Radioactivity concentration measurements in fish and shellfish samples from the west coast of Canada after the Fukushima nuclear accident (2011-2018).

Radioactive contamination of the Pacific Ocean following the Fukushima nuclear accident has raised public concern about seafood safety, particularly in coastal Indigenous communities. To address this, Health Canada and partners have collected and analyzed a total of 621 samples of commonly consumed salmon, ground fish, and shellfish from the Canadian west coast from 2011 to 2018. While the vast majority of the 137Cs and 134Cs levels were below the Minimum Detectable Concentration (MDC, typically 0.7-1.0 Bq kg-1 fw for a 6 h counting), further examination of 19 fish samples revealed 137Cs concentrations of 0.17-0.53 Bq kg-1 fw with an average value and uncertainty (k = 1) of 0.29 ± 0.02 Bq kg-1 fw. Of these, only two samples were found to have trace levels of 134Cs likely derived from the Fukushima accident. The global fallout contribution from atmospheric nuclear weapons testing to the observed 137Cs in these two samples was determined to be 0.26 ± 0.08 Bq kg-1 fw (49 ± 14%) and 0.12 ± 0.02 Bq kg-1 fw (24 ± 4%) for collection years 2015 and 2016, respectively. The annual average level of 137Cs in fish and shellfish was also determined by spectral summation for collection years 2014-2018. In fish, 137Cs levels determined through spectral summation were relatively constant (0.18-0.25 Bq kg-1 fw) with an average value and uncertainty of 0.21 ± 0.02 Bq kg-1 fw. By contrast, 38 shellfish samples (bivalves) were measured and revealed no radiocesium or other anomalies in either tissue or shell. In all, measurements over eight years showed that the radioactivity in fish and shellfish was dominated by natural radionuclides and that the level of anthropogenic radionuclides, as indicated by the radioactive cesium content, remained small. An upper bound for ingested dose from 137Cs was determined to be approximately 0.26 µSv per year, far below the worldwide average annual effective dose of 2400 µSv from exposure to natural background radiation. We can therefore conclude that fish, such as salmon, ground fish, and shellfish from the Canadian west coast are of no radiological health concern despite the Fukushima Dai-ichi nuclear accident of 2011.

210Po in Pacific Salmon from the West Coast of Canada and its Contribution to Dose by Ingestion.

In response to public concern in Canada regarding health impacts attributable to the Fukushima Daiichi nuclear accident, oceanic seawater samples from the north Pacific and Arctic oceans, coastal seawater samples from 16 locations along the British Columbia coastline, and seafood samples (salmon, steelhead trout, and shellfish) from British Columbia coastal waters were collected and analyzed. This paper reports radiological analysis results of Pacific salmon samples (Oncorhynchus species) obtained from summer 2013 to fall 2016. While radioactive cesium from the Fukushima disaster was not detectable in most salmon samples, naturally occurring Po was measured in almost all individual samples in varying activity concentrations, from below the detection limit of 0.2 Bq kg fresh weight up to 4.7 Bq kg fresh weight. The average Po concentration among 297 salmon samples was 0.73 Bq kg fresh weight. The average ingested radiation dose per kilogram of salmon from Po is estimated to be 0.88 µSv, and the average dose from Cs is estimated to be 0.0026 µSv. The annual dose from ingested salmon would be only a fraction of the worldwide average annual effective dose from exposure to natural background radiation (2,400 µSv y) (). The measurement results showed clearly that radiation doses to people consuming fish (such as salmon) from the Canadian west coast pose no health concern.

Anaphylaxis and ethnicity: higher incidence in British South Asians.

BACKGROUND: The incidence of anaphylaxis in South Asians (Indian, Pakistani and Bangladeshi ethnicity) is unknown. Birmingham is a British city with a disproportionately large population of South Asians (22.5%) compared with the rest of the UK (4.9%). The main aims of this study were to determine the incidence and severity of anaphylaxis in this population and to investigate the differences between the South Asian and White populations. METHODS: A retrospective electronic search of emergency department attendances at three hospitals in Birmingham during 2012 was carried out. Wide search terms were used, medical notes were scrutinized, and the World Allergy Organization diagnostic criteria for anaphylaxis were applied. Patients' age, sex, ethnicity and home postal code were collected, reactions were graded by severity, and other relevant details including specialist assessment were extracted. Multivariate analysis was undertaken using 2011 UK census data. RESULTS: Age-, sex- and ethnicity-standardized incidence rate of anaphylaxis was 34.5 per 100 000 person-years. Multivariate logistic regression which controlled for the confounders of age, sex and level of socioeconomic deprivation showed that incidence was higher in the South Asian population (OR 1.48, P = 0.005). Incidence rate in the South Asian population was 58.3 cases per 100 000 person-years compared to 31.5 in the White population. South Asian children were more likely to present with severe anaphylaxis (OR 5.31, P = 0.002). CONCLUSIONS: Incidence of anaphylaxis is significantly higher in British South Asians compared to the white population. British South Asian children are at a greater risk of severe anaphylaxis than White children.

Ambulance handovers: can a dedicated ED nurse solve the delay in ambulance turnaround times?

With ever increasing concern over ambulance handover delays this paper looks at the impact of dedicated A&E nurses for ambulance handovers and the effect it can have on ambulance waiting times. It demonstrates that although such roles can bring about reduced waiting times, it also suggests that using this as a sole method to achieve these targets would require unacceptably low staff utilisation.

Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries.

OBJECTIVES: To examine the clinical effectiveness of a stepped care approach over a 12-month period after an acute whiplash injury; to estimate the costs and cost-effectiveness of each strategy including treatments and subsequent health-care costs; and to gain participants' perspective on experiencing whiplash injury, NHS treatment, and recovery within the context of the Managing Injuries of the Neck Trial (MINT). DESIGN: Two linked, pragmatic, randomised controlled trials. In Step 1, emergency departments (EDs) were cluster randomised to usual care advice (UCA) or The Whiplash Book advice (WBA)/active management advice. In Step 2, participants were individually randomised to either a single session of advice from a physiotherapist or a physiotherapy package of up to six sessions. An economic evaluation and qualitative study were run in parallel with the trial. SETTING: Twelve NHS trusts in England comprising 15 EDs. PARTICIPANTS: People who attended EDs with an acute whiplash injury of whiplash-associated disorder grades I-III were eligible for Step 1. People who had attended EDs with whiplash injuries and had persistent symptoms 3 weeks after ED attendance were eligible for Step 2. INTERVENTIONS: In Step 1, the control intervention was UCA and the experimental intervention was a psycho-educational intervention (WBA/active management advice). In Step 2 the control treatment was reinforcement of the advice provided in Step 1 and the experimental intervention was a package of up to six physiotherapy treatments. MAIN OUTCOME: The primary outcome was the Neck Disability Index (NDI), which measures severity and frequency of pain and symptoms, and a range of activities including self-care, driving, reading, sleeping and recreation. Secondary outcomes included the mental and physical health-related quality-of-life (HRQoL) subscales of the Short Form questionnaire-12 items (SF-12) and the number of work days lost. RESULTS: A total of 3851 patients were recruited to Step 1 of the trial. 1598 patients attending EDs were randomised to UCA, and 2253 were randomised to WBA/active management. Outcome data were obtained at 12 months for 70% and 80% of participants at Step 1 and Step 2, respectively. The majority of people recovered from the injury. Eighteen per cent of the Step 1 cohort had late whiplash syndrome. There was no statistically or clinically significant difference observed in any of the outcomes for participants attending EDs randomised to UCA or active management advice [difference in NDI 0.5, 95% confidence interval (CI) -1.8 to 2.8]. In Step 2 the physiotherapy package resulted in improvements in neck disability at 4 months compared with a single advice session, but these effects were small at the population level (difference in NDI -3.2, 95% CI -5.8 to -0.7). The physiotherapy package was accompanied by a significant reduction in the number of work days lost at 4-month follow-up (difference -40.2, 95% CI -44.3 to -35.8). CONCLUSIONS: MINT suggests that enhanced psycho-educational interventions in EDs are no more effective than UCA in reducing the burden of acute whiplash injuries. A physiotherapy package provided to people who have persisting symptoms within the first 6 weeks of injury produced additional short-term benefits in neck disability compared with a single physiotherapy advice session. However, from a health-care perspective, the physiotherapy package was not cost-effective at current levels of willingness to pay. Both experimental treatments were associated with increased cost with no discernible gain in health-related quality of life. However, an important benefit of the physiotherapy package was a reduction in work days lost; consequently, the intervention may prove cost-effective at the societal level. TRIAL REGISTRATION: Current Controlled Trials ISRCTN33302125. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 49. See the HTA programme website for further project information.

Patients who leave emergency departments without being seen: literature review and English data analysis.

OBJECTIVES: The purpose of this review was to determine the rate of those that leave the emergency department (ED) without being seen and their reasons, to clarify if such behaviour poses a health risk, to analyse the impact initiatives have made on the leave without being seen (LWBS) rate, and to discuss the implications of using it as a national performance indicator within the NHS. METHODS: A combination of data sources was reviewed: a 'realistic' literature review, analysis of hospital episode statistics data from England and a local NHS trust audit. MAJOR FINDINGS: LWBS rates vary across the world, from 15% to 0.36%. Also initiatives to reduce LWBS rates demonstrated mixed outcomes, with reductions in the rate by as much as 96%, while others were ineffective. The most common reason quoted for LWBS was long waiting times and there were few data to suggest LWBS posed a risk to patient health. CONCLUSIONS: LWBS is an issue experienced in many countries that has responded in a varying manner to many initiatives in attempts to reduce it; however, it is clearly associated with the waiting times experienced in ED and therefore working within a packet of performance measures it would assess the effect of waiting times from another perspective.

In 'big bang' major incidents do triage tools accurately predict clinical priority?: a systematic review of the literature.

INTRODUCTION: The term "big bang" major incidents is used to describe sudden, usually traumatic,catastrophic events, involving relatively large numbers of injured individuals, where demands on clinical services rapidly outstrip the available resources. Triage tools support the pre-hospital provider to prioritise which patients to treat and/or transport first based upon clinical need. The aim of this review is to identify existing triage tools and to determine the extent to which their reliability and validity have been assessed. METHODS: A systematic review of the literature was conducted to identify and evaluate published data validating the efficacy of the triage tools. Studies using data from trauma patients that report on the derivation, validation and/or reliability of the specific pre-hospital triage tools were eligible for inclusion.Purely descriptive studies, reviews, exercises or reports (without supporting data) were excluded. RESULTS: The search yielded 1982 papers. After initial scrutiny of title and abstract, 181 papers were deemed potentially applicable and from these 11 were identified as relevant to this review (in first figure). There were two level of evidence one studies, three level of evidence two studies and six level of evidence three studies. The two level of evidence one studies were prospective validations of Clinical Decision Rules (CDR's) in children in South Africa, all the other studies were retrospective CDR derivation, validation or cohort studies. The quality of the papers was rated as good (n=3), fair (n=7), poor (n=1). CONCLUSION: There is limited evidence for the validity of existing triage tools in big bang major incidents.Where evidence does exist it focuses on sensitivity and specificity in relation to prediction of trauma death or severity of injury based on data from single or small number patient incidents. The Sacco system is unique in combining survivability modelling with the degree by which the system is overwhelmed in the triage decision system. The practicalities, training implications, performance characteristics and reliance on computer technology during a mass casualty incident require further evaluation.

The carbon footprint of a renal service in the United Kingdom.

BACKGROUND: Anthropogenic climate change presents a major global health threat. However, the very provision of healthcare itself is associated with a significant environmental impact. Carbon footprinting techniques are increasingly used outside of the healthcare sector to assess greenhouse gas emissions and inform strategies to reduce them. AIM: This study represents the first assessment of the carbon footprint of an individual specialty service to include both direct and indirect emissions. METHODS: This was a component analysis study. Activity data were collected for building energy use, travel and procurement. Established emissions factors were applied to reconcile this data to carbon dioxide equivalents (CO(2)eq) per year. RESULTS: The Dorset Renal Service has a carbon footprint of 3006 tonnes CO(2)eq per annum, of which 381 tonnes CO(2)eq (13% of overall emissions) result from building energy use, 462 tonnes CO(2)eq from travel (15%) and 2163 tonnes CO(2)eq (72%) from procurement. The contributions of the major subsectors within procurement are: pharmaceuticals, 1043 tonnes CO(2)eq (35% of overall emissions); medical equipment, 753 tonnes CO(2)eq (25%). The emissions associated with healthcare episodes were estimated at 161 kg CO(2)eq per bed day for an inpatient admission and 22 kg CO(2)eq for an outpatient appointment. CONCLUSION: These results suggest that carbon-reduction strategies focusing upon supply chain emissions are likely to yield the greatest benefits. Sustainable waste management and strategies to reduce emissions associated with building energy use and travel will also be important. A transformation in the way that clinical care is delivered is required, such that lower carbon clinical pathways, treatments and technologies are embraced. The estimations of greenhouse gas emissions associated with outpatient appointments and inpatient stays calculated here may facilitate modelling of the emissions of alternative pathways of care.

Are current UK tetanus prophylaxis procedures for wound management optimal?

Tetanus is a potentially fatal disease that occurs after contamination of a wound with Clostridium tetani spores. The introduction of comprehensive infant vaccination programmes in the 1960s dramatically reduced the incidence of tetanus in the UK. To achieve comprehensive protection against tetanus, the World Health Organization guidelines recommend the administration of the five-dose childhood immunisation regimen and an additional sixth dose, after approximately 10 years, to ensure long-lasting immunity. To supplement these measures, tetanus prophylaxis with human tetanus immunoglobulin is considered essential for incompletely immunised individuals presenting with dirty wounds. However, identifying those individuals who are not fully immunised has, until recently, been problematical. The use of a new rapid, point-of-care immunoassay to assess tetanus immune status may facilitate the optimal management of patients with wounds.

In an emergency--call the clinical librarian!

This paper reviews the role of the clinical librarian in the emergency department.

Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial.

BACKGROUND: Severe ankle sprains are a common presentation in emergency departments in the UK. We aimed to assess the effectiveness of three different mechanical supports (Aircast brace, Bledsoe boot, or 10-day below-knee cast) compared with that of a double-layer tubular compression bandage in promoting recovery after severe ankle sprains. METHODS: We did a pragmatic, multicentre randomised trial with blinded assessment of outcome. 584 participants with severe ankle sprain were recruited between April, 2003, and July, 2005, from eight emergency departments across the UK. Participants were provided with a mechanical support within the first 3 days of attendance by a trained health-care professional, and given advice on reducing swelling and pain. Functional outcomes were measured over 9 months. The primary outcome was quality of ankle function at 3 months, measured using the Foot and Ankle Score; analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN37807450. RESULTS: Patients who received the below-knee cast had a more rapid recovery than those given the tubular compression bandage. We noted clinically important benefits at 3 months in quality of ankle function with the cast compared with tubular compression bandage (mean difference 9%; 95% CI 2.4-15.0), as well as in pain, symptoms, and activity. The mean difference in quality of ankle function between Aircast brace and tubular compression bandage was 8%; 95% CI 1.8-14.2, but there were little differences for pain, symptoms, and activity. Bledsoe boots offered no benefit over tubular compression bandage, which was the least effective treatment throughout the recovery period. There were no significant differences between tubular compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences between treatments. Reported events (all treatments combined) were cellulitis (two cases), pulmonary embolus (two cases), and deep-vein thrombosis (three cases). INTERPRETATION: A short period of immobilisation in a below-knee cast or Aircast results in faster recovery than if the patient is only given tubular compression bandage. We recommend below-knee casts because they show the widest range of benefit. FUNDING: National Co-ordinating Centre for Health Technology Assessment.

Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial.

OBJECTIVE: To estimate the clinical effectiveness and cost-effectiveness of three methods of ankle support compared with double layer tubular compression bandage. DESIGN: A randomised controlled trial, designed to reflect practice in UK hospital emergency departments. SETTING: Eight emergency departments in England. PARTICIPANTS: Aged 16 or over with acute severe ankle sprain, unable to weight bear, no fracture. INTERVENTIONS: 584 participants were randomised to one of four treatment arms: tubular bandage, below knee cast, Aircast ankle brace or Bledsoe boot, all applied 2-3 days after presentation to allow swelling to resolve. MAIN OUTCOME MEASURES: Response to treatment was assessed using the Foot and Ankle Outcome Score and generic measures (Functional Limitations Profile, SF-12 and EQ-5D). RESULTS: When adjusted for age, sex and baseline scores, the below knee cast offered a small but statistically significant benefit at 4 weeks in terms of pain (FAOS pain difference 5.1; 95% CI 0.4-9.8), foot- and ankle-related quality of life (QoL) (FAOS QoL difference 5.9; 95% CI 0.1-11.8) and the physical component of the SF-12 (SF-12 score difference 2.2; 95% CI 0.0-4.4). Neither the Aircast brace nor the Bledsoe boot was statistically or clinically better. At 12 weeks the below knee cast was significantly better than tubular bandage in terms of pain (FAOS pain difference 5.1; 95% CI 0.3-10.0), activities of daily living (FAOS ADL difference 3.5; 95% CI 0.4-6.6), sports (FAOS sports difference 8.7; 95% CI 1.6-15.7) and QoL (FAOS QoL difference 8.7; 95% CI 2.4-15.0), and the Aircast brace was better only in terms of ankle-related QoL and mental health. The Bledsoe boot conferred no significant advantage over tubular bandage. By 9 months there were no significant differences. Based on mean direct health-care costs per participant, the Bledsoe boot was the most expensive (215 pounds) and tubular bandage the least so (1 pound 44 pence). Inclusion of indirect costs (sick leave) raised overall costs substantially and removed any significant differences between the therapies. Cost-utility analysis demonstrated that the Aircast brace [301 pounds per quality-adjusted life-year (QALY)] and below knee cast (339 pounds per QALY) were more cost-effective than the Bledsoe boot (2116 pounds per QALY). However, inclusion of indirect costs produced different rank orders, depending on the assumptions made, and results should be treated with caution. CONCLUSIONS: The below knee cast and the Aircast brace offered cost-effective alternatives to tubular bandage for acute severe ankle sprain, the former having the advantage in terms of overall recovery at 3 months. As there were no differences in long-term outcome, practitioners should consider likely compliance and acceptability to patients when choosing a brace.

A descriptive review and discussion of litigation claims against ambulance services.

INTRODUCTION: Litigation claims against the NHS are increasing. Society is less tolerant of mistakes or inadequate service and litigation claims are now becoming increasingly accepted. METHODS: All claims registered with the NHS litigation authority, both closed and still open, were collated from all the ambulance trusts across England in the past 10 years. All incidents notified between 19 December 1995 and 19 April 2005 were included. The data were then analysed according to time, description of the incident, cause of the incident and type of damage incurred. Cases were also described according to the total claim. Potential actions and further work are discussed. RESULTS: Between 19 December 1995 and 19 April 2005 there were 272 cases of litigation conducted through the NHS litigation authority against ambulance services across the United Kingdom. The greatest proportion of claims was as a result of lack of assistance or care, which was alleged in 75 cases. Another significant proportion of cases related to a "failure/delay in treatment" or "diagnosis" accounting for 36 and 34 cases, respectively. The most common type of injury was a fatality in 69 cases and unnecessary pain in a further 56 claims. 17 claims were for sums of over pound 1 million; however, most of these cases were still ongoing. These cases are described in more detail; the type of outcome tended to be brain damage or significant spinal injury rather than a fatality, reflecting the higher cost of continuing long-term care of a chronically injured person. CONCLUSION: This study suggests that the key clinical areas that need to be addressed are obstetric care, spinal injury recognition and the decision not to convey a person to hospital. The first two of these have been addressed in the recent release of the Joint Royal Colleges Ambulance Liaison Committee guidelines. The major areas of organisation relate to reducing delays and providing the safe transfer of patients.

Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings. DESIGN: Systematic review of randomised and quasi-randomised controlled trials, and meta-analysis. DATA SOURCES: Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews. REVIEW METHODS: Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors. DATA EXTRACTION: Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement. RESULTS: 19 studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral. CONCLUSIONS: Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.

Short stay emergency admissions to a West Midlands NHS Trust: a longitudinal descriptive study, 2002 2005.

OBJECTIVES: To describe changes and characteristics in emergency admissions to a West Midlands National Health Service Trust, 2002-2005, with a focus on short stay emergency admissions. METHODS: A longitudinal descriptive study using retrospective analysis of routine admissions data. Admissions were categorised as short (0/1 day) or long (>or=2 days) and examined separately using a General Linear Model. Factors favouring short stays as opposed to long stays were examined using multivariable logistic regression. RESULTS: There were 151 478 emergency admissions to the Trust between 1 April 2002 and 31 December 2005, of which 2910 (1.92%) had no discharge date recorded. Adjusted means showed a 7.76% increase in emergency admissions in winter months (October-January) and a 14.50% increase across the study period. Increases were greater in short stay (34.03%) than long stay emergency admissions (8.38%). Odds of short stays in admitted patients increased by 25%. Higher odds of short stays were also associated with younger age, winter month and medical admitting specialty (p<0.001). CONCLUSIONS: Increases in emergency admissions were greater in short stay than long stay cases. Reasons for this may be both appropriate (increased use of clinical protocols and falling average length of stay) and detrimental (pressure to meet 4 h emergency department target, changing primary care provision). Further research is needed before generalising findings to other Trusts.