A decision tree model for the implementation of a safety strategy in the horse-racing industry.

OBJECTIVES: The profession of a horse-racing jockey is a dangerous one. We developed a decision tree model quantifying the effects of implementing different safety strategies on jockey fall and injury rates and their associated costs. METHODS: Data on race-day falls were obtained from stewards' reports from August 2002 to July 2009. Insurance claim data were provided by Principal Racing Authorities and workers' compensation authorities in each jurisdiction. Fall and claim incidence data were used as baseline rates. The model considered (1) the status quo, in which policy was unchanged; and (2) compared it with four hypothetical changes in policy that restricted apprentice jockeys from riding less-accomplished horses, with the aim of improving safety by reducing incidence of injurious jockey falls. Second-order Monte Carlo simulations were conducted to account for uncertainties. RESULTS: The point estimate for mean costs of falls under the status quo was $30.73/ride, with falls by apprentice jockeys with <250 career race rides riding horses with less than five race starts contributing the highest costs ($98.49/ride). The hypothetical safety strategies resulted in a 1.04%-5.07% decrease in fall rates versus status quo. For three of the four strategies, significant reductions of 8.74%-13.13% in workers' compensation costs over one single race season were predicted. Costs were highly sensitive to large claims. CONCLUSIONS: This model is a useful instrument for comparing potential changes in cost and risks associated with implementing new safety strategies in the horseracing industry.

Clinical Outcomes of a Treat and Extend Regimen with Intravitreal Aflibercept Injections in Patients with Diabetic Macular Edema: Experience in Clinical Practice.

INTRODUCTION: Treat-and-extend (T&E) and pro re nata (PRN; 'as needed') regimens of intravitreal anti-vascular endothelial growth factor (VEGF) treatment have been found to reduce the injection burden on patients and improve the cost effectiveness of the treatment of macular edema. The aim of this study was to assess the effectiveness of a T&E regimen of aflibercept, in a clinical setting, in patients with diabetic macular edema (DME) who were either intravitreal anti-VEGF therapy naive or with minimal exposure to anti-VEGF (≤ 6 treatments) in the previous 12 months. METHODS: This prospective, single arm, open label study recruited patients with DME (macular thickness of ≥ 300 µm) and best-corrected visual acuity (BCVA) between 28-78 ETDRS letters. Participants received five loading doses of intravitreal aflibercept at 4-weekly intervals. BCVA measurements and macular optical coherence tomography were performed at each visit. If no disease activity was detected, treatment intervals were increased by 2 weeks to a maximum of 12 weeks. Outcome measures included: changes in BCVA and retinal anatomical measures (central foveal thickness [CFT] and central macular volume within 6 mm of the fovea [CSVol]) between baseline and 2 years, patient treatment intervals; and adverse events. RESULTS: Of the 36 patients who provided informed consent to participate in the study and were screened, 26 patients (eyes) were eligible to participate in the study. After regression analysis, adjustment for repeated measures, and significant covariates, the mean BCVA increased by 3.8 letters (95% confidence interval [CI] 1.1, 6.4) and the CFT and CSVol decreased by 127.2 µm (95% CI 91.7, 162.5) and 1.6 mm3 (95% CI 1.2, 2.0), respectively, over the course of the study. In the second year, 16 of the 25 patients still participating had their treatment intervals extended to 12 weeks. There was no evidence of any new adverse events that would require changes to the aflibercept safety profile. CONCLUSION: For the majority of patients presenting with DME, a T&E regimen of aflibercept in the first 2 years of therapy is a practical alternative to PRN treatment with regular review. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number, ACTRN12618000428268. FUNDING: This investigator-initiated study was supported by Bayer Australia Ltd. who provided the study treatment and some financial assistance.

The VEGF Treatment of AMD Switch Study (The vTAS Study).

PURPOSE: To evaluate the effect of aflibercept on anatomic and visual outcomes in patients with choroidal neovascularization (CNV) previously treated with intravitreal ranibizumab with persistent fluid on optical coherence tomography (OCT). DESIGN: Prospective, open-label study. METHODS: Eighteen patients (19 eyes) with CNV being treated with monthly ranibizumab, with persistent fluid on OCT, were switched to intravitreal aflibercept injections at intervals of up to 8 weeks. The primary outcome was the proportion of patients maintaining vision [<5 letter loss in visual acuity (VA)] at week 48. Secondary outcomes included the change in VA and central macular thickness (CMT) and the frequency of treatment necessary along with the safety of intravitreal aflibercept. RESULTS: Forty-eight weeks after switching to aflibercept, 16/19 eyes had maintained VA. There was a median increase in vision of 5 letters [interquartile range (IQR): 0, 15; P = 0.06)] and median CMT was reduced from 313 µm (IQR: 214, 334) to 258 µm (IQR: 200, 299; P = 0.02). After stratification by fluid location the reduction in CMT was statistically significant for eyes with intraretinal fluid (IRF) at baseline [median change, -25 µm (IQR: -14, -64); P = 0.01]. Macular volume within 6 mm of the fovea (CMTVol) was significantly reduced in eyes with subretinal fluid (SRF) [-0.20 mm³ (IQR: -1.45, -0.05); P = 0.03]. CONCLUSIONS: In this small cohort of eyes, switching to aflibercept seemed beneficial. The majority maintained or improved vision and eyes with IRF or SRF had significant reductions in macular edema. However, visual improvement was not always indicative of anatomical improvement.

Workplace Injuries in Thoroughbred Racing: An Analysis of Insurance Payments and Injuries amongst Jockeys in Australia from 2002 to 2010.

BACKGROUND: There is no comprehensive study of the costs of horse-related workplace injuries to Australian Thoroughbred racing jockeys. OBJECTIVES: To analyse the characteristics of insurance payments and horse-related workplace injuries to Australian jockeys during Thoroughbred racing or training. METHODS: Insurance payments to Australian jockeys and apprentice jockeys as a result of claims for injury were reviewed. The cause and nature of injuries, and the breakdown of payments associated with claims were described. RESULTS: The incidence of claims was 2.1/1000 race rides, with an average cost of AUD 9 million/year. Race-day incidents were associated with 39% of claims, but 52% of the total cost. The mean cost of race-day incidents (AUD 33,756) was higher than non-race day incidents (AUD 20,338). Weekly benefits and medical expenses made up the majority of costs of claims. Fractures were the most common injury (29.5%), but head injuries resulting from a fall from a horse had the highest mean cost/claim (AUD 127,127). CONCLUSIONS: Costs of workplace injuries to the Australian Thoroughbred racing industry have been greatly underestimated because the focus has historically been on incidents that occur on race-days. These findings add to the evidence base for developing strategies to reduce injuries and their associated costs.

Accident rates amongst regular bicycle riders in Tasmania, Australia.

PURPOSE: To characterise the demographics, cycling habits and accident rates of adult cyclists in Tasmania. METHODS: Volunteers ≥18 years of age who had cycled at least once/week over the previous month provided information on demographics; cycling experience; bicycles owned; hours/km/trips cycled per week; cycling purpose; protective equipment used; and major (required third-party medical treatment or resulted ≥1 day off work) or minor (interfered with individuals' regular daily activities and/or caused financial costs) accidents while cycling. RESULTS: Over 8-months, 136 cyclists (70.6% male) completed the telephone survey. Mean (standard deviation) age was 45.4 (12.1) years with 17.1 (11.4) years of cycling experience. In the week prior to interview, cyclists averaged 6.6 trips/week (totalling 105.7km or 5.0h). The most common reason for cycling was commuting/transport (34% of trips), followed by training/health/fitness (28%). The incidence of major and minor cycling accidents was 1.6 (95% CI 1.1-2.0) and 3.7 (2.3-5.0) per 100,000km, respectively. Male sex was associated with a significantly lower minor accident risk (incidence rate ratio=0.34, p=0.01). Mountain biking was associated with a significantly higher risk of minor accident compared with road or racing, touring, and city or commuting biking (p<0.05). CONCLUSIONS: Physical activity of regular cyclists' exceeds the level recommended for maintenance of health and wellbeing; cyclists also contributed substantially to the local economy. Accident rates are higher in this sample than previously reported in Tasmania and internationally. Mountain biking was associated with higher risks of both major and minor accidents compared to road/racing bike riding.

Longitudinal associations of adiposity with adult lung function in the Childhood Determinants of Adult Health (CDAH) study.

Childhood BMI has been reported to be positively associated with adult lung function. The aim of this study was to investigate the effect of childhood BMI on young adult lung function independently of the effects of lean body mass (LBM). Clinical and questionnaire data were collected from 654 young Australian adults (aged 27-36 years), first studied when age 9, 12, or 15 years. Adult lung function was measured by forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)), FEV(1)/FVC ratio, and the forced expiratory flow in the middle 50% of FVC (FEF(25-75)). BMI and LBM were derived from anthropometric measures at baseline (1985) and at follow-up (2004-2006). Multivariable models were used to investigate the effect of age and sex standardized BMI in childhood on adult lung function, before and after adjustment for LBM. Adult adiposity had a strong deleterious effect on lung function, irrespective of childhood BMI, and adjustment for childhood LBM eliminated any apparent beneficial effect of childhood BMI on adult FEV(1) or FVC. This suggests that the beneficial effect of increased BMI in childhood on adult FEV(1) and FVC observed in previous longitudinal studies is likely to be attributable to greater childhood LBM not adiposity. Obese children who become obese adults can expect to have poorer lung function than those who maintain healthy weight but large deficits in lung function are also likely for healthy weight children who become obese adults. This highlights the importance of lifetime healthy weight maintenance.

Overweight and obesity from childhood to adulthood: a follow-up of participants in the 1985 Australian Schools Health and Fitness Survey.

OBJECTIVE: To examine overweight and obesity in Australian children followed through to adulthood. DESIGN AND PARTICIPANTS: A cohort study of 8498 children aged 7-15 years who participated in the 1985 Australian Schools Health and Fitness Survey; of these, 2208 men and 2363 women completed a follow-up questionnaire at age 24-34 years in 2001-2005. MAIN OUTCOME MEASURES: Height and weight were measured in 1985, and self-reported at follow-up. The accuracy of self-reported data was checked in 1185 participants. Overweight and obesity in childhood were defined according to international standard definitions for body mass index (BMI), and, in adulthood, as a BMI of 25-29.9 and > or =30 kg/m2, respectively, after correcting for self-report error. RESULTS: In those with baseline and follow-up data, the prevalence of overweight and obesity in childhood was 8.3% and 1.5% in boys and 9.7% and 1.4% in girls, respectively. At follow-up, the prevalence was 40.1% and 13.0% in men and 19.7% and 11.7% in women. The relative risk (RR) of becoming an obese adult was significantly greater for those who had been obese as children compared with those who had been a healthy weight (RR = 4.7; 95% CI, 3.0-7.2 for boys and RR = 9.2; 95% CI, 6.9-12.3 for girls). The proportion of adult obesity attributable to childhood obesity was 6.4% in males and 12.6% in females. CONCLUSION: Obesity in childhood was strongly predictive of obesity in early adulthood, but most obese young adults were a healthy weight as children.