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Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI.To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs).A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with5 patients, review articles, or animal studies were excluded from our analysis.After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review.Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.

Background with rationale Traumatic spinal injuries (TSI) include column fractures, spinal cord injury, or both. They are among the most severe injuries with potential long-term physical, psychological, and social consequences. Primary causes of TSIs are falls and motor vehicle crashes, however, mental illness and substance use are known to significantly increase all injury risk. Injury is also known to increase risks of mental deterioration and physical complications including self-harm and self-neglect. Main Aim We aimed to identify comorbid mental illness and/or substance use at incident TSI, quantifying associated costs and health service management of these inequities. Methods NSW record-linkage administrative data analyses (2013-2016) will determine accurate prevalence of mental illness and/or substance use disorder among all patients who sustained acute TSI during the study period. Using recurrent event analyses, we will estimate the contributions of mental illness and/or substance use disorder on the impact on hospital acquired complications (HAC), length of stay and costs; assessing records for social work and/or psychologist consultation. Results 13,489 individuals were hospitalised with acute TSI; 21% had either mental health and/or substance use diagnoses; 8.7% had both. These patients were more likely to have experienced falls or intentional self-harm, be male and have multiple comorbidity. Acute care stay and costs were on average twice that of patients with TSI without mental health and/or substance use diagnoses; additionally they were more than twice as likely to experience HACs. Only 56% of TSI patients with these comorbid conditions in the context of TSI, had documented social work or psychologist consultation. Conclusion Patients with mental illness and/or substance use disorder, experience significant health disparities that require concerted health system attention that should begin early in acute care.

Background: Addressing policy change in traumatic injury care demands a strong evidence base from which to inform necessary amendments, and measure the impact of any change. Current recommendations for acute traumatic spinal cord injury include admission to a specialist Spinal Cord Injury Unit within 24 hours from injury. This study aimed to document pathways for patients with traumatic spinal cord injury across a state-wide Health Service in a historical cohort, prior to and in order to inform trauma policy changes. Methods: Retrospective analysis of a large Ambulance service record-linked dataset, containing 2.04 million Ambulance records linked with hospital and death records (2006-09). Incident cases of traumatic spinal cord injury were identified using ICD-10-AM codes. Multivariate analysis aimed to identify factors associated with admission to specialist units within 24 hours. Results: Of 311 patients with confirmed traumatic spinal cord injury, 177 (56.9%) were admitted to a specialist Spinal Cord Injury Unit, with 130 of these (73.4%) being within 24 hours post injury. The remaining 47 (26.6%) had up to several months delayed transfer to SCIU. Patients were significantly more likely to have timely admission to SCIU with a cervical level cord injury (OR 2.05), aeromedical transfer to a specialist unit (OR 2.5), outer regional geographic location of injury (OR 2.05), or a surgical spinal procedure within 24 hours (OR 3.1). Patients were significantly less likely to be admitted to a specialist unit within 24 hours were those who experienced more than one hospital transfer (OR 0.28), and patients >75 years (OR 0.35). Conclusion: Historically across this state-wide Health Service, patients with traumatic spinal cord injury did not experience consistent treatment pathways. Publication of this study importantly provides a baseline from which changes to clinical policies that have occurred since 2009 can be evaluated.

The risk of suicidal behaviour in Australia varies by age, sex, sexual preference and Indigenous status. Suicide stigma is known to affect suicide rates and help-seeking for suicidal crises. The aim of this study was to investigate the sociodemographic correlates of suicide stigma to assist in prevention efforts. We surveyed community members and individuals who had attended specific emergency departments for suicidal crisis. The respondents were part of a large-scale suicide prevention trial in New South Wales, Australia. The data collected included demographic characteristics, measures of help-seeking and suicide stigma. The linear regression analyses conducted sought to identify the factors associated with suicide stigma. The 5426 participants were predominantly female (71.4%) with a mean (SD) age of 41.7 (14.8) years, and 3.9% were Indigenous. Around one-third of participants reported a previous suicide attempt (n = 1690, 31.5%) with two-thirds (n = 3545, 65.3%) seeking help for suicidal crisis in the past year. Higher stigma scores were associated with Indigenous status (β 0.123, 95%CI 0.074–0.172), male sex (β 0.527, 95%CI 0.375–0.626) and regional residence (β 0.079, 95%CI 0.015–0.143). Lower stigma scores were associated with younger age (β −0.002, 95%CI −0.004–−0.001), mental illness (β −0.095, 95%CI −0.139 to −0.050), male bisexuality (β −0.202, 95%CI −0.351 to −0.052) and males who glorified suicide (β −0.075, 95%CI −0.119 to −0.031). These results suggested that suicide stigma differed across the community, varying significantly by sex, sexual orientation and Indigenous status. Targeted educational programs to address suicide stigma could assist in suicide prevention efforts.

This study illustrates the application of a tri-axial accelerometer and gyroscope sensor device on a trampolinist performing the walking-the-wall manoeuvre on a high-performance trampoline to determine the performer dynamic conditions. This research found that rigid vertical walls would allow the trampolinist to obtain greater control and retain spatial awareness at greater levels than what is achievable on non-rigid vertical walls. With a non-rigid padded wall, the reaction force from the wall can be considered a variable force that is not constrained, and would not always provide the feedback that the trampolinist needs to maintain the balance with each climb up the wall and fall from height. This research postulates that unattenuated vertical walls are safer than attenuated vertical walls for walking-the-wall manoeuvres within trampoline park facilities. This is because non-rigid walls would provide higher g-force reaction feedback from the wall, which would reduce the trampolinist’s control and stability. This was verified by measuring g-force on a horizontal rigid surface versus a non-rigid surface, where the g-force feedback was 27% higher for the non-rigid surface. Control and stability are both critical while performing the complex walking-the-wall manoeuvre. The trampolinist experienced a very high peak g-force, with a maximum g-force of approximately 11.5 g at the bottom of the jump cycle. It was concluded that applying impact attenuation padding to vertical walls used for walking-the-wall and similar activities would increase the likelihood of injury, therefore, padding of these vertical surfaces is not recommended.

Background To describe pre-hospital, emergency department and acute care assessment and management practices of senior clinicians for patients with acute traumatic spinal cord injury (TSCI) across Australia; and to describe clinical practice variation. Methods We used a descriptive, cross-sectional study design to survey senior clinicians (greater than 10 years practice in this field) caring for patients with acute TSCI. The assessment, management and referral practices of prehospital, emergency department/trauma and surgical expert clinicians, across prehospital, early hospital care, diagnostic imaging and haemodynamic management were surveyed. Results We invited 95 eligible senior clinicians; the response rate was 75%. Survey findings demonstrated overall lack of awareness or consistent use of evidence based published guidelines; many clinicians following ‘locally written’ or ‘no particular’ guideline. Practitioners were conflicted across multiple areas including patient assessment and diagnosis, treatment and transport decisions. Reported spinal immobilisation practices differed substantially, as did target setting for blood pressure; the majority of clinicians actively monitored risk of respiratory deterioration. Specialist care consult and specialist service bed availability was reported as problematic by more than one third of clinicians. Conclusions Unwarranted clinical practice variation is known to contribute to different health outcomes for patients with similar etiologies. Clinical practice guidelines offer evidence based, best practice standards, however are only effective if adopted throughout the healthcare system. Wide variability in acute care practices, pathways and timing to specialist centres for TSCI was evidenced by this survey despite seniority among clinicians. This devastating injury requires prompt, consistent, evidence based care from the moment of first responder. Improved outcomes for patients with TSCI would be more likely with standardised care across pre-hospital, emergency and acute care phases of care. Keywords Spinal Cord Injuries, Multiple Trauma, Practice Guideline, Treatment Outcome, Surveys and Questionnaires, Expert Testimony

Background Serious injuries and fatalities among vulnerable road users on two wheeled motorised vehicles have increased across Australia and internationally in the past decade yet fallen for motor vehicle occupants. Almost half of all reported motorcycle injury crashes cause serious injury or death, nearly double that of motor vehicle police-reported crashes. This study explores associations with sociodemographic and pre-injury health characteristics and health outcomes after a road traffic injury; aiming to compare motorcyclists with other road users and inform recovery care. Methods An inception cohort study recruited 1854 individuals aged > 17 years, injured following land-transport crashes in New South Wales, Australia (July 2013–November 2016). Interviews conducted at baseline, 6-and 12-months post-injury elicited demographic, socioeconomic, and self-reported health conditions. Results Primary analysis involved 1854 participants who were recruited at baseline as three distinct road user groups; 628 (33.9%) motorcyclists, 927 (50%) vehicle occupants and 299 (16.1%) bicyclists. At baseline, injury patterns differed significantly between road user groups; motorcyclists were more than twice as likely to sustain lower extremity injury (p p p p = 0.002) and reported lower pain scores (− 0.51 (− 0.83, − 0.2), p Conclusions Road user types differ in important characteristics, including pre-injury health status and recovery after injury. As vulnerable road users experiencing transport crash and considering their higher initial injury severity, the degree of recovery among motorcyclists compared with other user types is remarkable and unexplained. Health and recovery outcomes after land-transport crashes is least favourable among vehicle occupants despite their higher levels of protection in a crash. This information is valuable for targeting early intervention strategies by road user type during the post-crash care phase, to improve long-term recovery.

Background Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. Methods This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013–2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. Results Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p p p p p p p = 0.05) with lower levels of injury (p p Conclusions Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.

BackgroundTimely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 hours from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 hours from injury.MethodsThis record linkage study included administrative pre-hospital, admissions and costs data for all patients aged ≥16 years with incident TSCI in NSW (2013-2016). Its aim was to examine potential geographical disparities in access to specialist care following TSCI using geospatial methods, and to better understand the impact of post-injury care pathways on patient outcomes.ResultsOf 316 cases with geospatial data, injury location analysis showed that over half (53%, n=168) of all patients were injured within 60 minutes road travel of a SCIU, yet only 28.6% (n=48) were directly transferred to a SCIU. Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, pConclusionsGetting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 minutes radius, enabling the benefits of specialised care.

ObjectiveThe aim of this study was to estimate the difference between treatment costs in acute care settings and the level of funding public hospitals would receive under the activity-based funding model. MethodsPatients aged ≥16 years who had sustained an incident traumatic spinal cord injury (TSCI) between June 2013 and June 2016 in New South Wales were included in the study. Patients were identified from record-linked health data. Costs were estimated using two approaches: (1) using District Network Return (DNR) data; and (2) based on national weighted activity units (NWAU) assigned to activity-based funding activity. The funding gap in acute care treatment costs for TSCI patients was determined as the difference in cost estimates between the two approaches. ResultsOver the study period, 534 patients sustained an acute incident TSCI, accounting for 811 acute care hospital separations within index episodes. The total acute care treatment cost was estimated at A$40.5 million and A$29.9 million using the DNR- and NWAU-based methods respectively. The funding gap in total costs was greatest for the specialist spinal cord injury unit (SCIU) colocated with a major trauma service (MTS), at A$4.4 million over the study period. ConclusionsThe findings of this study suggest a substantial gap in funding for resource-intensive patients with TSCI in specialist hospitals under current DRG-based funding methods. What is known about the topic?DRG-based funding methods underestimate the treatment costs at the hospital level for patients with complex resource-intensive needs. This underestimation of true direct costs can lead to under-resourcing of those hospitals providing specialist services. What does this paper add?This study provides evidence of a difference between true direct costs in acute care settings and the level of funding hospitals would receive if funded according to the National Efficient Price and NWAU for patients with TSCI. The findings provide evidence of a shortfall in the casemix funding to public hospitals under the activity-based funding for resource-intensive care, such as patients with TSCI. Specifically, depending on the classification system, the principal referral hospitals, the SCIU colocated with an MTS and stand-alone SCIU were underfunded, whereas other non-specialist hospitals were overfunded for the acute care treatment of patients with TSCI. What are the implications for practitioners?Although health care financing mechanisms may vary internationally, the results of this study are applicable to other hospital payment systems based on diagnosis-related groups that describe patients of similar clinical characteristics and resource use. Such evidence is believed to be useful in understanding the adequacy of hospital payments and informing payment reform efforts. These findings may have service redesign policy implications and provide evidence for additional loadings for specialist hospitals treating low-volume, resource-intensive patients.

Background Risk of traumatic injury is increased in individuals with mental illness, substance use disorder and dual diagnosis (mental disorders); these conditions will pre-exist among individuals hospitalised with acute traumatic spinal injury (TSI). Although early intervention can improve outcomes for people who experience mental disorders or TSI, the incidence, management and cost of this often complex comorbid health profile is not sufficiently understood. In a whole population cohort of patients hospitalised with acute TSI, we aimed to describe the prevalence of pre-existing mental disorders and compare differences in injury epidemiology, costs and inpatient allied health service access. Methods Record linkage study of all hospitalised cases of TSI between June 2013 and June 2016 in New South Wales, Australia. TSI was defined by specific International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes. Mental disorder status was considered as pre-existing where specific ICD-10-AM codes were recorded in incident admissions. Results 13 489 individuals sustained acute TSI during this study. 13.11%, 6.06% and 1.82% had pre-existing mental illness, substance use disorder and dual diagnosis, respectively. Individuals with mental disorder were older (p Conclusion Individuals hospitalised for TSI with pre-existing mental disorder have greater likelihood of increased injury severity and more complex, costly acute care admissions compared with individuals without mental disorder. Care pathway optimisation including prevention of hospital-acquired complications for people with pre-existing mental disorders hospitalised for TSI is warranted.

This study aimed to measure the subsequent health and health service cost burden of a cohort of workers hospitalised after sustaining work-related traumatic spinal injuries (TSI) across New South Wales, Australia. A record-linkage study (June 2013&ndash, June 2016) of hospitalised cases of work-related spinal injury (ICD10-AM code U73.0 or workers compensation) was conducted. Of the 824 individuals injured during this time, 740 had sufficient follow-up data to analyse readmissions &le, 90 days post-acute hospital discharge. Individuals with TSI were predominantly male (86.2%), mean age 46.6 years. Around 8% (n = 61) experienced 119 unplanned readmission episodes within 28 days from discharge, over half with the primary diagnosis being for care involving rehabilitation. Other readmissions involved device complications/infections (7.5%), genitourinary or respiratory infections (10%) or mental health needs (4.3%). The mean &plusmn, SD readmission cost was $6946 &plusmn, $14,532 per patient. Unplanned readmissions shortly post-discharge for TSI indicate unresolved issues within acute-care, or poor support services organisation in discharge planning. This study offers evidence of unmet needs after acute TSI and can assist trauma care-coordinators&rsquo, comprehensive assessments of these patients prior to discharge. Improved quantification of the ongoing personal and health service after work-related injury is a vital part of the information needed to improve recovery after major work-related trauma.

Study Design. Record linkage study using healthcare utilization and costs data. Objective. To identify predictors of higher acute-care treatment costs and length of stay for patients with traumatic spinal cord injury (TSCI). Summary of Background Data. There are few current or population-based estimates of acute hospitalization costs, length of stay, and other outcomes for people with TSCI, on which to base future planning for specialist SCI health care services. Methods. Record linkage study using healthcare utilization and costs data; all patients aged more than or equal to 16 years with incident TSCI in the Australian state of New South Wales (June 2013–June 2016). Generalized Linear Model regression to identify predictors of higher acute care treatment costs for patients with TSCI. Scenario analysis quantified the proportionate cost impacts of patient pathway modification. Results. Five hundred thirty-four incident cases of TSCI (74% male). Total cost of all acute index episodes approximately AUD$40.5 (95% confidence interval [CI] 4.5) million; median cost per patient was AUD$45,473 (Interquartile Range: $15,535–$94,612). Patient pathways varied; acute care was less costly for patients admitted directly to a specialist spinal cord injury unit (SCIU) compared with indirect transfer within 24 hours. Over half (53%) of all patients experienced at least one complication during acute admission; their care was less costly if they had been admitted directly to SCIU. Scenario analysis demonstrated that a reduction of indirect transfers to SCIU by 10% yielded overall cost savings of AUD$3.1 million; an average per patient saving of AUD$5,861. Conclusion. Direct transfer to SCIU for patients with acute TSCI resulted in lower treatment costs, shorter length of stay, and less costly complications. Modeling showed that optimizing patient-care pathways can result in significant acute-care cost savings. Reducing potentially preventable complications would further reduce costs and improve longer-term patient outcomes. Key words: complications, costs, length of stay, record linkage, traumatic spinal cord injury.

Suicide prevention strategies internationally appear to be falling short of making a meaningful impact on global suicide deaths. Increasing the rates of general community participation in suicide research may improve knowledge generalisability as it relates to suicidal behaviour and leads to new suicide prevention approaches. This study aims to explore the motivations of a community-based sample to participate in suicide research. A subsample of the Australian general population took part in an online survey which is part of a multilevel suicide prevention trial. The survey concluded with an optional open-text question asking about peoples’ motivations for participating in the study, 532 participants left a response to this question. These responses were qualitatively analysed using Thematic Network Analysis. Motivations to participate in suicide research were represented by four global themes: altruism, solve systemic problems, lived experience, and personal benefit. Of these themes, three were focused on the benefit of others, while only the final theme articulated motivation to participate that was self-focused. The impact of suicide is felt throughout the wider community. This new understanding of the motivations of community-based samples to participate in suicide research should be used to increase participation rates and reach people who would not normally contribute their voice to suicide research.

IntroductionTraumatic spinal cord injuries have significant consequences both for the injured individual and the healthcare system, usually resulting in lifelong disability. Evidence has shown that timely medical and surgical interventions can lead to better patient outcomes with implicit cost savings. Potentially preventable secondary complications are therefore indicators of the effectiveness of acute care following traumatic injury. The extent to which policy and clinical variation within the healthcare service impact on outcomes and acute care costs for patients with traumatic spinal cord injury (TSCI) in Australia is not well described.Methods and analysisA comprehensive data set will be formed using record linkage to combine patient health and administrative records from seven minimum data collections (including costs), with an existing data set of patients with acute TSCI (Access to Care Study), for the time period June 2013 to June 2016. This person-level data set will be analysed to estimate the acute care treatment costs of TSCI in New South Wales, extrapolated nationally. Subgroup analyses will describe the associated costs of secondary complications and regression analysis will identify drivers of higher treatment costs. Mapping patient care and health service pathways of these patients will enable measurement of deviations from best practice care standards and cost-effectiveness analyses of the different pathways.Ethics and disseminationEthics approval has been obtained from the New South Wales Population and Health Services Research Ethics Committee. Dissemination strategies include peer-reviewed publications in scientific journals and conference presentations to enable translation of study findings to clinical and policy audiences.

This study aimed to describe the epidemiological characteristics, the occupational context, and the cost of hospitalised work-related traumatic spinal injuries, across New South Wales, Australia. A record-linkage study of hospitalised cases of work-related spinal injury (ICD10-AM code U73.0 or workers compensation) was conducted. Study period 2013&ndash, 2016. Eight hundred and twenty-four individuals sustained work-related spinal injuries, 86.2% of whom were males and had a mean age of 46.6 years. Falls led to 50% of the injuries, predominantly falls from building/structures, ladders or between levels. Falls occurred predominantly in the construction industry (78%). Transport crashes caused 31% of injuries and 24% in heavy vehicles. Half of all the transport injuries occurred &lsquo, off road&rsquo, The external cause was coded as &lsquo, non-specific work activity&rsquo, in 44.5% of cases, missing in 11.5%. Acute care bed days numbered at 13,302, total cost $19,500,000. High numbers of work-related spinal injuries occurred in the construction industry, particularly falling from a height. Off-road transport-related injuries were significant and likely unaddressed by &lsquo, on-road&rsquo, prevention policies. Medical record documentation was insufficient in injury mechanism and context specificity. Workers in the construction industry or those using vehicles off-road were at high risk of spinal injury, suggesting inefficient systems approaches or ineffective prevention policies. Reducing the use of non-specific external cause codes in patients&rsquo, medical records would improve the measurement of policy effectiveness.

OBJECTIVE: Evidence-based management for patients with acute traumatic spinal cord injury (TSCI) in the ED has a critical impact on long-term outcomes. Acute hypotension post-injury may compromise spinal cord perfusion and extend neurological damage. Published guidelines recommend mean arterial blood pressure (BP) maintenance between 85 and 90 mmHg for 7 days post-injury; the extent to which this is followed in Australia is unknown. METHODS: Prospective observational study of patients ≥16 years with TSCI, treated at 48 hospitals across two Australian states. Mean arterial BPs were recorded in the Ambulance, and ED arrival and discharge. Patients' medical records documented treatment provided (intravenous fluids, vasopressors or both) for BP augmentation. Hypotension was defined as mean arterial BP

© 2018 The Authors Objective: To quantify an apparent increase in indoor trampoline park related injuries in children and young people across Australia, and to understand the implications for current regulatory standards. Methods: Retrospective analyses of three state-based Injury Surveillance databases, identifying children and adolescents presenting to emergency departments between the years 2005 and 2017, who had sustained injuries during trampolining activity at an indoor trampoline park. Results: Across the three datasets, 487 cases were identified. No cases were recorded prior to 2012, the year the first indoor trampoline park opened. At least half occurred among those aged 10–14 years. In Victoria, 58% were male, with 52% in Queensland and 60% in Western Australia being male, respectively. Hospital admission rates in these states were 15%, 11.7% and 14.5%, respectively. The most frequent injury types were dislocations, sprains and strains, followed by fractures, with some head and spinal injuries. Conclusions: Across several states in Australia, the incidence of indoor trampoline park related injuries is concerning, as these venues are increasing in number. Some injuries can be serious and result in lifelong disability for children or adolescents. Implications for public health: National safety standards that apply to indoor trampoline park operators are not currently mandatory; injury prevention efforts would be assisted if such standards were mandatory.

To identify the predictors of traumatic spinal cord injury (TSCI) and describe the differences between confirmed and potential TSCI cases in the prehospital setting.A retrospective cohort study including all adult patients over a six-year period (2007-12) with potential TSCI who were attended and transported by Ambulance Victoria (AV). We extracted potential TSCI cases from the AV data warehouse and linked with the Victorian State Trauma Registry to compare with final hospital diagnosis.We included a total of 106,059 patients with potential TSCI in the study, with 257 having a spinal cord injury confirmed at hospital (0.2%). The median [First and third Quartiles] age of confirmed TSCI cases was 49 [32-69] years, with males comprising 84.1%. Confirmed TSCI were mainly due to falls (44.8%) and traffic incidents (40.5%). AV spinal care guidelines had a sensitivity of 100% to detect confirmed TSCI. There were several factors associated with a diagnosis of TSCI. These were meeting AV Potential Major Trauma criteria, male gender, presence of neurological deficit, presence of an altered state of consciousness, high falls (3 meters), diving, or motorcycle or bicycle collisions.This study identified several predictors of TSCI including meeting AV Potential Major Trauma criteria, male gender, presence of neurological deficit, presence of an altered state of consciousness, high falls (3 meters), diving, or motorcycle or bicycle collisions. Most of these predictors are included in NEXUS and/or CCR criteria, however, Potential Major Trauma criteria have not previously been linked to the presence of TSCI. Therefore, Emergency Medical Systems are encouraged to integrate similar Potential Major Trauma criteria into their guidelines and protocols to further improve the provider's accuracy in identifying TSCI and to be more selective in their spinal immobilization, thereby reducing unwarranted adverse effects of this practice.

Introduction Around 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year; a relatively low incidence injury with extremely high long-term associated costs. Care standards are inconsistent nationally, lacking in consensus across important components of care such as prehospital spinal immobilisation, timing of surgery and timeliness of transfer to specialist services. This study aims to develop ‘expertly defined’ and agreed standards of care across the majority of disciplines involved for these patients. Methods and analysis A modified e-Delphi process will be used to gain consensus for best practice across specific clinical early care areas for the patient with TSCI; invited participants will include clinicians across Australia with relevant and significant expertise. A rapid literature review will identify available evidence, including any current guidelines from 2005 to 2015. Level and strength of evidence identified, including areas of contention, will be used to formulate the first round survey questions and statements. Participants will undertake 2–3 online survey rounds, responding anonymously to questionnaires regarding care practices and indicating their agreement or otherwise with practice standard statements. Relevant key stakeholders, including patients, will also be interviewed face to face. Ethics and dissemination Ethics approval for this study was obtained by the NSW Population & Health Services Research Ethics Committee on 14 January 2016 (HREC/12/CIPHS/74). Seeking comprehensive understanding of how the variation in early care pathways and treatment can be addressed to achieve optimal patient outcomes and economic costs; the overall aim is the agreement to a consistent approach to the triage, treatment, transport and definitive care of acute TSCI victims. The agreed practice standards of care will inform the development of a Clinical Pathway with practice change strategies for implementation. These standards will offer a benchmark for state-wide and potentially national policy.

Objective: The study aimed to examine the difference in response rates between opt‐out and opt‐in participant recruitment in a population‐based study of heavy‐vehicle drivers involved in a police‐attended crash. Methods: Two approaches to subject recruitment were implemented in two different states over a 14‐week period and response rates for the two approaches (opt‐out versus opt‐in recruitment) were compared. Results: Based on the eligible and contactable drivers, the response rates were 54% for the opt‐out group and 16% for the opt‐in group. Conclusions and Implications: The opt‐in recruitment strategy (which was a consequence of one jurisdiction's interpretation of the national Privacy Act at the time) resulted in an insufficient and potentially biased sample for the purposes of conducting research into risk factors for heavy‐vehicle crashes. Australia's national Privacy Act 1988 has had a long history of inconsistent practices by state and territory government departments and ethical review committees. These inconsistencies can have profound effects on the validity of research, as shown through the significantly different response rates we reported in this study. It is hoped that a more unified interpretation of the Privacy Act across the states and territories, as proposed under the soon‐to‐be‐released Australian Privacy Principles1 will reduce the recruitment challenges outlined in this study.

Heavy-vehicle driving involves a challenging work environment and a high crash rate. We investigated the associations of sleepiness, sleep disorders, and work environment (including truck characteristics) with the risk of crashing between 2008 and 2011 in the Australian states of New South Wales and Western Australia. We conducted a case-control study of 530 heavy-vehicle drivers who had recently crashed and 517 heavy-vehicle drivers who had not. Drivers' crash histories, truck details, driving schedules, payment rates, sleep patterns, and measures of health were collected. Subjects wore a nasal flow monitor for 1 night to assess for obstructive sleep apnea. Driving schedules that included the period between midnight and 5:59 am were associated with increased likelihood of crashing (odds ratio = 3.42, 95% confidence interval: 2.04, 5.74), as were having an empty load (odds ratio = 2.61, 95% confidence interval: 1.72, 3.97) and being a less experienced driver (odds ratio = 3.25, 95% confidence interval: 2.37, 4.46). Not taking regular breaks and the lack of vehicle safety devices were also associated with increased crash risk. Despite the high prevalence of obstructive sleep apnea, it was not associated with the risk of a heavy-vehicle nonfatal, nonsevere crash. Scheduling of driving to avoid midnight-to-dawn driving and the use of more frequent rest breaks are likely to reduce the risk of heavy-vehicle nonfatal, nonsevere crashes by 2-3 times.

Background Heavy vehicle transportation continues to grow internationally; yet crash rates are high, and the risk of injury and death extends to all road users. The work environment for the heavy vehicle driver poses many challenges; conditions such as scheduling and payment are proposed risk factors for crash, yet the precise measure of these needs quantifying. Other risk factors such as sleep disorders including obstructive sleep apnoea have been shown to increase crash risk in motor vehicle drivers however the risk of heavy vehicle crash from this and related health conditions needs detailed investigation. Methods and Design The proposed case control study will recruit 1034 long distance heavy vehicle drivers: 517 who have crashed and 517 who have not. All participants will be interviewed at length, regarding their driving and crash history, typical workloads, scheduling and payment, trip history over several days, sleep patterns, health, and substance use. All participants will have administered a nasal flow monitor for the detection of obstructive sleep apnoea. Discussion Significant attention has been paid to the enforcement of legislation aiming to deter problems such as excess loading, speeding and substance use; however, there is inconclusive evidence as to the direction and strength of associations of many other postulated risk factors for heavy vehicle crashes. The influence of factors such as remuneration and scheduling on crash risk is unclear; so too the association between sleep apnoea and the risk of heavy vehicle driver crash. Contributory factors such as sleep quality and quantity, body mass and health status will be investigated. Quantifying the measure of effect of these factors on the heavy vehicle driver will inform policy development that aims toward safer driving practices and reduction in heavy vehicle crash; protecting the lives of many on the road network.

OBJECTIVE: Many authorities recommend screening adolescents for risk of suicide. The ED is a potential setting for such screening. The aim of this study is to explore the use of the Risk of Suicide Questionnaire (RSQ) as a screening tool for suicidality in patients who come to the ED without mental health concerns and without recent mental health history. The Suicide Ideation Questionnaire (SIQ) was the comparison standard. METHODS: A cross-sectional convenience sample of overtly psychiatrically asymptomatic adolescents presenting to a large paediatric ED underwent both the RSQ and SIQ. Adolescents with positive screens underwent formal assessment by mental health practitioners. RESULTS: Two hundred and one patients were identified and 110 consented to participate. One hundred participants completed both questionnaires. Twenty-two per cent of participants had positive RSQ (95% CI 14-31%). No adolescent yielded a positive SIQ: prevalence of suicidality was 0.0% (95% CI 0.0-3.6%). No participant showed suicidal ideation on formal review. One question in the RSQ - 'Has something very stressful happened to you in the past few weeks?' - accounted for the majority of false positive screens. CONCLUSION: The prevalence of suicidal ideation in asymptomatic patients presenting to this paediatric ED is very low. Using this selection method, the RSQ could not be validated, but would be unlikely to be suitable for screening this low-risk population with a high false positive rate. Language: en

STUDY OBJECTIVES: As obstructive sleep apnea (OSA) is associated with a higher risk of motor vehicle crashes, there is increasing regulatory interest in the identification of commercial motor vehicle (CMV) drivers with this condition. This study aimed to determine the relationship between subjective versus objective assessment of OSA in CMV drivers. DESIGN: Cross-sectional survey. SETTINGS: Heavy vehicle truck stops located across the road network of 2 large Australian states. PARTICIPANTS: A random sample of long distance commercial vehicle drivers (n = 517). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Drivers were interviewed regarding their driving experience, personal health, shift schedules, payments, and various questions on sleep and tiredness in order to describe their sleep health across a range of variables. In addition, home recordings using a flow monitor were used during one night of sleep. Only 4.4% of drivers reported a previous diagnosis of sleep apnea, while our at home diagnostic test found a further 41% of long-distance heavy vehicle drivers likely to have sleep apnea. The multivariable apnea prediction index, based on self-report measures, showed poor agreement with the home-monitor detected sleep apnea (AUC 0.58, 95%CI = 0.49-0.62), and only 12% of drivers reported daytime sleepiness (Epworth Sleepiness Scale score > 10). Thirty-six percent of drivers were overweight and a further 50% obese; 49% of drivers were cigarette smokers. CONCLUSIONS: Sleep apnea remains a significant and unrecognized problem in CMV drivers, who we found to have multiple health risks. Objective testing for this sleep disorder needs to be considered, as symptom reports and self-identification appear insufficient to accurately identify those at risk. CITATION: Sharwood LN; Elkington J; Stevenson M; Grunstein RR; Meuleners L; Ivers RQ; Haworth N; Norton R; Wong KK. Assessing sleepiness and sleep disorders in Australian long-distance commercial vehicle drivers: self-report versus an "at home" monitoring device. SLEEP 2012;35(4):469-475. Language: en

Introduction: Untreated sleep disorders can increase driver crash risk by up to 7 fold, and truck drivers have a variety of risk factors for sleep disorders. Measures currently used to identify drivers at risk depend predominantly on the ability of the driver to identify and report themselves as sleepy. Methods: This case report presents a 54 year old long distance truck driver who participated in a case-control study, underwent at home breathing monitoring and was followed up with an in-depth interview. Results: Self-reported measures did not identify this driver as at risk of sleepiness or sleep apnea; yet he was subsequently diagnosed with severe sleep apnea using an at home monitor and polysomnography. Conclusions: Self-assessment of risk factors is insufficient as a screen for sleep apnea. General practitioners are in an ideal position to identify potential sleep apnea sufferers and can initiate the enquiry process that leads to diagnostic testing.

Summary Introduction: The question of whether opioid analgesia should be given in patients with undifferentiated acute abdominal pain has been characterized by concerns about its efficacy and that signs used to determine accurate diagnosis may be masked by the drug. The objective of this review is to critically analyze pertinent pediatric randomized controlled studies considering this issue. Methods: A comprehensive literature search was conducted via Medline in October 2007, using the terms ‘abdominal pain’, ‘physical examination’, ‘analgesics’, ‘opioid’ and ‘appendicitis’. Other articles were identified using the bibliographies of papers found through Medline; alternate databases were searched but did not reveal additional studies. Results: A total of four trials were identified, and their validity and applicability were reviewed. In all studies, randomization to the analgesia group was associated with significant reduction in pain; one study showing no greater effect with opioid than placebo. All studies used a 10 cm Visual Analogue Scale to assess pain. All studies were only sufficiently powered to consider the primary outcome of opioid efficacy in abdominal pain vs placebo rather than diagnostic accuracy, although they all reported on diagnostic accuracy. Meta-analysis of results for efficacy and accuracy was not possible due to the heterogeneity of study populations. Conclusions: A large, probably multi-centred trial is needed to answer with sufficient power the question of whether opioid analgesia impairs diagnostic accuracy in children with undifferentiated acute abdominal pain.

OBJECTIVE: To quantify an anecdotally apparent increase in motorcycle-related injuries in children and adolescents across Victoria. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of paediatric motorcycle injuries (1 July 2000 - 30 June 2004) from a statewide emergency department (ED) database (Victorian Emergency Minimum Dataset [VEMD]) and the Trauma Registry database at the Royal Children's Hospital (RCH), Melbourne. MAIN OUTCOME MEASURES: Trends in paediatric motorcycle-related injuries over time; patient demographics, circumstances of accidents (on or off road), and injury characteristics, including severity markers. RESULTS: The VEMD recorded 3163 patients aged

OBJECTIVE To characterise the understanding of good clinical research practice (GCRP) among clinical researchers. DESIGN, PARTICIPANTS AND SETTING Survey of all staff within the largest clinical research group (Critical Care and Neurosciences) of a non-government research institute affiliated with a major children's hospital, between 1 April and 31 May 2007. MAIN OUTCOME MEASURES Staff's role and research activity; knowledge of relevant guidelines and translation into practice; GCRP training; and experience of research audits. RESULTS 122 of 154 research staff (79%) responded and were divided into three categories: clinicians (45%); research students/junior researchers (32%); and researchers (23%). While 60% of researchers reported they had read (at least in part) the two key Australian documents (the National statement on ethical conduct in human research and the Australian code for the responsible conduct of research), only 36% of clinicians and 30% of students/junior researchers stated they had done so. GCRP, such as obtaining consent and document storage, was only partially understood. 13% of all respondents had experienced a research project audit and 10% had undertaken formal GCRP training. Reasons given for the lack of GCRP training included insufficient resources, no training provided, and no time. 79% of staff felt that research auditing was important and 74% would like more education in GCRP. CONCLUSIONS Many clinical researchers are unaware of all the responsibilities involved in GCRP. A formal mandatory training program and GCRP auditing would be likely to improve practice.

The popularity of off-pump (beating heart) coronary artery bypass grafting (CABG) was initially stimulated by numerous theoretical benefits including lower incidence of stroke and neurocognitive dysfunction. With a postoperative stroke rate of less than 1% for elective CABG, it has been very difficult to demonstrate any significant differences in this outcome between techniques. However, changes in neurocognitive function are more common in the postoperative setting and thus provide greater power for demonstrating improvement with changes in surgical technique. The aim of this meta-analysis was to assess whether there were significant differences in neurocognitive outcomes in patients after undergoing off-pump versus on-pump CABG. A database search for prospective randomised controlled trials of off-pump versus on-pump CABG in any language was conducted. Eight trials incorporating 892 patients fulfilled all the inclusion criteria for reporting of neurocognitive outcomes, and were able to be included in this meta-analysis. Sufficient data were available across the seven studies to combine results for five neurocognitive tests (Rey Auditory Verbal Learning, Grooved Pegboard, Trail A and B, and Digit Symbol). Overall there were no convincing differences in outcomes in neurocognitive testing between off-pump and on-pump CABG groups. The results of this meta-analysis show that there are no significant neurocognitive benefits when comparing off-pump versus on-pump CABG.

OBJECTIVE. Nitrous oxide is an attractive agent for procedural sedation and analgesia in the emergency department; however, there are limited safety data for high-concentration continuous-flow nitrous oxide (50%–70%) and its use in young children. We set out to characterize the depth of sedation and incidence of adverse events associated with various concentrations of nitrous oxide used in a pediatric emergency department. METHODS. This was a prospective observational study of nitrous oxide use for procedural sedation and analgesia in a tertiary children's hospital emergency department. Nitrous oxide concentration, adverse events, and sedation depth were recorded. Adverse events were categorized as mild or serious. Sedation depth was recorded on a sedation scale from 0 to 6. RESULTS. A total of 762 patients who were aged 1 to 17 years received nitrous oxide during the 2-year study period. A total of 548 (72%) received nitrous oxide 70%, and 101 (13%) received nitrous oxide 50%. Moderate or deep sedation with scores of ≤2 occurred in 3% of patients who had received nitrous oxide 70% and no patients who had received nitrous oxide 50%. Mean sedation scores were 4.4 at nitrous oxide 70% and 4.6 at nitrous oxide 50%. Sixty-three (8.3%) patients sustained 70 mild and self-resolving adverse events, most of which were vomiting (5.7%); 2 (0.2%) patients had serious adverse events. There was no significant difference in adverse events rates between nitrous oxide 70% (8.4%) and nitrous oxide 50% (9.9%). There was no significant difference in the percentage of deep sedation when children who were ≤3 years of age (2.9%) were compared with older children (2.8%). CONCLUSIONS. In this largest prospective emergency department series, high-concentration continuous-flow nitrous oxide (70%) was found to be a safe agent for procedural sedation and analgesia when embedded in a comprehensive sedation program. Nitrous oxide also seems safe in children aged 1 to 3 years.

Original article published as "Sharwood LN; Elkington J; Stevenson M; Grunstein RR; Meuleners L; Ivers RQ; Haworth N; Norton R; Wong KK. Assessing sleep-iness and sleep disorders in Australian long-distance commercial vehicle drivers: self-report versus an “at home” monitoring device. SLEEP2012;35(4):469-475."

To improve care of adolescents in mental health crisis, the role of routine follow-up calls in discharged patients with referral plans after emergency department (ED) presentation to a children's hospital was explored. Main outcome measure was patient attendance at referral sites. In 113 mental health patients with follow-up appointments, either patient/carers or corresponding referral services could be contacted. Median age was 14 years, 77% were girls, and most presentations were after self-harm/depression (61%). Eighty-three per cent (95% CI 75% to 90%) were compliant with the discharge plan without prompting from the ED staff. Fourteen per cent (95% CI 8% to 22%) did not comply after being called by ED staff, and only 3% (95% CI 1% to 7%) were persuaded to attend their outpatient care after being prompted by ED staff. Routine follow-up calls for adolescent mental health patients after ED care are not warranted in all settings.

The question of whether opioid analgesia should be given in patients with undifferentiated acute abdominal pain has been characterized by concerns about its efficacy and that signs used to determine accurate diagnosis may be masked by the drug. The objective of this review is to critically analyze pertinent pediatric randomized controlled studies considering this issue.A comprehensive literature search was conducted via Medline in October 2007, using the terms 'abdominal pain', 'physical examination', 'analgesics', 'opioid' and 'appendicitis'. Other articles were identified using the bibliographies of papers found through Medline; alternate databases were searched but did not reveal additional studies.A total of four trials were identified, and their validity and applicability were reviewed. In all studies, randomization to the analgesia group was associated with significant reduction in pain; one study showing no greater effect with opioid than placebo. All studies used a 10 cm Visual Analogue Scale to assess pain. All studies were only sufficiently powered to consider the primary outcome of opioid efficacy in abdominal pain vs placebo rather than diagnostic accuracy, although they all reported on diagnostic accuracy. Meta-analysis of results for efficacy and accuracy was not possible due to the heterogeneity of study populations.A large, probably multi-centred trial is needed to answer with sufficient power the question of whether opioid analgesia impairs diagnostic accuracy in children with undifferentiated acute abdominal pain.

Objectives: Ketamine is an attractive agent for pediatric procedural sedation. There are limited data on time to discharge comparing intramuscular (IM) vs. intravenous (IV) ketamine. The authors set out to determine whether IM or IV ketamine leads to quicker discharge from the emergency department (ED) and how side effect profiles compare. Methods: All patients who had received ketamine IM or IV at a tertiary children’s hospital ED during the 3-year study period (2004–2007) were identified. Prospective sedation registry data, retrospective medical records, and administrative data were reviewed for drug dosages, use of additional agents, time of drug administration to discharge, total ED time (triage to discharge), and adverse events. A subgroup analysis for patients requiring five or fewer sutures (short suture group) was performed. Results: A total of 229 patients were enrolled (60% male) with median age of 2.8 years (IQR =1.8–4.3 years) and median weight of 15.7 kg (range = 8.7–74 kg). Ketamine was most frequently employed for laceration repair (80%) and foreign body removal (9%). Overall, 48% received ketamine IM and 52% received it IV. In the short-suture subgroup, 52% received ketamine IM, while 48% received it IV. Multivariate linear regression analysis determined time from drug administration to patient discharge as 21 minutes shorter for IV compared with IM administration, adjusted for age and number of additional doses (R2 = −0.35; 95% CI = −0.5 to −0.19; p

Study objective: Nitrous oxide (N 2 O) is an attractive agent for procedural analgesia and sedation of children in the emergency department (ED). Despite increasing use, efficacy data for painful procedures are limited. This study aimed to determine pain scores during ED procedural sedation with N 2 O in the ED setting. Methods: Prospective observational study of N 2 O use as a sole agent for procedural analgesia at a tertiary children’s hospital ED. Pain scores were obtained from patients and parents using visual analogue or faces scales, as appropriate. Parent and staff satisfaction with sedation and analgesia were assessed. Results: 124 children aged 1–17 years (mean 8.1) underwent procedural analgesia with N 2 O for 131 procedures. Most procedures were orthopaedic (44%) or laceration repair (30%). In 51% of patients (95% CI 42% to 60 to 23%) pain scores remained unchanged and in 34% (95% CI 26% to 43%) pain scores increased. Overall, 34% (95% CI 26% to 43%) patients had intraprocedural scores of 50 mm or greater and 21% (95% CI 14% to 29%) had pain scores of 70 mm or greater. Some procedures such as fracture reduction had a larger proportion of patients with high pain scores or 50 mm or greater (45%) and 70 mm or greater (29%). Staff rated both sedation and analgesia as “adequate” in 92%. Parents contacted in follow-up were satisfied or very satisfied with procedures in 96% and sedations in 93%. Conclusion: Data indicate that parents and staff are generally satisfied with N 2 O for procedural use in the ED. The efficacy of N 2 O as a sole agent in very painful procedures is limited.

Objective: Acute otitis media (AOM) is common in children, yet the optimal management of ear pain associated with AOM has not been well studied. We set out to determine the efficacy of topical aqueous 2% lignocaine eardrops compared with a placebo (saline) for pain relief of AOM in children. Design: Double-blind, randomised, placebo-controlled trial. Setting: Tertiary children’s hospital emergency department. Patients and interventions: Children aged between 3 and 17 years with earache and AOM without evidence of perforation were eligible. Patients were randomised to receive either 2% lignocaine or saline eardrops (placebo). Main outcome measures: Pain scores were measured before and after ear-drop administration. Patient and physician-interpreted pain scores were measured by using the Bieri faces pain scale and visual analogue scale at 10, 20 and 30 minutes. The primary outcome measure was reduction in patient-measured pain scores by 50% from the baseline. Secondary outcome measures were reduction in patient- measured pain scores by 25% or by at least two points. Telephone follow-up occurred after 1 day and 1 week. Analysis was by intention to treat. Results: 63 children (31 were treated with lignocaine, 32 with placebo) aged 3 to 12 years were enrolled. The groups were demographically and clinically similar, with similar proportions having received analgesia in the preceding 4 hours. Children receiving lignocaine showed significantly lower patient-measured pain scores with a reduction by 50% from baseline at 10 minutes (RR 2.06, 95% CI 1.03–4.11, p = 0.03) and 30 minutes (RR 1.44, 95% CI 1.07–1.93, p = 0.009) but not at 20 minutes (RR 1.35 95% CI 0.88–2.06). The response to lignocaine treatment showed significantly lower patient-measured pain scores for 25% reduction at all time points and for two-point reduction at 10 minutes and favoured lignocaine at 20 minutes and 30 minutes without reaching statistical significance. There were no serious adverse events during the 30 minute follow-up period. Conclusion: This study suggests that topical aqueous 2% lignocaine eardrops provide rapid relief for many young children presenting with ear pain attributed to AOM. The concurrent use of simple oral analgesia is a likely contributor to effective management of this painful childhood condition.

To quantify an anecdotally apparent increase in motorcycle-related injuries in children and adolescents across Victoria.Retrospective analysis of paediatric motorcycle injuries (1 July 2000 - 30 June 2004) from a statewide emergency department (ED) database (Victorian Emergency Minimum Dataset [VEMD]) and the Trauma Registry database at the Royal Children's Hospital (RCH), Melbourne.Trends in paediatric motorcycle-related injuries over time; patient demographics, circumstances of accidents (on or off road), and injury characteristics, including severity markers.The VEMD recorded 3163 patients agedor = 16 years presenting to EDs with motorcycle injuries during the study period; population-based rates of these injuries increased by an average of 9.6% per year (95% CI, 6.2%-13.1%; P0.005). In the same period, there was a total of 167 motorcycle-related admissions to the RCH, increasing annually in line with statewide ED presentations. About a quarter of paediatric motorcycle accidents occurred in children aged under 10 years (VEMD, 22%; RCH, 27%) and most occurred off road (VEMD,89%; RCH, 71%). At the RCH, median length of stay was 3 days (interquartile range [IQR], 1-7 days) and the median Injury Severity Score was 9 (IQR, 4-10); 41% of patients required an operation, 13% were admitted to an intensive care unit, and two died.In Victoria, the incidence of motorcycle-related injuries is increasing in children and adolescents. Most of these injuries occur off road, outside of any legislative framework. There is an urgent need for coordinated legislative changes and educational efforts to decrease motorcycle injuries in children.

We are writing in response to the editorial comment1 regarding our paper about the analgesic efficacy of nitrous oxide (N2O) in paediatric emergency department (ED) procedures.2 The editorial comment was headed “Nitrous is not enough” and stated that “nitrous oxide is not enough to provide adequate analgesia”. We would like to clarify further the utility of …

To determine whether there is an association between use of substances that contain caffeine and the risk of crash in long distance commercial vehicle drivers.Case-control study.New South Wales (NSW) and Western Australia (WA), Australia.530 long distance drivers of commercial vehicles who were recently involved in a crash attended by police (cases) and 517 control drivers who had not had a crash while driving a commercial vehicle in the past 12 months.The likelihood of a crash associated with the use of substances containing caffeine after adjustment for factors including age, health disorders, sleep patterns, and symptoms of sleep disorders as well as exposures such as kilometres driven, hours slept, breaks taken, and night driving schedules.Forty three percent of drivers reported consuming substances containing caffeine, such as tea, coffee, caffeine tablets, or energy drinks for the express purpose of staying awake. Only 3% reported using illegal stimulants such as amphetamine ("speed"); 3,4 methylenedioxymethamphetamine (ecstasy); and cocaine. After adjustment for potential confounders, drivers who consumed caffeinated substances for this purpose had a 63% reduced likelihood of crashing (odds ratio 0.37, 95% confidence interval 0.27 to 0.50) compared with drivers who did not take caffeinated substances.Caffeinated substances are associated with a reduced risk of crashing for long distance commercial motor vehicle drivers. While comprehensive mandated strategies for fatigue management remain a priority, the use of caffeinated substances could be a useful adjunct strategy in the maintenance of alertness while driving.

Background Traumatic spinal cord injury is a devastating condition impacting adversely on the health and wellbeing, functioning and independence, social participation and quality of life of the injured person. In Australia, there are approximately 15 new cases per million population per year; economic burden estimates suggest 2 billion dollars annually. For optimal patient outcomes expert consensus recommends expeditious transfer (“24 hours) in a Spinal Cord Injury Unit. Examining current health service and clinical intervention pathways in this Australian population-based sample, in relation to their outcomes, will provide an understanding of factors associated with patient flow, resource utilisation and cost, and patient and family quality of life. Barriers to streamlined effective early-care pathways and facilitators of optimal treatment for these patients will be identified.