Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocol is a set of peri-operative strategies to increase speed of recovery. ERAS is well established in adults but has not been well studied in children. OBJECTIVE: The purpose of the current study was to establish the safety and efficacy of an ERAS protocol in pediatric urology patients undergoing reconstructive operations. It was hypothesized that ERAS would reduce length of stay and decrease complications when compared with historical controls. STUDY DESIGN: Institutional Review Board approval was obtained to prospectively enroll patients aged <18 years if they had undergone urologic reconstruction that included a bowel anastomosis. ERAS included: no bowel preparation, administration of pre-operative oral carbohydrate liquid, avoidance of opioids, regional anesthesia, laparoscopy when feasible, no postoperative nasogastric tube, early feeding, and early removal of intravenous fluids (IVF). Recent (2009-2014) historical controls were propensity matched in a 2:1 ratio on age, sex, ventriculoperitoneal shunt status and whether the patient was undergoing bladder augmentation. Outcomes were protocol adherence, length of stay (LOS), emergency department (ED) visits, re-admission within 30 days, re-operations and adverse events occurring within 90 days of surgery. RESULTS: A total of 26 historical and 13 ERAS patients were included. Median ages were 10.4 (IQR 8.0-12.4) and 9.9 years (IQR 9.1-11), respectively (P = 0.94) (see Summary Table). There were no significant between-group differences in prior abdominal surgery (38% vs 62%), rate of augmentation (88% vs 92%) or primary diagnosis of spina bifida (both 62%). ERAS significantly improved use of pre-operative liquid load (P < 0.001), avoidance of opioids (P = 0.046), early discontinuation of IVF (P < 0.001), and early feeding (P < 0.001). Protocol adherence improved from 8/16 (IQR 4-9) historically to 12/16 (IQR 11-12) after implementation of ERAS. LOS decreased from 8 days to 5.7 days (P = 0.520). Complications of any grade per patient decreased from 2.1 to 1.3 (OR 0.71, 95% CI 0.51-0.97). There were fewer complications per patient across all grades with ERAS. No differences were seen in emergency department (ED) visits, re-admissions and re-operations. DISCUSSION: Implementation improved consistency of care delivered. Tenets of ERAS that appeared to drive improvements included maintenance of euvolemia through avoidance of excess fluids, multimodal analgesia, and early feeding. CONCLUSION: ERAS decreased length of stay and 90-day complications after pediatric reconstructive surgery without increased re-admissions, re-operations or ED visits. A multicenter study will be required to confirm the potential benefits of adopting ERAS.

Inter-rater reliability of the APD, SFU and UTD grading systems in fetal sonography and MRI.

INTRODUCTION: Antenatal hydronephrosis (ANH) is frequently detected on screening obstetric ultrasonography. Common ANH grading systems include the anterior-posterior diameter (APD) and the Society for Fetal Urology (SFU) grading system. Recent developments in the management of ANH include the use of fetal magnetic resonance imaging (MRI), and a new grading system - Urinary Tract Dilation (UTD). This study reviewed patients who underwent fetal MRI and ultrasound, and compared the grading systems across these imaging modalities. MATERIALS AND METHODS: Patients who underwent paired fetal MRI and ultrasound studies between January 2012 and January 2014 were included. Two pediatric urologists and a pediatric radiologist reviewed the studies. Data collected included APD, SFU grade, and UTD grade. Fleiss' kappa statistic determined the inter-rater reliability (IRR) of the SFU and UTD grading within each imaging modality. Intra-class correlation assessed the consistency of the APD measurements. RESULTS: Forty-seven patients and 88 renal units were evaluated. Median gestational age was 22 weeks. Kappa values of the SFU grading system indicated fair IRR for ultrasound imaging and moderate IRR for MRI imaging, while the UTD grading system reached moderate IRR for both. The IRR of the SFU grading system was improved with the use of MRI, while the UTD grading system was no different. The APD intraclass correlation coefficient improved significantly when measured by MRI. As the ultrasound SFU grade increased, the odds of the MRI SFU grade being scored higher increased by a factor of 3.7. There was no difference between ultrasound and MRI when using the UTD grading system. DISCUSSION: This study was the first to assess the UTD system in a cohort of patients who underwent paired ultrasound and MRI studies. The results suggested that the UTD system might improve IRR, compared with the SFU system. The use of fetal MRI may improve the IRR of the SFU grading system. It also found that the proportion of SFU grades was affected by the imaging modality, raising the possibility that MRI 'overcalls' the SFU grade, compared with ultrasound. This difference was not observed using the UTD grading system. The most important limitation was the selection bias favoring complex pathology with severe ANH diagnosed at an early gestational age. CONCLUSIONS: In this unique cohort, the UTD system improved IRR when compared to the SFU grading system. Fetal MRI improved the IRR of the SFU grading system, and improved the APD intraclass correlation. The SFU grading was likely to be higher when assessed by MRI vs ultrasound, but the UTD grade was not affected by the imaging modality.

An evaluation of mouthguard requirements and dental injuries in New Zealand rugby union.

OBJECTIVES: To document the effects of compulsory mouthguard wearing on rugby related dental injury claims made to ACC, the administrator of New Zealand's accident compensation scheme. METHODS: An ecological study was conducted. Estimates of mouthguard wearing rates were available from prospective studies conducted in 1993, 2002, and 2003. Rugby related dental injury claims were available for the period 1995-2003. Player numbers were available from 1998. Mouthguard wearing was made compulsory during match play for rugby players at under 19 level and below at the beginning of the 1997 season, and for all grades of domestic rugby at the beginning of the 1998 season. Greater powers of enforcement were provided to referees at the beginning of the 2003 season. RESULTS: The self reported rate of mouthguard use was 67% of player-weeks in 1993 and 93% in 2003. A total of 2644 claims was reported in 1995. There was a 43% (90% confidence interval 39% to 46%) reduction in dental claims from 1995 to 2003. On the reasonable assumption that the number of players and player-matches remained constant throughout the study period, the relative rate of injury claims for non-wearers versus wearers was 4.6 (90% confidence interval 3.8 to 5.6). The cumulative savings in claim costs compared with the cost per year if claim numbers had remained constant from 1995 is 1.87 million NZD. CONCLUSION: Although ecological studies have acknowledged weaknesses, the findings provide evidence that mouthguard use is a simple and effective injury prevention strategy for rugby players. The use of mouthguards for all players in both matches and contact practice situations is strongly recommended.

Playing conditions, player preparation and rugby injury: a case-control study.

This paper investigates the effect of player preparation, ground conditions and weather conditions upon the injury risk for Rugby Union players. A population-based case-control study was performed using a sample (n= 1043) of New Zealand Rugby Union players aged 16 y and above. Details concerning game preparation (warm-up and usual position), and ground and weather conditions (precipitation, wind and temperature) were obtained from the players. If players were injured during the season (n= 624) they were asked to provide details about the game in which they were last injured. Uninjured players (n= 419) provided details about the last game in which they played. Injuries were more likely to occur when games were played on hard grounds or in calm or warm conditions. Playing out of position and the duration of warming up did not significantly alter the risk of injury. When player preparation, ground and weather conditions, grade, age, playing position and rugby experience were simultaneously controlled for, hard ground and the absence of wind were associated with increased risk. The influence of these factors may be indirect, through adaptation to the conditions in which a game is played.

Continuous local anesthetic infusion for children with spina bifida undergoing major reconstruction of the lower urinary tract.

OBJECTIVE: While many options for postoperative analgesia are available to the general patient population, choices are limited for individuals with spinal dysraphism. We hypothesized that the use of continuous local anesthetic infusion following major reconstruction of the lower urinary tract in children with spina bifida would significantly decrease need for opiate use, while maintaining adequate pain control. MATERIALS AND METHODS: Children with spina bifida who underwent major reconstruction of the lower urinary tract at Children's Hospital Colorado were identified from January, 2003 through January, 2013 were identified. In addition to enterocycstoplasty, procedures included Mitrofanoff or Monti creation, bladder neck reconstruction, and Malone antegrade continence enema. Patients who had local anesthetic infusion catheters placed in the incision were compared to patients without catheters. Opioid consumption was calculated by conversion of any opiates into IV morphine (mg/kg) on postoperative days (POD) 0-3. Pain was assessed by mean and maximum FLACC scores on POD 0-2. Use of antiemetic medications and wound related complications were recorded as secondary metrics. Patients with other etiologies for neurogenic bladder and bowel were excluded. Patients whose pain was assessed by other assessment scales were excluded. Chi-squared analysis was used for nominal variables, students t-test was used for analysis of continuous variables. P values <0.05 were considered significant. RESULTS: 36 myelomeningocele patients who underwent primary enterocystoplasty met the inclusion criteria. All surgeries were open procedures. 24 patients in the infusion catheter group were compared to 12 patients who received primary analgesia by PCA or IV narcotics. There were no significant differences in age, sex, weight or spinal defect level between the two groups. Opioid use, as defined by IV morphine equivalents, was significantly less in the wound soaker group on all PODs. The total opioid use after POD #0-3 was 0.55 mg/kg in the wound soaker group vs 1.66 mg/kg in the IV/PCA group (p = 0.03). FLACC scores were uniformly lower in the wound soaker group, but were not significantly different. There was a significant decrease in need for postoperative antiemetic use in the wound soaker group (36.5% vs 83.3%, p = 0.014). Complications and hospital stay were similar between both groups. DISCUSSION: The advantage of local anesthesia is the reduction of systemic opioids and their subsequent adverse side effects. Our results suggest that in children with spina bifida undergoing major reconstruction of the lower urinary tract narcotic consumption is approximately 1/3 when continuous local anesthetic catheters are placed into the incision. The need for antiemetic medication is also significantly less. While this technique has been validated in a variety of other settings, it may be most beneficial in patients with myelomeningocele or other spinal dysraphism where epidural placement is generally contraindicated and narcotic use may have a particularly deleterious effect on preexisting neurogenic bowel function. The primary limitation of our study is that it is a retrospective review of a limited number of patients. Patients were not randomized and subject to other management differences that could have influenced our results in unknown ways. CONCLUSIONS: Continuous local anesthetic catheters are a simple, effective alternative strategy to provide postoperative analgesia while reducing systemic opiate use and associated adverse effects.

Differential actions of 3-(4-chlorophenyl) glutamic acid stereoisomers and L-trans-pyrrolidine-2,4-dicarboxylic acid upon L-homocysteic acid- and L-glutamic acid-induced responses from rat spinal motoneurones.

The four recently synthesized stereoisomers of 3-(4-chlorophenyl) glutamic acid (chlorpheg) were individually examined for their abilities to potentiate depolarizations of neonatal rat motoneurones evoked by L-homocysteic acid (L-HCA, 10 microM). This property had previously been observed using the racemate and is believed to be mediated by uptake inhibition. Both the (2S,3S)- and (2S,3R)- isomers were selective potentiators of L-HCA- (vs L-Glu) induced depolarizations although the (2S,3S)- isomer was more effective. The (2R,3S)- isomer had a slight but significant depressant action which could be attributed to N-methyl-D-aspartate (NMDA) receptor antagonism. Comparison of the potentiating properties of (2S,3S)- and (2S,3R)-chlorpheg with those of L-trans-pyrrolidine-2,4-dicarboxylic acid (tPDC, a L-Glu uptake inhibitor) upon L-HCA- and L-Glu-evoked responses revealed that both chlorpheg isomers (500 microM each) selectively potentiated responses evoked by L-HCA (10 microM) but had no significant effect upon those evoked by L-Glu (50 microM). On the other hand, use of tPDC at the same concentration significantly enhanced the depolarizations evoked by both amino acids, although its action on L-Glu-evoked responses was greater. It is concluded that (i) the (2S,3S)- isomer and to a lesser extent, the (2S,3R)- isomer of chlorpheg are responsible for the potentiating actions seen with the chlorpheg racemate used in previous studies and (ii) (2R,3S)-chlorpheg is a weak NMDA antagonist. The apparently selective action of (2S,3S)- and (2S,3R)-chlorpheg upon L-HCA-relative to L-Glu-induced depolarizations supports the existence of multiple excitatory amino acid uptake sites, some of which may yet be unidentified.

Diastereoselective synthesis of all four isomers of 3-(4-chlorophenyl) glutamic acid: identification of the isomers responsible for the potentiation of L-homocysteic acid-evoked depolarizations in neonatal rat motoneurons.

All four isomers of 3-(4-chlorophenyl)glutamic acid (5-8) were prepared by diastereoselective synthesis. Addition of (6S)-(+)-bis-lactim ether 15 to cis-4-chlorocinnamate 12 gave a mixture comprising mainly the (2R,3S)- and (2R,3R)-isomers 5 and 6, respectively (in a ratio of 56:40), while addition of (6R)-(-)-bis-lactim ether 16 to 4-chlorocinnamate 12 gave a mixture comprising mainly the (2S,3R)- and (2S,3S)-isomers 8 and 7, respectively (in a ratio of 56:42). The four stereoisomers (5-8) were therefore conveniently prepared by addition of either 3-lithio-(6S)- or -(6R)-bis-lactim ether (15 or 16, respectively) to 4-chlorocinnamate 12 and separation of the resultant mixtures of diastereoisomers (23-26) by flash silica gel chromatography. The absolute configurations of 6 and 7 were confirmed by X-ray crystallography. Both the (2S,3S)- and (2S,3R)-isomers (7 and 8, respectively) at a concentration of 100 microM significantly potentiated depolarizations induced by 10 microM L-homocysteic acid (L-HCA) (% control +/- sem: 130.4 +/- 3.6, n = 20 and 114.5 +/- 2.4, n = 11, respectively) while the (2R,3S)-isomer 5 significantly reduced L-HCA response amplitude (94.2 +/- 1.4, n = 9) and the (2R,3R)-isomer 6 was inactive. Experiments designed to compare the agonist-potentiating actions of 7 and 8 in the neonatal rat spinal cord with L-trans-pyrrolidine-2,4-dicarboxylic acid, the well-known L-Glu uptake inhibitor, provided additional evidence for the selective enhancement of depolarizations due to L-HCA and not those due to L-Glu. This selective action supports the existence of multiple excitatory amino acid uptake sites.

Utilization of the resolved L-isomer of 2-amino-6-phosphonohexanoic acid (L-AP6) as a selective agonist for a quisqualate-sensitized site in hippocampal CA1 pyramidal neurons.

Brief exposure of rat hippocampal slices to quisqualic acid (QUIS) sensitizes neurons to depolarization by the alpha-amino-omega-phosphonate excitatory amino acid (EAA) analogues AP4, AP5 and AP6. These phosphonates interact with a novel QUIS-sensitized site. Whereas L-AP4 and D-AP5 cross-react with other EAA receptors, DL-AP6 has been shown to be relatively selective for the QUIS-sensitized site. This specificity of DL-AP6, in conjunction with the apparent preference of this site for L-isomers, suggested that the hitherto unavailable L-isomer of AP6 would be a potent and specific agonist. We report the resolution of the D- and L-enantiomers of AP6 by fractional crystallization of the L-lysine salt of DL-AP6. We also report the pharmacological responses of kainate/AMPA, NMDA, lateral perforant path L-AP4 receptors and the CA1 QUIS-sensitized site to D- and L-AP6, and compare these responses to the D- and L-isomers of AP3, AP4, AP5 and AP7. The D-isomers of AP4, AP5 and AP6 were 5-, 3- and 14-fold less potent for the QUIS-sensitized site than their respective L-isomers. While L-AP4 and L-AP5 cross-reacted with NMDA and L-AP4 receptors, L-AP6 was found to be highly potent and specific for the QUIS-sensitized site (IC50 = 40 microM). Its IC50 values for kainate/AMPA, NMDA and L-AP4 receptors were > 10, 3 and 0.8 mM, respectively. As with AP4 and AP5, sensitization to L-AP6 was reversed by L-alpha-aminoadipate.

Mouthguards. Protection for the mouth in rugby union.

The mouthguard is a resilient device or appliance which is placed inside the mouth to protect against injuries to the teeth, lacerations to the mouth and fractures and dislocations of the jaw. There is clear support in the scientific literature for the use of mouthguards in contact sports such as rugby. Moreover, there is evidence that mouthguards are effective in protecting against concussion and injuries to the cervical spine. There is a high level of acceptance of mouthguards by players and an increasing number are regularly wearing mouthguards. This is especially true among the elite players, but acceptance and wearing rates are moderately high among club players as well. There is strong support among players and researchers for mouthguard wearing to be made compulsory. It is generally recommended that: (i) mouthguards be worn during both practice sessions and games; (ii) the habit of wearing a mouthguard begins at an early age; (iii) mouthguards be regularly replaced while children are still growing; and (iv) adult players replace their mouthguards at least every 2 years. The selection of a mouthguard will depend on a number of factors including the age of the individual, effectiveness and cost. The type I (stock), or 'off-the-shelf', mouthguards are considered inferior when compared with the other available types, and their use is discouraged. Type II (mouth-formed) mouthguards come in 2 forms, the shell-liner version and the popular thermoplastic 'boil and bite' version. While the effectiveness of the shell-liner mouthguard was examined in one experimental study, no such research has been reported for the thermoplastic mouthguard. Type III (custom-fabricated) mouthguards are recommended for players playing in the more vulnerable positions and in the higher grades. Most experimental studies in which the effectiveness of mouthguards has been demonstrated have involved type III mouthguards.

The risky and protective motorcycling opinions and behaviours of young on-road motorcyclists in New Zealand.

This research documented the frequency of protective and risky motorcycling opinions and behaviours and investigated whether these opinions and behaviours were more frequently expressed by licensed than unlicensed riders and by riders with high rather than low exposure to motorcycling. Areas where there was scope for improvement were identified to help guide the promotion of protective strategies. As part of a broader study of a birth cohort, 217 18 year old motorcyclists were administered a motorcycling computer questionnaire. Evidence of positive protective opinions was found, but there was considerable scope for behavioural improvements. While 92% had worn a helmet, optimal protection was reported less frequently for other body areas: most often for the feet (54%), hands (47%) and upper body (35%) and least often for the legs (8%). Most (87%) riders considered conspicuity increased safety, 68% favoured mandatory day-time headlight use, and 66% used dipped headlights in day-time. While 55% favoured mandatory wearing of high-visibility clothing, only 15% of day-time and 20% of night-time riders reported doing this. During the past month, 16% had driven within two hours of drinking alcohol and 6% when too tired to be fully in control. Overall, 22% had been penalized for a motorcycle driving offence, most often speeding. While 46% said they agreed with the Graduated Driver Licensing System (GDLS), most licensed under that system reported breaking licence conditions and most were not apprehended. Licensed motorcyclists were significantly more likely than the unlicensed to favour mandatory day-time headlight usage, report using dipped headlights in day-time, and wear better protection for the head, upper body and hands, but were also more likely to report drinking and driving and traffic convictions--probably because of their greater exposure. Other, non-significant, results were in the same direction, except that fewer licensed than unlicensed riders were in favour of mandatory high visibility clothing or the GDLS. A similar pattern of more protective attitudes and behaviours was found for high rather than low exposure riders, though it was generally weaker, and high exposure was associated with drinking and driving, driving while tired and traffic convictions. The issues of representativeness and reliability are discussed and some implications for public policies towards motorcycling by young people are considered. Further research is recommended in order to determine which are the best predictors of motorcycling opinions and behaviours: personal characteristics, the formal training associated with licensure, or exposure to motorcycling.

Psychological and social predictors of motorcycle use by young adult males in New Zealand.

Motorcycle riding is a significant cause of serious injuries to young males. Little is known about the psychological and social characteristics of these riders, despite such knowledge being potentially important for the targeting of appropriate injury prevention interventions. Using problem-behaviour theory to broadly guide and structure the research, the present study focused on identifying predictors of motorcycle riding. Previous research investigating differences between riders and non-riders has tended to be inconclusive, methodologically limited, and lacking in explicit theoretical foundations. The present research was based on the birth cohort enrolled in the Dunedin Multidisciplinary Health and Development Study (DMHDS), a comprehensive New Zealand longitudinal study of health, development, attitudes, and behaviours. Logistic regression models were built using prior measures of health risk behaviour, other psychological and social factors, and motorcycle riding history as potential predictors of any motorcycle use at the age of 18 years. The strongest predictors were early motorcycle riding, including illegal on-road driving at age 13 (OR 4.0; 95% CI 1.7, 9.1), below average reading skills (OR 2.4; 95% CI 1.3, 4.6) and fighting in a public place at age 15 (OR 2.9; 95% CI 1.2, 6.9). It was of particular interest that this profile tended to fit less well those subgroups of riders with greatest exposure to on-road motorcycle driving. Although based on small numbers, this finding was consistent with earlier cross-sectional research that linked casual and unlicensed driving with less protective motorcycling opinions and behaviours. Some implications for injury prevention and public policies regarding motorcycling are discussed. In particular, stricter enforcement of present licensing regulations and stronger penalties for their violation could help to reduce the number of less responsible riders.

Use of protective equipment in a cohort of rugby players.

PURPOSE: To describe the level of usage of protective devices and equipment in a cohort of New Zealand rugby players. METHODS: Male and female players (N = 327) from a range of competitive grades were followed over the course of the season. Participants were interviewed weekly about their participation in rugby and use of protective equipment. The main outcome measure was percentage of all player-weeks of follow-up for which each equipment item was used. RESULTS: Mouthguards, the most commonly used equipment item, were worn for 64.9% of player-weeks. Mouthguard usage ranged from 55.0% of player-weeks in Schoolgirls grade to 72.9% of player-weeks in Senior A competition. The next most common item was taping of body joints (23.7% of player-weeks). The sites most commonly taped were the ankle, knee, and hand. Overall usage for the other protective equipment items studied (shin guards, padded headgear, head tape, support sleeves, and grease) was below 15%. In general, forwards had higher usage of protective equipment than backs, and male players had higher usage than female players. The most common self-reported reasons for using protective equipment were to prevent injury and because of a past injury. Players exhibited considerable week-to-week variation in their usage of protective equipment. CONCLUSIONS: In general, equipment usage was highest in those at greatest risk of injury, namely, forwards, male players, and the senior grades. The high voluntary use of mouthguards is encouraging and indicative of a base of player support for their role in this sport.

Rider training, reasons for riding, and the social context of riding among young on-road motorcyclists in New Zealand.

Serious injuries to young motorcyclists represent an important public health problem. Little is known about the opinions and behaviours of the young riders at risk. We document the training experiences of young motorcyclists, and their reasons for riding or discontinuing riding, and identify the role models and sources of disapproval of motorcycling. The research was part of a longitudinal study of health, development, attitudes and behaviours of a birth cohort. At age 18 years, cohort members who had ridden a motorcycle during the past year completed a comprehensive questionnaire. Initial riding instruction was rarely received from a qualified instructor but was usually informal, from a male friend or father, and occurred off the road, usually on a farm. The most commonly given reasons for riding were excitement and economy. Most motorcyclists who had ceased riding attributed this to the lack of access to a motorcycle, and few mentioned safety. Mothers were the main source of disapproval. The young riders were not a homogeneous group. More licensed than unlicensed riders said manoeuvrability in traffic and ease of parking were reasons for riding. Licensed motorcyclists had more friends who rode and were more likely than unlicensed riders to have received paternal instruction. Early informal training off the road may establish attitudes and behaviours inappropriate in a traffic context. The main reasons for motorcycling (excitement, economical and manoeuvrable transport, freedom from supervision) and for discontinuing riding (lack of access) indicate motivations that should be considered before implementation of injury prevention interventions.

Compliance of Dunedin school playground equipment with the New Zealand playground standard.

OBJECTIVE: Injuries resulting from falls from playground equipment are a public health concern in New Zealand. Like many other countries, New Zealand has a safety standard aimed at reducing the incidence and severity of these injuries by limiting the height from which children can fall from playground equipment and requiring the provision of impact-absorbing surfaces beneath equipment from which falls are possible. The purpose of this study was to examine progress towards achieving compliance with these requirements in Dunedin school playgrounds. METHODS: Sixty-two schools were audited over the summer of 1997/98 and information recorded on equipment type, maximum fall height, surface type, and depth of loose-fill surface materials. Comparisons were made with audits conducted in 1989 and 1981. RESULTS: Substantial increases in the amount of playground equipment and in the provision of impact-absorbing surfaces were observed. A small increase in compliance with the requirement that the maximum fall height of equipment not exceed 2.5 metres was also observed. CONCLUSIONS: Any gains in safety achieved through increased compliance with the height and surface requirements of the New Zealand Standard have been counteracted by the substantial increase in the amount of equipment available in playgrounds. IMPLICATIONS: A more drastic measure is needed to achieve a meaningful reduction in the incidence of injury following falls from playground equipment.

Evaluating Tackling Rugby Injury: the pilot phase for monitoring injury.

OBJECTIVE: To assess the suitability of two previously unused data sources for monitoring rugby injury throughout New Zealand. METHOD: Interviews were conducted with respondents sampled from players registered with the Rugby Football Unions (RFUs) and players claiming for rugby injuries from the Accident Rehabilitation and Compensation Insurance Corporation (ACC) in Auckland and Dunedin. RESULTS: Of the 500 RFU players sampled, 63% were interviewed and of these 39 (12%) had been injured playing rugby union. Of the 456 ACC claimants sampled, 66% were interviewed and 265 (88%) had been injured playing rugby union. CONCLUSION: Identifying injured players through ACC claims was more efficient, both procedurally and because a smaller sample size was required to detect changes in incidence. IMPLICATIONS: With no routine surveillance of sports injury being undertaken, recording sporting codes in national injury surveillance systems would assist the monitoring of sports injury.

Falls from moving motor vehicles in New Zealand.

Injuries due to falls from moving motor vehicles have received relatively little attention from the research community. Injury events of this type in New Zealand were examined using national injury mortality and hospitalisation data from the New Zealand National Health Statistics Centre (NHSC). Also used were data obtained from the New Zealand Post Motor Registration Centre and from coroner's investigation reports held by the Department of Justice. Fifty-six fatal falls from moving motor vehicles occurred during the period 1977-1986 (0.18 per 100,000 population per year). The average age of fatalities was 23. The total potential years of life lost due to these fatalities was 2,696, or an average of 48 years per person. Thirty-nine persons (70%) fell while riding on the exterior of a vehicle. None of the 56 fatalities was using a belt restraint when he/she fell. Four hundred and twenty-three admissions to hospital occurred during 1986 and 1987 (6.5 per 100,000 persons per year). The average age of those hospitalised was 18. Incidence rates were highest in the 0-4, 15-19, and 20-24 year age groups. In the case of both deaths and hospitalisations, the incidence rate for males was approximately double the rate for females. In addition, the rate of falls (per unit registered motor vehicle) from trucks was significantly higher than the rate of falls from cars. Means of preventing falls from motor vehicles are discussed.

Biomechanical analysis of arm fracture in obese boys.

OBJECTIVE: To determine the role of the biomechanical factors of force of impact, bone strength, fall height and surface stiffness on the risk of forearm fracture in obese children compared to non-obese children. METHODOLOGY: Anthropometric and dual-energy X-ray absorptiometry bone density data from 50 boys (25 obese pair-matched with 25 non-obese subjects) aged 4-17 years were entered into a rheological-stochastic simulation model of arm impact. RESULTS: Obese children were shown to be at 1.7 times greater risk of fracture compared to non-obese children. Lower fall heights and softer impact surfaces were found not to reduce the relative risk of fracture between obese and non-obese children. CONCLUSIONS: Environmental modifications are unlikely to lower the risk of arm fracture in obese children to the same levels experienced by non-obese children. The best option available for obese children to reduce fracture risk is to take steps to attain a healthy bodyweight.

Place of occurrence of injury events in New Zealand compared with the available ICD codes.

The distribution of the place of occurrence of selected injury events in New Zealand was compared with the allocation of place of occurrence codes in the International Classification of Disease (ICD). National injury mortality and morbidity data for 1984 were upgraded to provide more specific information on the location of injury events than is allowed by the ICD codes. This highlighted a number of shortcomings in the ICD codes. For example, whereas only 0.1% of the injury morbidity occurred in a mine or quarry, 57 times that amount occurred on a rugby league ground. Despite this, mines and quarries have a unique code and rugby grounds are included under the general code "place for recreation and sport". Several modifications to existing codes are proposed. The lack of mutually exclusive categories, the confusion of activity with place of occurrence, and restrictions in the recommended use of the codes are discussed.

Tackling Rugby injury: lessons learned from the implementation of a five-year sports injury prevention program.

Rugby Union football is a very popular sport in New Zealand but of all the major sports played in that country, it has the highest reported incidence of injury. In 1995, a national rugby injury prevention program was instigated to address this problem. Known as Tackling Rugby Injury, this multifaceted program was implemented over a five-year period. The program was based on the results of a prospective cohort study of rugby injury, known as the Rugby Injury and Performance Project (RIPP), and was organised around seven themes, five relating to the prevention of injury: coaching, fitness, injury management, tackling, and foul play, and two relating to the implementation and evaluation of the program. The purpose of this paper is to describe the lessons learned from the implementation of Tackling Rugby Injury. Qualitative research methods were used to describe the process of implementation, including informant interviews, participant observation, and the scrutiny of written, visual and archival material. Among the lessons learned were the importance of basing injury prevention strategies on scientific evidence rather than popular belief, the difficulty in implementing complex interventions, the advantages of a formal agreement between partners in the implementation of a program, the central role played by coaches in promoting injury prevention strategies, and the value of describing the process of implementation as well as monitoring injury outcomes and changes in knowledge, attitudes and behaviour. It is hoped that other sports wishing to develop injury prevention programs can learn from this experience.

Rugby headgear study.

A two year randomised controlled trial of headgear in Rugby Union football is being conducted in Sydney, Australia. This paper gives an overview of this study in progress and presents results related to the development and laboratory performance of the headgear. The study commenced in 2002. Participants recruited to the study are in the under 13, 15, school open (U18) and colts age groups. There are three study arms: control, IRB-approved headgear, and modified headgear. The IRB approved headgear is a popular model in rugby, the Canterbury Honeycomb model manufactured by BodyArmour in New Zealand. The dimensions of this model were altered by increasing foam density and thickness to produce the modified headgear. In impact energy attenuation tests of 15 and 20 Joules onto a flat anvil, the modified headgear demonstrated average maximum headform accelerations of 23% and 33% of the standard model, respectively. Whether or not this improvement translates into reductions in injury will be determined by a comparison of the rates and severities of head injuries across study arms. Furthermore, these dimensional changes may not be acceptable to rugby players. Player attitudes towards safety and the use of protective clothing, injury history, experience and on-field behaviour will be examined via structured pre- and end of season surveys and analysis of match video.