Helmet use and risk of neck injury in skiers and snowboarders.

In a case-control study, the authors examined the relation between helmet use and neck injury among Québec, Canada, skiers and snowboarders using 10 years of ski patrol data (1995-1996 to 2004-2005). Cases were defined as persons with any neck injury (n = 2,986), an isolated neck injury requiring ambulance evacuation (n = 522), or a cervical spine fracture or dislocation (n = 318). The control group included persons with non-head, non-neck injuries (n = 97,408) in an unmatched analysis. The authors also matched cases with controls injured at the same ski area, during the same activity (skiing vs. snowboarding), and during the same season. Helmet use was the primary exposure variable. For the unmatched analysis, the authors used unconditional logistic regression and adjusted for clustering by ski area and other covariates. They used conditional logistic regression for the matched analysis. Multiple imputation was used to address missing values. The adjusted odds ratio was 1.09 (95% confidence interval (CI): 0.95, 1.25) for any neck injury, 1.28 (95% CI: 0.96, 1.71) for isolated ambulance-evacuated neck injuries, and 1.02 (95% CI: 0.79, 1.31) for cervical spine fractures or dislocations. Similar results were found in the conditional logistic regression analysis and in analyses restricted to children under age 11 years. These results do not suggest that helmets increase the risk of neck injuries among skiers and snowboarders.

Factors related to the frequency of citation of epidemiologic publications.

BACKGROUND: Previous studies have demonstrated that the frequency with which a publication is cited varies greatly. Our objective was to determine whether author, country, journal, or topic were associated with the number of times an epidemiological publication is cited. METHODS: We used outcome-based sampling and investigated one public health issue - child injury prevention, and one clinical topic - coronary artery disease (CAD) prevention. Using the Institute for Scientific Information's (ISI) Web of Science(R) databases, we limited searches to full articles involving humans published in English between 1998 and 2004. We calculated the citation rate and, after frequency-matching on year of publication, selected the 36 most frequently cited and 36 least frequently cited articles per year, for a total of 252 highly-cited and 252 infrequently-cited articles per topic area (child injury prevention and CAD prevention). RESULTS: Highly-cited articles in both CAD and child injury prevention were more likely to be published in medium or high impact journals or in journals with medium or high circulations. They were also more likely to be published by authors from U.S. institutions. Among articles examining CAD prevention, the highly-cited articles often involved risk factors, and the association between topics and frequency of citation persisted after adjusting for impact factor. Among articles addressing child injury prevention, topic was not statistically associated with citation. CONCLUSION: Journal and country appear to be the factors most strongly associated with frequency of citation. In particular, highly-cited articles are predominantly published in high-impact, high-circulation journals. The factors, however, differ somewhat depending on the area of research the journals represent. Among CAD prevention articles, for example, topic is also an important predictor of citation whereas the same is not true for articles addressing injury prevention. CONDENSED ABSTRACT: Our objective was to determine whether author, country, journal, or topic were associated with the number of times an epidemiological publication is cited. We used outcome-based sampling and investigated one public health issue, child injury prevention, and one clinical topic, coronary artery disease (CAD) prevention. Using the Institute for Scientific Information (ISI) Web of Science(R) databases, we limited searches to full articles involving humans published in English between 1998 and 2004. We calculated the citation rate and, after frequency-matching on year of publication, selected the 36 most frequently cited and 36 least frequently cited articles per year, for a total of 252 highly-cited and 252 infrequently-cited articles per topic area (child injury prevention and CAD prevention). Highly-cited articles in both CAD and child injury prevention were more likely to be published in medium or high impact journals or in journals with medium or high circulations. They were also more likely to be published by authors from U.S. institutions. Among articles examining CAD prevention, the highly-cited articles often involved risk factors, and the association between topics and frequency of citation persisted after adjusting for impact factor. Among articles addressing child injury prevention, topic was not statistically associated with citation.

Preventing product-related injuries: a randomized controlled trial of poster alerts.

BACKGROUND: The Product Safety Programme (PSP) of Health Canada is responsible for preventing product-related injuries. If PSP decides a product is dangerous, it can publicize its dangers, prohibit, or control its distribution; but for child products, the preferred option is to publicize its concerns. In the past, this included sending posters to paediatricians' offices and, more recently, placing alerts on the PSP website. This study examines the effectiveness of this process. METHODS: 15 Montreal paediatricians participated in a modified crossover randomized trial. During a randomly chosen intervention week, two product-related notices were posted in the paediatricians' waiting area. In the following or preceding week, these notices did not appear. Parents were interviewed by telephone to determine if they saw the posters and acted on the information received. RESULTS: We interviewed 808 parents (86%) of the 940 who agreed to participate. Of these, only 16% of the intervention and less than 1% of the control group reported seeing the posters. There were no differences in reported changes in behaviours related to the notices. These findings are unchanged after taking account of socio-economic status. No parents cited the posters, websites, or paediatricians as their main source of information about dangerous products. CONCLUSION: Product safety notices, whether sent to paediatricians' practices or posted on a website, cannot be relied upon to reach parents of preschool age children. Other approaches require consideration, such as increasing the power of PSP to regulate product safety.

Previous head injury is a risk factor for subsequent head injury in children: a longitudinal cohort study.

OBJECTIVE: The objective of this study was to determine whether children who sought care for a head injury were at greater risk of having a subsequent head injury within the following 6 and 12 months compared with children who sought care for an injury other than to the head. DESIGN/SETTING: This was a longitudinal cohort study conducted in the emergency departments of 2 Montreal (Quebec, Canada) pediatric hospitals. PARTICIPANTS: The parents of 11,867 injured children aged 1 to 18 years were interviewed by telephone at 6 (n = 10,315) and 12 (n = 9486) months after their child's injury to ascertain outcome (ie, subsequent head injury) and to provide information on potential risk factors (age, gender, chronic medical condition, activity level, and socioeconomic status). MAIN OUTCOME MEASURE: The outcome of interest was a head injury requiring medical attention within the following year ascertained by parental recall or physician claims data. RESULTS: A total of 245 and 386 previously head-injured children sustained a subsequent head injury within 6 and 12 months, respectively. Children who sought care for an initial head injury (n = 3599) were at higher risk of having a subsequent head injury within 6 months than children who sought care for an injury not to the head (n = 6716). The adjusted odds ratio suggested weak confounding by age, gender, and history of previous head injury. Results were consistent on the basis of physician claims data and 12-month follow-up interview data. CONCLUSIONS: These results provide evidence that having a head injury increases a child's risk of having a subsequent head injury. Although age, gender, and history of previous head injury confound the relationship, the effect remains substantial.

Home safety measures and the risk of unintentional injury among young children: a multicentre case-control study.

BACKGROUND: Young children may sustain injuries when exposed to certain hazards in the home. To better understand the relation between several childproofing strategies and the risk of injuries to children in the home, we undertook a multicentre case-control study in which we compared hazards in the homes of children with and without injuries. METHODS: We conducted this case-control study using records from 5 pediatric hospital emergency departments for the 2-year period 1995-1996. The 351 case subjects were children aged 7 years and less who presented with injuries from falls, burns or scalds, ingestions or choking. The matched control subjects were children who presented during the same period with acute non-injury-related conditions. A home visitor, blinded to case-control status, assessed 19 injury hazards at the children's homes. RESULTS: Hazards found in the homes included baby walkers (21% of homes with infants), no functioning smoke alarm (17% of homes) and no fire extinguisher (51% of homes). Cases did not differ from controls in the mean proportion of home hazards. After controlling for siblings, maternal education and employment, we found that cases differed from controls for 5 hazards: the presence of a baby walker (odds ratio [OR] 9.0, 95% confidence interval [CI] 1.1-71.0), the presence of choking hazards within a child's reach (OR 2.0, 95% CI 1.0-3.7), no child-resistant lids in bathroom (OR 1.6, 95% CI 1.0-2.5), no smoke alarm (OR 3.2, 95% CI 1.4-7.7) and no functioning smoke alarm (OR 1.7, 95% CI 1.0-2.8). INTERPRETATION: Homes of children with injuries differed from those of children without injuries in the proportions of specific hazards for falls, choking, poisoning and burns, with a striking difference noted for the presence of a baby walker. In addition to counselling parents about specific hazards, clinicians should consider that the presence of some hazards may indicate an increased risk for home injuries beyond those directly related to the hazard found. Families with any home hazard may be candidates for interventions to childproof against other types of home hazards.

Risk-compensation behavior in children: myth or reality?

OBJECTIVE: To assess risk compensation and risk homeostasis theory in children. DESIGN: We used a case-control study design in children aged 8 to 18 years who had an injury while participating in an activity that did or could entail the use of protective equipment (PE). SETTING: Montreal Children's Hospital emergency department from December 1, 2001, to November 30, 2002. PARTICIPANTS: We interviewed consenting children and compared the reports of risk-taking behaviors in those who did and those who did not report using PE. MAIN OUTCOME MEASURES: Indicators of risk-taking behavior and injury severity. RESULTS: A total of 674 children presented with injuries during the study, and 394 were interviewed (235 PE users and 159 nonusers). There was no evidence of an association between indicators of risk-taking behavior and PE use after adjusting for age, sex, personality, and type of activity and no relationship between injury severity and PE use. CONCLUSIONS: Results of this study provide no support for hypotheses about risk homeostasis theory among children using PE. The validity of the theory appears highly doubtful for children in this age range.

Hearing thresholds and tympanic membrane sequelae in children managed medically or surgically for otitis media with effusion.

OBJECTIVE: To determine the long-term effects of ventilation tube insertion on hearing thresholds and tympanic membrane pathologic abnormalities in children with otitis media with effusion. DESIGN: Prospective cohort study. SETTING: Tertiary care children's hospital, otorhinolaryngology and audiology service. PARTICIPANTS: Patients aged 8 to 16 years who participated in a randomized controlled trial of medical vs surgical (ventilation tube [VT]) treatment for recurrent otitis media with effusion at ages 2.5 to 7 years. MAIN OUTCOME MEASURES: Hearing thresholds and tympanic membrane sequelae. METHODS: One hundred thirteen of 125 children who had participated in the trial underwent blinded audiometric, tympanometric, otomicroscopic, and parental questionnaire evaluation 6 to 10 years following the trial. Thirty of 57 [corrected] medical subjects received ventilation tubes and 18 of 56 [corrected] VT subjects received more than 1 set of tubes. To evaluate sequelae risk associated with ventilation tubes independent of disease severity, we compared 27 medical subjects who never received ventilation tubes and 38 subjects randomized to VT who only received 1 set of tubes. RESULTS: Tympanic membrane pathologic abnormalities were present in 81% of VT subjects and 19% of medical subjects (relative risk, 4.4; 95% confidence interval, 2.2-9.9). Hearing thresholds were 2.1 to 8.1 dB higher in subjects treated with tubes (P = .005). CONCLUSIONS: In children who were candidates for ventilation tube insertion randomly assigned to receive medical or VT treatment for otitis media with effusion, elevated hearing thresholds and tympanic membrane pathologic abnormalities were more common in VT subjects 6 to 10 years after insertion.

The effect of wrist guard use on upper-extremity injuries in snowboarders.

The objective of this investigation was to determine the effect of wrist guard use on all upper-extremity injuries in snowboarders. This matched case-control study was conducted at 19 ski areas in Quebec, Canada. Cases were 1,066 injured snowboarders who reported upper-extremity injuries to the ski patrol during the 2001-2002 season. Controls were 970 snowboarders with non-upper-extremity injuries who were matched to cases on ski area and the nearest date, age, and sex, in that order. The response rate was 71.8% (73.5% for cases and 70.1% for controls). Cases were compared with controls with regard to wrist guard use. The prevalence of wrist guard use among snowboarders with hand, wrist, or forearm injuries was 1.6%; for those with elbow, upper arm, or shoulder injuries, it was 6.3%; and for controls, it was 3.9%. Thus, wrist guard use reduced the risk of hand, wrist, or forearm injury by 85% (adjusted odds ratio = 0.15, 95% confidence interval: 0.05, 0.45). However, the adjusted odds ratio for elbow, upper arm, or shoulder injury was 2.35 (95% confidence interval: 0.70, 7.81). These results provide evidence that use of wrist guards reduces the risk of hand, wrist, and forearm injuries but may increase the risk of elbow, upper arm, and shoulder injuries.

Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study.

OBJECTIVE: To determine the effect of helmets on the risk of head and neck injuries in skiers and snowboarders. DESIGN: Matched case-control and case crossover study. SETTING: 19 ski areas in Quebec, Canada, November 2001 to April 2002. PARTICIPANTS: 1082 skiers and snowboarders (cases) with head and neck injuries reported by the ski patrol and 3295 skiers and snowboarders (controls) with non-head or non-neck injuries matched to cases at each hill. MAIN OUTCOME MEASURES: Estimates of matched odds ratios for the effect of helmet use on the risk of any head or neck injury and for people requiring evacuation by ambulance. RESULTS: The adjusted odds ratio for helmet use in participants with any head injury was 0.71 (95% confidence interval 0.55 to 0.92), indicating a 29% reduction in the risk of head injury. For participants who required evacuation by ambulance for head injuries, the adjusted odds ratio for helmet use was 0.44 (0.24 to 0.81). Similar results occurred with the case crossover design (odds ratio 0.43, 0.09 to 1.83). The adjusted odds ratio for helmet use for participants with any neck injury was 0.62 (0.33 to 1.19) and for participants who required evacuation by ambulance for neck injuries it was 1.29 (0.41 to 4.04). CONCLUSIONS: Helmets protect skiers and snowboarders against head injuries. We cannot rule out the possibility of an increased risk of neck injury with helmet use, but the estimates on which this assumption is based are imprecise.

The effect of helmet use on injury severity and crash circumstances in skiers and snowboarders.

The aim of this study was to examine the effect of helmet use on non-head-neck injury severity and crash circumstances in skiers and snowboarders. We used a matched case-control study over the November 2001 to April 2002 winter season. 3295 of 4667 injured skiers and snowboarders reporting to the ski patrol at 19 areas in Quebec with non-head, non-neck injuries agreed to participate. Cases included those evacuated by ambulance, admitted to hospital, with restriction of normal daily activities (NDAs) >6 days, with non-helmet equipment damage, fast self-reported speed, participating on a more difficult run than usual, and jumping-related injury. Controls were injured participants without severe injuries or high-energy crash circumstances and were matched to cases on ski area, activity, day, age, and sex. Conditional logistic regression was used to relate each outcome to helmet use. There was no evidence that helmet use increased the risk of severe injury or high-energy crash circumstances. The results suggest that helmet use in skiing and snowboarding is not associated with riskier activities that lead to non-head-neck injuries.

Injuries among skiers and snowboarders in Quebec.

BACKGROUND: Snow sports such as skiing and snowboarding are recognized as hazardous, but population-based injury rates or specific risk factors have been difficult to estimate as a result of a lack of complete data for both numerator and denominator. METHODS: We used data from 3 surveys to estimate the number of participants and annual number of outings in Quebec by age, sex, activity, and calendar year. Injuries reported by ski patrollers were used to estimate injury rates among skiers and snowboarders for the head and neck, trunk, upper extremity, and lower extremity. RESULTS: Head-neck and trunk injury rates increased over time from 1995-1996 to 1999-2000. There was a steady increase in the rate of injury with younger age for all body regions. The rate of head-neck injury was 50% higher in snowboarders than in skiers (adjusted rate ratio [ARR] = 1.5; 95% confidence interval = 1.3-1.8). Women and girls had a lower rate of head-neck injury (0.73; 0.62-0.87). Snowboarders were twice as likely as skiers to have injuries of the trunk (2.1; 1.7-2.6), and more than 3 times as likely to have injuries of the upper extremities (3.4; 2.9-4.1). Snowboarders had a lower rate of injury only of the lower extremities (0.79; 0.66-0.95). Snowboarder collision-related injury rates increased substantially over time. CONCLUSIONS: Except for lower extremity injuries, snowboarders have a higher rate of injuries than skiers. Furthermore, collision-related injury rates have increased over time for snowboarders. Targeted injury prevention strategies in this group seem justified.

Home injury patterns in children: A comparison by hospital sites.

BACKGROUND: Many intervention studies typically require data from several centres to ensure adequate power. The usual intention is to pool data after testing for heterogeneity. Sites that differ in sample characteristics may, on the one hand, complicate the assessment of the intervention, but on the other hand, they may add important insights through analysis of site-specific findings. OBJECTIVES: The aims of the present paper were to compare the distribution of injuries and risk factors among children participating in a five-centre study of a home-based injury prevention program, and to contrast parental injury awareness and knowledge with home safety measures. METHODS: Five children's hospitals in Canada agreed to participate in a case-control study combined with a randomized controlled trial. Patients were children zero to seven years of age presenting to a hospital emergency department with a fall, burn, ingestion or choking. Two controls were matched to each case, one with another injury and another with a minor illness. A home visitor completed a home hazard assessment based on observed safety measures. To determine whether data could be pooled, comparisons across sites were made with respect to types of injuries seen, sociodemographic characteristics, observed hazards and the parents' reported beliefs about severity of injuries, safety measures, preventability of injuries and susceptibility to injuries. RESULTS: There were few differences between the five hospitals. The mean age was 2.2 years (range 1.4 to 3.3). There were 219 falls (56%), 80 burns (20.4%), 54 poisonings (13.8%), and 38 chokings (9.7%), all distributed in a proportionately similar manner, except for poisoning, at each site. There were significantly more well-educated fathers at one hospital and younger parents with less education at another. Homes were generally lacking five recommended safety measures. However, most parents at all sites perceived their home as being very safe for any of the specific injuries, and their child as being at low risk of sustaining any of these injuries. CONCLUSIONS: The similarity across sites supports the pooling of these data regarding hospital-treated injuries in young children in urban Canada. Most parents at all sites perceived their home as being very safe in spite of their homes lacking one-quarter of the recommended safety measures. This discrepancy between parental perception and home safety highlights the needs for further education and prevention efforts.