are rare. Smaller boats and having less experience in sailing with the current boat were associated with more injuries. Preventive strategies should include a sailing experience requirement on the boat being sailed for all crew members, increasing the minimum boat size requirement for sailing events, and mandatory first-aid training prior to a cruising event for all crew members.

Sailing Injuries: A Review of the Literature.

Sailors are at risk for acute injuries, overuse injuries, environmental injuries, and sailing-related illnesses. Sailing-related injury rates vary from 0.29 to 5.7 per 1,000 hours which is lower than many other land-based sports. However, the fatality rate of 1.19 per million sailing-days is relatively high. The most common injuries are contusions and lacerations predominantly to the upper and lower extremities. Falls and impacts from various parts of the sailboat are the most common mechanisms of traumatic injury. High winds, operator inexperience, and operator inattention are the most common contributing factors for injury. Among Olympic-class sailors, overuse injuries to the back (29-45%) and knees (13-22%) are commonly reported. As many as seventy-three percent of sailing-related deaths are due to drowning as a result of falls overboard (39-44%) or capsizing the vessel (20-40%). Eighty-two percent of sailing-related drowning victims in US waters were not wearing a lifejacket. Leading contributing factors to fatal sailing accidents are high winds (12-27%), alcohol use (10-15%), and operator inexperience (8%). [Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

Injuries and Fatalities on Sailboats in the United States 2000-2011: An Analysis of US Coast Guard Data.

BACKGROUND: Prior sailing injury studies have been small, focused investigations. This large, population-based study examined the mechanisms and factors contributing to sailboat-related injuries and deaths. METHODS: A retrospective data analysis of the Boating Accident Report Database compiled by the US Coast Guard between 2000 and 2011 was performed. The database was analyzed looking at frequency of events. For each subgroup, proportions were determined and 95% CIs were calculated. These data, used in conjunction with the 2011 US Coast Guard National Recreational Boating Survey, were used to estimate a fatality rate. RESULTS: Two hundred seventy-one sailing-related fatalities and 841 injuries were reported. A fatality rate was calculated at 1.19 deaths per million sailing person-days. Weather or hazardous waters were listed as primary contributing factors in 28.0% (95% CI, 22.7-33.4) of deaths; 70.1% (95% CI, 64.7-75.6) of deaths occurred after falling overboard or capsizing. Drowning was the most common cause of death (73.1%; 95% CI, 67.8-78.4), and 81.6% of victims were not wearing a life jacket. Alcohol intoxication contributed to 12.2% (95% CI, 8.3-16.1) of deaths. Operator- or passenger-preventable factors contributed to 52.7% (95% CI, 49.3-56.1) of all injuries; 51.6% (95% CI, 46.1-57.1) of injuries on nonmotorized sailboats were the result of capsizing, and 46.4% (95% CI, 42.1-50.7) of all injuries on motorized sailboats were the result of collisions or grounding. CONCLUSIONS: The calculated fatality rate is similar to that of alpine skiing. Falls overboard and capsizing were the most common fatal accidents. Operator inattention, inexperience, and alcohol use were common preventable factors contributing to fatal and nonfatal injury.

Pre-Participation Medical Evaluation for Adventure and Wilderness Watersports.

A request for a preparticipation medical evaluation for wilderness watersports may be made by guiding agencies, instructional camps, or by patients presenting for an annual visit. Although guidelines have been published regarding preparticipation physical evaluation for traditional competitive high school and collegiate sports, little has been written about medical evaluations for those wishing to engage in wilderness and adventure watersports. in this article, we offer guidance based on literature review and expert opinion. Watersports are among the most common recreational activities in the United states and are generally safe. Drowning, however, is a significant risk, particularly in small, self-propelled craft, and among children. Medical counseling before participation in watersports should include screening for medical conditions which may impair swimming ability, including a history of seizures, heart disease, and lung disease. Physicians should also promote preventive health measures such as use of lifejackets and sun protection, as well as alcohol avoidance. Swim testing tailored to specific activities should be strongly considered for children and those with questionable swimming ability.

Pre-Participation Medical Evaluation for Adventure and Wilderness Watersports.

A request for a preparticipation medical evaluation for wilderness watersports may be made by guiding agencies, instructional camps, or by patients presenting for an annual visit. Although guidelines have been published regarding preparticipation physical evaluation for traditional competitive high school and collegiate sports, little has been written about medical evaluations for those wishing to engage in wilderness and adventure watersports. In this article, we offer guidance based on literature review and expert opinion. Watersports are among the most common recreational activities in the United States and are generally safe. Drowning, however, is a significant risk, particularly in small, self-propelled craft, and among children. Medical counseling before participation in watersports should include screening for medical conditions which may impair swimming ability, including a history of seizures, heart disease, and lung disease. Physicians should also promote preventive health measures such as use of lifejackets and sun protection, as well as alcohol avoidance. Swim testing tailored to specific activities should be strongly considered for children and those with questionable swimming ability.

Assessment of Integrated Pedestrian Protection Systems with Autonomous Emergency Braking (AEB) and Passive Safety Components.

OBJECTIVE: Autonomous emergency braking (AEB) systems fitted to cars for pedestrians have been predicted to offer substantial benefit. On this basis, consumer rating programs-for example, the European New Car Assessment Programme (Euro NCAP)-are developing rating schemes to encourage fitment of these systems. One of the questions that needs to be answered to do this fully is how the assessment of the speed reduction offered by the AEB is integrated with the current assessment of the passive safety for mitigation of pedestrian injury. Ideally, this should be done on a benefit-related basis. The objective of this research was to develop a benefit-based methodology for assessment of integrated pedestrian protection systems with AEB and passive safety components. The method should include weighting procedures to ensure that it represents injury patterns from accident data and replicates an independently estimated benefit of AEB. METHODS: A methodology has been developed to calculate the expected societal cost of pedestrian injuries, assuming that all pedestrians in the target population (i.e., pedestrians impacted by the front of a passenger car) are impacted by the car being assessed, taking into account the impact speed reduction offered by the car's AEB (if fitted) and the passive safety protection offered by the car's frontal structure. For rating purposes, the cost for the assessed car is normalized by comparing it to the cost calculated for a reference car. The speed reductions measured in AEB tests are used to determine the speed at which each pedestrian in the target population will be impacted. Injury probabilities for each impact are then calculated using the results from Euro NCAP pedestrian impactor tests and injury risk curves. These injury probabilities are converted into cost using "harm"-type costs for the body regions tested. These costs are weighted and summed. Weighting factors were determined using accident data from Germany and Great Britain and an independently estimated AEB benefit. German and Great Britain versions of the methodology are available. The methodology was used to assess cars with good, average, and poor Euro NCAP pedestrian ratings, in combination with a current AEB system. The fitment of a hypothetical A-pillar airbag was also investigated. RESULTS: It was found that the decrease in casualty injury cost achieved by fitting an AEB system was approximately equivalent to that achieved by increasing the passive safety rating from poor to average. Because the assessment was influenced strongly by the level of head protection offered in the scuttle and windscreen area, a hypothetical A-pillar airbag showed high potential to reduce overall casualty cost. CONCLUSIONS: A benefit-based methodology for assessment of integrated pedestrian protection systems with AEB has been developed and tested. It uses input from AEB tests and Euro NCAP passive safety tests to give an integrated assessment of the system performance, which includes consideration of effects such as the change in head impact location caused by the impact speed reduction given by the AEB.

Estimate of potential benefit for Europe of fitting Autonomous Emergency Braking (AEB) systems for pedestrian protection to passenger cars.

OBJECTIVE: The objective of the current study was to estimate the benefit for Europe of fitting precrash braking systems to cars that detect pedestrians and autonomously brake the car to prevent or lower the speed of the impact with the pedestrian. METHODS: The analysis was divided into 2 main parts: (1) Develop and apply methodology to estimate benefit for Great Britain and Germany; (2) scale Great Britain and German results to give an indicative estimate for Europe (EU27). The calculation methodology developed to estimate the benefit was based on 2 main steps: 1. Calculate the change in the impact speed distribution curve for pedestrian casualties hit by the fronts of cars assuming pedestrian autonomous emergency braking (AEB) system fitment. 2. From this, calculate the change in the number of fatally, seriously, and slightly injured casualties by using the relationship between risk of injury and the casualty impact speed distribution to sum the resulting risks for each individual casualty. The methodology was applied to Great Britain and German data for 3 types of pedestrian AEB systems representative of (1) currently available systems; (2) future systems with improved performance, which are expected to be available in the next 2-3 years; and (3) reference limit system, which has the best performance currently thought to be technically feasible. RESULTS: Nominal benefits estimated for Great Britain ranged from £119 million to £385 million annually and for Germany from €63 million to €216 million annually depending on the type of AEB system assumed fitted. Sensitivity calculations showed that the benefit estimated could vary from about half to twice the nominal estimate, depending on factors such as whether or not the system would function at night and the road friction assumed. Based on scaling of estimates made for Great Britain and Germany, the nominal benefit of implementing pedestrian AEB systems on all cars in Europe was estimated to range from about €1 billion per year for current generation AEB systems to about €3.5 billion for a reference limit system (i.e., best performance thought technically feasible at present). Dividing these values by the number of new passenger cars registered in Europe per year gives an indication that the cost of a system per car should be less than ∼€80 to ∼€280 for it to be cost effective. CONCLUSIONS: The potential benefit of fitting AEB systems to cars in Europe for pedestrian protection has been estimated and the results interpreted to indicate the upper limit of cost for a system to allow it to be cost effective.

Analysis of lifeguard-recorded data at Hanauma Bay, Hawaii.

OBJECTIVE: To describe rescue events at Hanauma Bay using data collected by lifeguards stationed at the bay. METHODS: Lifeguard collected data documenting estimates of daily beach attendance, and characteristics of rescue victims and events were analyzed for the period 2000 to 2007. RESULTS: A total of 4888 Logsheets spanning 2000 to 2007 and 1567 Incident Reports spanning 2000 to 2002 and 2006 to 2007 documenting 1249 rescues were available for analyses. Lifeguard estimates of attendance summing tallies made at 12, 2, and 4 pm overestimated actual attendance by a factor of 1.78 (SD = 0.08) while estimates summing 12 and 4 pm tallies underestimated actual attendance by a factor of 0.91 (SD = 0.04). Both estimates were strongly correlated with actual attendance values (R = 0.98 and R = 0.98, respectively). The average rescue rate for the study period was 7 rescues per 10,000 bathers. Nonresidents accounted for 88% of all visitors to the bay and accounted for a disproportionate percentage of the rescue population (96%, p-value = 0.04). A majority of rescues (63.2%) occurred at a single location called "The Slot." Following rescues, 91.4% of rescue victims were released to the beach, 5.9% were released to their parents or guardians, and 1.4% required transfer to a hospital via ambulance. CONCLUSION: Lifeguard estimates of attendance at Hanauma were precise, and summing 12 and 4 pm attendance tallies provided the most accurate estimate of actual attendance. Rescues at Hanauma Bay occurred predominantly among nonresidents and were concentrated to a single location called "The Slot."

Sailing injury and illness: results of an online survey.

OBJECTIVE: The purpose of this study was to describe the relative frequency, patterns, and mechanisms of sailing-related injuries in dinghies and keelboats. Data were also collected on risky and risk-averse behaviors of sailors, as well as on sailing-related illnesses. METHODS: A web-based, logic-driven, multiple-choice survey was developed and links were posted on sailing-related websites. Data were collected from March through November 2006 on any injuries or illnesses sailors sustained over the prior 12 months. RESULTS: From 1188 respondents, a total of 1715 injuries and 559 illnesses was reported. The top 3 injuries for keel boats were leg contusions (11%), hand lacerations (8%), and arm contusions (6%), and in dinghies they were leg contusions (13%), knee contusions (6%), and leg lacerations (6%). The most common mechanisms of injury were "trip/fall," "hit by object," and "caught in lines." Tacking, heavy weather, and jibing were the most common factors contributing to injury. The rates of injury and severe injury in this internet-based survey were 4.6 and 0.57 per 1000 days of sailing, respectively. Of the 70 severe injuries, 25% were fractures, 16% were torn tendons or cartilage, 14% were concussions, and 8% were dislocations. The median rate of lifejacket use was 30%, and median rate of sunscreen use was 80%. Sixteen percent of sailors reported sunburn over the prior 12 months. Seven percent of sailors reported use of alcohol within the 2 hours preceding injury. CONCLUSIONS: The most common injuries in both keel boats and dinghies are soft-tissue injuries to the extremities. Severe injuries and illnesses in sailing are uncommon in this study population.

Injury and illness at the Newport-Bermuda race 1998- 2006.

OBJECTIVE: To describe the relative frequency and types of injury and illness in the Newport-Bermuda off-shore yachting race. METHODS: At the end of each race held in even numbered years from 1998-2006, the captain of each boat was asked to complete a survey detailing any injury or illness among his/her crew. RESULTS: There was an overall 87% response rate to the survey. During the study period, 38 injuries and 57 illnesses were reported for an estimated 8105 sailors, yielding rate of injury or illness of 12 per 1000 races per sailor. Most common were injuries to the upper extremity (47%), and lacerations were the most common type of injury (45%). Sea sickness was the most common illness, and the rate of illness and injury increased in races that took place in heavy weather. Radio consultations were used 4 times, and 3 sailors required transport to a hospital. CONCLUSIONS: The rate of injury and illness was relatively low in the Newport-Bermuda race. Injuries to the upper extremities and lacerations were most common, and sea sickness was the most common illness. The majority of illness and injury can be initially managed onboard.

Competitive surfing injuries: a prospective study of surfing-related injuries among contest surfers.

BACKGROUND: Surfing is a sport that has been growing rapidly in popularity, yet little is known about surfing injuries. PURPOSE: To calculate an accurate injury rate for competitive surfing and to describe the relative frequency, mechanisms, and risk factors for acute surfing injuries. STUDY DESIGN: Descriptive epidemiology study. METHODS: This prospective study of acute competitive surfing injuries was carried out at 32 professional and amateur surfing contests worldwide between 1999 and 2005. All acute injuries sustained during competition were recorded by on-site medical personnel. The wave size, type of seafloor, and number of surfing heats were also recorded for each day. The total number of injuries was divided by the total number of athlete exposures to determine injury rates. A multiple logistic regression was used to determine risk factors for injury. RESULTS: There were 116 injuries documented, 89 of which occurred during competition. There were 15,675 athlete exposures, yielding an injury rate of 5.7 per 1000 athlete exposures, or 13 per 1000 hours of competitive surfing. There were 6.6 significant injuries per 1000 hours of competitive surfing. Risk of injury was 2.4 (95% confidence interval, 1.5-3.9) times greater when surfing in waves overhead or bigger relative to smaller waves and 2.6 (95% confidence interval, 1.3-5.2) times greater when surfing over a rock or reef bottom relative to a sandy bottom. CONCLUSION: There were 13 acute surfing injuries per 1000 hours of competitive surfing. The risk of injury was more than doubled when surfing in large waves or over a hard seafloor.

Peer review and feedback can modify pain treatment patterns for emergency department patients with fractures.

Consecutive fracture patients presenting to an adult (AED) or pediatric trauma center (PED) or a community teaching hospital (CED) were reviewed for treatment. Physicians received individual and group feedback. Data were dichotomized by age, gender, race and insurance status. Logistic regression analysis modeled variables approaching statistical significance. A total of 1454 patients participated in the study. The aggregate initial treatment rate was 54%, with no subgroup differences. Significant improvements were seen in all sites/subgroups; the final aggregate treatment rate was 84% (P < .001). PED and CED patients were less likely to receive treatment than AED patients (odds ratios = 0.49, 0.68). After feedback, whites were treated more often than were non-whites (84% vs 71%, P < .0001); CED alone did not show this pattern (odds ratios = AED 4.14, PED 2.67, CED1.28). Patients at all sites received improved pain treatment in association with directed feedback. Race and treatment site were significant factors.

Surfing injuries.

The purpose of this study was to describe the relative frequency, pattern, and mechanism of surfing injuries. Descriptive data of surfing injuries was collected by using a Web site-based interactive multiple choice survey. Data was collected from May 1998 to August 1999. Completed surveys were obtained from 1,348 individuals reporting 1,237 acute injuries and 477 chronic injuries. Lacerations accounted for 42% of all acute injuries, contusions 13%, sprains/strains 12%, and fractures 8%. Thirty-seven percent of acute injuries were to the lower extremity, and 37% to the head and neck. Fifty-five percent of injuries resulted from contact with ones own board, 12% from another surfer's board, and 17% from the sea floor. Sixty-seven percent of acute surfing injuries are caused by board contact. Older surfers, more expert surfers, and those surfing large waves have a higher relative risk for significant injury. Equipment modifications are suggested that may decrease the risk for injury.