Fun ride or risky transport: Golf cart-related injuries treated in U.S. emergency departments from 2007 through 2017

Introduction: Golf cart-related injuries constitute a substantial source of morbidity, most notably in pediatric populations. Despite the high rate of injuries, there have been no meaningful changes in golf cart design or legislation to reduce the overall burden of these injuries. This study sought to characterize the epidemiology of golf cart-related injuries treated in United States hospital emergency departments. Method: A retrospective analysis was conducted by using data from the National Electronic Injury Surveillance System for patients of all ages who were treated in emergency departments (EDs) (2007–2017) for a golf cart-related injury. Results: From 2007 through 2017, an estimated 156,040 (95% CI = 102,402–209,679) patients were treated in U.S. EDs for golf cart-related injuries. The average rate of traumatic brain injuries (TBIs) in children (1.62 per 100,000 children) was more than three times that of TBIs in adults (0.52 per 100,000 adults; rate ratio = 2.38; 95% CI = 2.36–2.41) and nearly twice that of TBIs in seniors (1.11 per 100,000 seniors; rate ratio = 1.21; 95% CI = 1.19–1.22). The rate of injuries in seniors increased significantly by 67.6% from 4.81 per 100,000 seniors in 2007 to 8.06 per 100,000 seniors in 2017 (slope = 0.096; p = 0.041). Conclusions: Golf cart use remains an important source of injury for people of all ages, especially in children. As use continues to increase, it is unlikely that golf cart-related injuries will decrease without substantial changes to product design, regulation, and/or legislation. Practical Applications: Use of golf carts pose a considerable risk of injury and morbidity; safety recommendations should be followed.     

An LC-MS/MS method for creatine and creatinine analysis in paraquat-intoxicated patients

Abstract

A sudden increase in serum creatinine after paraquat intoxication has been reported in several clinical studies. However, this dramatic change of creatinine may be possibly due to an interconversion of creatine-creatinine in relation to paraquat toxicity. In order to investigate the creatine-creatinine relationship, a liquid chromatography tandem mass spectrometry in combination with electrospray ionization was developed and validated for simultaneous determination of creatine and creatinine in the serum. The chromatographic separation was achieved on a Gemini® C₆-Phenyl column with a gradient elution consisting of 0.1% formic acid in ultrapure water and methanol as the mobile phase. The method yielded suitable levels of specificity and selectivity, and calibration curves of creatine and creatinine in serum were linear over the concentration range of 0.5–200?µg mL^?1. The limit of quantification of both compounds was 0.5?µg mL^?1, and the method was accurate within the recovery range of 96.23–102.75%, indicating the robustness of the method. The method was successfully applied to toxicological samples from paraquat-intoxicated patients, and the concentrations of creatine and creatinine were quantified. High creatine concentrations in serum samples were observed which may lead to high serum creatinine despite normal kidney function as creatine is converted to creatinine in proportion to its concentration.     

Features of fatal injuries in older cyclists in vehicle–bicycle accidents in Japan

Objective: The purpose of this study was to identify and better understand the features of fatal injuries in cyclists aged 75 years and over involved in collisions with either hood- or van-type vehicles.

Methods: This study investigated the fatal injuries of cyclists aged 75 years old and over by analyzing accident data. We focused on the body regions to which the fatal injury occurred using vehicle–bicycle accident data from the Institute for Traffic Accident Research and Data Analysis (ITARDA) in Japan. Using data from 2009 to 2013, we examined the frequency of fatally injured body region by gender, age, and actual vehicle travel speed. We investigated any significant differences in distributions of fatal injuries by body region for cyclists aged 75 years and over using chi-square tests to compare with cyclists in other age groups. We also investigated the cause of fatal head injuries, such as impact with a road surface or vehicle.

Results: The results indicated that head injuries were the most common cause of fatalities among the study group. At low vehicle travel speeds for both hood- and van-type vehicles, fatalities were most likely to be the result of head impacts against the road surface.

The percentage of fatalities following hip injuries was significantly higher for cyclists aged 75 years and over than for those aged 65–74 or 13–59 in impacts with hood-type vehicles. It was also higher for women than men in the over-75 age group in impacts with these vehicles.

Conclusions: For cyclists aged 75 years and over, wearing a helmet may be helpful to prevent head injuries in vehicle-to-cyclist accidents. It may also be helpful to introduce some safety measures to prevent hip injuries, given the higher level of fatalities following hip injury among all cyclists aged 75 and over, particularly women.     

Emergency department visits by pediatric patients sustained as a passenger on a motorcycle

Objective: Currently only 5 out of the 50 states in the United States have laws restricting the age of passengers permitted to ride on a motorcycle. This study sought to characterize the visits by patients under the age of 16 to U.S. emergency departments (EDs) for injuries sustained as a passenger on a motorcycle.

Methods: In this retrospective cohort study, data were obtained from the Nationwide Emergency Department Sample (NEDS) for the years 2006 to 2011. Pediatric patients who were passengers on a motorcycle that was involved in a crash were identified using International Classification of Diseases, Ninth Revision (ICD-9) External Cause of Injury codes. We also examined gender, age, disposition, regional differences, common injuries, and charges.

Results: Between 2006 and 2011 there were an estimated 9,689 visits to U.S. EDs by patients under the age of 16 who were passengers on a motorcycle involved in a crash. The overall average patient age was 9.4 years, and they were predominately male (54.5%). The majority (85%) of these patients were treated and released. The average charges for discharged patients were $2,116.50 and amounted to roughly $17,500,000 during the 6 years. The average cost for admission was $51,446 per patient and totaled over $54 million. The most common primary injuries included superficial contusions; sprains and strains; upper limb fractures; open wounds of head, neck, and trunk; and intracranial injuries.

Conclusion: Although there were only about 9,700 visits to U.S. EDs for motorcycle crashes involving passengers less than 16 years old for 2006 to 2011, the total cost of visits that resulted in either ED discharge or hospital admission amounted to over $71 million.     

Evaluation of give kids a boost: A school-based program to increase booster seat use among urban children in economically disadvantaged areas

Objective: This study evaluated the effectiveness of a series of 1-year multifaceted school-based programs aimed at increasing booster seat use among urban children 4–7 years of age in economically disadvantaged areas.

Methods: During 4 consecutive school years, 2011–2015, the Give Kids a Boost (GKB) program was implemented in a total of 8 schools with similar demographics in Dallas County. Observational surveys were conducted at project schools before project implementation (P₀), 1–4 weeks after the completion of project implementation (P₁), and 4–5 months later (P₂). Changes in booster seat use for the 3 time periods were compared for the 8 project and 14 comparison schools that received no intervention using a nonrandomized trial process.

The intervention included (1) train-the-trainer sessions with teachers and parents; (2) presentations about booster seat safety; (3) tailored communication to parents; (4) distribution of fact sheets/resources; (5) walk-around education; and (6) booster seat inspections.

The association between the GKB intervention and proper booster seat use was determined initially using univariate analysis. The association was also estimated using a generalized linear mixed model predicting a binomial outcome (booster seat use) for those aged 4 to 7 years, adjusted for child-level variables (age, sex, race/ethnicity) and car-level variables (vehicle type). The model incorporated the effects of clustering by site and by collection date to account for the possibility of repeated sampling.

Results: In the 8 project schools, booster seat use for children 4–7 years of age increased an average of 20.9 percentage points between P₀ and P₁ (P₀ = 4.8%, P₁ = 25.7%; odds ratio [OR] = 6.9; 95% confidence interval [CI], 5.5, 8.7; P < .001) and remained at that level in the P₂ time period (P₂ = 25.7%; P < .001, for P₀ vs. P₂) in the univariate analysis. The 14 comparison schools had minimal change in booster seat use. The multivariable model showed that children at the project schools were significantly more likely to be properly restrained in a booster seat after the intervention (OR = 2.7; 95% CI, 2.2, 3.3) compared to the P₀ time period and compared to the comparison schools.

Conclusion: Despite study limitations, the GKB program was positively associated with an increase in proper booster seat use for children 4–7 years of age in school settings among diverse populations in economically disadvantaged areas. These increases persisted into the following school year in a majority of the project schools. The GKB model may be a replicable strategy to increase booster seat use among school-age children in similar urban settings.     

Validation of a booted finite element model of the WIAMan ATD lower limb in component and whole-body vertical loading impacts with an assessment of the boot influence model on response

Objective: A novel anthropomorphic test device (ATD) representative of the 50th percentile male soldier is being developed to predict injuries to a vehicle occupant during an underbody blast (UBB). The main objective of this study was to develop and validate a finite element (FE) model of the ATD lower limb outfitted with a military combat boot and to insert the validated lower limb into a model of the full ATD and simulate vertical loading experiments.

Methods: A Belleville desert combat boot model was assigned contacts and material properties based on previous experiments. The boot model was fit to a previously developed model of the barefoot ATD. Validation was performed through 6 matched pair component tests conducted on the Vertically Accelerated Loads Transfer System (VALTS). The load transfer capabilities of the FE model were assessed along with the force-mitigating properties of the boot. The booted lower limb subassembly was then incorporated into a whole-body model of the ATD. Two whole-body VALTS experiments were simulated to evaluate lower limb performance in the whole body.

Results: The lower limb model accurately predicted axial loads measured at heel, tibia, and knee load cells during matched pair component tests. Forces in booted simulations were compared to unbooted simulations and an amount of mitigation similar to that of experiments was observed. In a whole-body loading environment, the model kinematics match those recorded in experiments. The shape and magnitude of experimental force–time curves were accurately predicted by the model. Correlation between the experiments and simulations was backed up by high objective rating scores for all experiments.

Conclusion: The booted lower limb model is accurate in its ability to articulate and transfer loads similar to the physical dummy in simulated underbody loading experiments. The performance of the model leads to the recommendation to use it appropriately as an alternative to costly ATD experiments.     

Injury risk functions for frontal oblique collisions

Objective: The objective of this article was the construction of injury risk functions (IRFs) for front row occupants in oblique frontal crashes and a comparison to IRF of nonoblique frontal crashes from the same data set.

Method: Crashes of modern vehicles from GIDAS (German In-Depth Accident Study) were used as the basis for the construction of a logistic injury risk model. Static deformation, measured via displaced voxels on the postcrash vehicles, was used to calculate the energy dissipated in the crash. This measure of accident severity was termed objective equivalent speed (oEES) because it does not depend on the accident reconstruction and thus eliminates reconstruction biases like impact direction and vehicle model year. Imputation from property damage cases was used to describe underrepresented low-severity crashes―a known shortcoming of GIDAS. Binary logistic regression was used to relate the stimuli (oEES) to the binary outcome variable (injured or not injured).

Results: IRFs for the oblique frontal impact and nonoblique frontal impact were computed for the Maximum Abbreviated Injury Scale (MAIS) 2+ and 3+ levels for adults (18–64 years). For a given stimulus, the probability of injury for a belted driver was higher in oblique crashes than in nonoblique frontal crashes. For the 25% injury risk at MAIS 2+ level, the corresponding stimulus for oblique crashes was 40 km/h but it was 64 km/h for nonoblique frontal crashes.

Conclusions: The risk of obtaining MAIS 2+ injuries is significantly higher in oblique crashes than in nonoblique crashes. In the real world, most MAIS 2+ injuries occur in an oEES range from 30 to 60 km/h.     

Evaluation of geometrically personalized THUMS pedestrian model response against sedan–pedestrian PMHS impact test data

Objective: Evaluating the biofidelity of pedestrian finite element models (PFEM) using postmortem human subjects (PMHS) is a challenge because differences in anthropometry between PMHS and PFEM could limit a model's capability to accurately capture cadaveric responses. Geometrical personalization via morphing can modify the PFEM geometry to match the specific PMHS anthropometry, which could alleviate this issue. In this study, the Total Human Model for Safety (THUMS) PFEM (Ver 4.01) was compared to the cadaveric response in vehicle–pedestrian impacts using geometrically personalized models.

Methods: The AM50 THUMS PFEM was used as the baseline model, and 2 morphed PFEM were created to the anthropometric specifications of 2 obese PMHS used in a previous pedestrian impact study with a mid-size sedan. The same measurements as those obtained during the PMHS tests were calculated from the simulations (kinematics, accelerations, strains), and biofidelity metrics based on signals correlation (correlation and analysis, CORA) were established to compare the response of the models to the experiments. Injury outcomes were predicted deterministically (through strain-based threshold) and probabilistically (with injury risk functions) and compared with the injuries reported in the necropsy.

Results: The baseline model could not accurately capture all aspects of the PMHS kinematics, strain, and injury risks, whereas the morphed models reproduced biofidelic response in terms of trajectory (CORA score = 0.927 ± 0.092), velocities (0.975 ± 0.027), accelerations (0.862 ± 0.072), and strains (0.707 ± 0.143). The personalized THUMS models also generally predicted injuries consistent with those identified during posttest autopsy.

Conclusions: The study highlights the need to control for pedestrian anthropometry when validating pedestrian human body models against PMHS data. The information provided in the current study could be useful for improving model biofidelity for vehicle–pedestrian impact scenarios.     

Polycyclic aromatic hydrocarbons in cigarette sidestream smoke particulates from a Taiwanese brand and their carcinogenic relevance

Polycyclic aromatic hydrocarbons (PAHs) adsorbed on cigarette sidestream smoke particulates (CSSPs) have been regarded as important contributors to lung carcinogenesis in never smokers. However, limited information is available on PAH levels in cigarette sidestream smoke. Here we determine the concentrations of 22 PAHs, including 16 US EPA priority PAHs, in CSSPs generated from a high market-share domestic brand in Taiwan. Five of the 22 PAHs are undetectable. The remaining 17 PAHs constitute about 0.022% of the total mass of CSSPs. Near one fifth of the PAH mass come from IARC group 1 and group 2 carcinogens. Carcinogenic potency is equivalent to 144 ng benzo[a]pyrene per cigarette converted according to potency equivalency factors (PEFs). The CSSP condensate could activate AhR activity and induce AhR target gene expression. High concentrations of CSSPs also exhibited AhR-independent cytotoxicity. However, mixing the 17 PAHs as the composition in the CSSP condensate could not reconstitute either capacity. Since AhR activation and cytotoxicity are important mechanisms underlying carcinogenic potency, the results suggest that other component compounds play a more active role in carcinogenesis. The approach of individual PAH profiling plus PEF conversion commonly used in risk assessment is likely to underestimate the risk caused by environmental cigarette smoke exposure.