In vitro hemolytic performance of the Realheart® V11C TAH prototype with porcine blood.

BACKGROUND: Hemolysis testing of new devices to treat heart failure is a regulatory requirement. The ASTM F1841-97 standard for hemolysis testing was developed for continuous flow pumps and does not specify test rig design. When research groups use different methodologies, results are difficult to compare. Pulsatile flow pump rigs require compliance chambers, and thus, the Aachen rig (Gräf et al) was developed for the pulsatile Reinheart TAH. The study objective was to use this rig to test the early Realheart TAH prototype V11C hemolysis performance compared to literature. METHODS: The experimental control was the continuous flow pump BPX-80 (Medtronic) and pooled heparinized porcine blood was used. RESULTS: The mgNIH of BPX-80 and V11C was 5.42 ± 1.47 and 25.20 ± 5.46 mg/100 L, respectively. The NIH ratio of V11C over BPX-80 was 5.5. CONCLUSION: The absolute and the relative hemolysis of the V11C are lower compared to both the large and small Reinheart TAH devices published values. Pulsatile pumps create more hemolysis in the Aachen rig, and it is not known if this is because how the rig handles pulsatile flow or due to the devices. Future studies will, therefore, use a pulsatile pump such as the SynCardia as clinical comparator and human blood to test the performance of future Realheart TAH prototypes.

Measuring recovery after open lower limb fractures: combined objective functional tests and global perceived recovery outperform narrower metrics and a standard generic patient reported outcome measure.

BACKGROUND: Open lower limb fractures are serious injuries requiring combined ortho-plastic surgery and have significantly worse outcomes than similar closed fractures. There is little objective published data to determine which functional outcome measures best reflect progress or completeness of physical recovery. Our hypothesis was that objective measures combining strength, mobility and balance would better reflect recovery than isolated parameters (e.g. range of motion ROM) and would compare well to patients' perceived recovery. METHODS: Adult open lower limb fracture patients were reviewed 6 and 12 weeks, 6, 9 and 12 months post-injury. The mechanism, injury pattern, age, gender and treatment were recorded. Isolated parameter objective functional outcome measures (OFOMs) (ROM and MRC strength grade) were compared to combined OFOMs (timed up and go, comfortable gait speed and fast gait speed, Edgren Side Step Test (TUAG, CGS, FGS, ESST) and Single Leg balance. Patient reported outcomes were recorded (Global Perceived Effect (GPE) score and Disability Rating Index (DRI)). Statistical analysis used non-parametric tests (e.g. Spearman correlation) compared each with time since injury. RESULTS: Sixty-eight patients (54 male) with a median age of 45(20-75) years. Of the 19 isolated OFOMs, only knee flexion and ankle plantar flexion ROM and strength improved with time (Spearman correlation p = 0.042, 0.008, 0.032, 0.036 respectively). TUAG, ESST, CGS, FGS and GPE scores showed significant improvement (Spearman correlation p < 0.001). Patients' estimation of recovery paralleled these measures (Spearman correlation p < 0.001) with all but 2 patients achieving the minimum clinical important difference in DRI by 12 months compared to baseline. However, the GPE score had a higher proportion of improving responses than DRI at each time-point. DISCUSSION: Functional recovery is a key determinant in patients returning to work, providing for themselves and their family or resuming independent living for older patients. This study has demonstrated time-related improvements in combined OFOMs measuring mobility, strength, agility and balance paralleling patients' perception of recovery in the 12 months after open lower limb fractures. Over the same time-frame, the simple GPE score compared favourably with the DRI. Such parameters could become part of a defined core outcomes set. Focussing rehabilitation towards these combined OFOMs may help hasten recovery. TRIAL REGISTRATION: South West Wales REC 06/WMW02/10).

In Vitro Benchmarking Study of Ventricular Assist Devices in Current Clinical Use.

BACKGROUND: Left ventricular assist devices (LVADs) offer live-saving therapy to transplant-ineligible heart failure patients. A major limitation of the technology includes pump thrombosis, bleeding, and recurrent infection that prove difficult to predict from in vivo animal testing. Shear stress introduced by the LVAD affects more than just hemolysis because platelets, leukocytes, and plasma proteins all contribute to the propensity for complications. It is important to assess overall damage by a new device against a baseline as early as possible in the development process so that design iterations can be made if required. METHODS: Explanted VADs currently in clinical use (HeartMate 2 and HVAD) were carefully cleaned, inspected, and run at 5 L/min and pressure at 100 mmHg in a standard 500 mL mock circulatory loop using bovine blood. The CentriMag was used as a control pump because of its low blood damage profile. Samples were collected at regular intervals and the following were analyzed: complete cell counts, hemolysis, platelet activation, leukocyte-derived microparticles (LMPs), and von Willebrand factor (vWF) degradation. RESULTS: The HeartMate 2 had the highest levels of hemolysis and platelet activation after 6 hours compared with the HVAD and CentriMag. A decreased granulocyte count, high numbers of LMPs and CD11bBrightHLADR- LMPs, and decreased vWF collagen binding activity was most evident in the HVAD. CONCLUSIONS: The results indicate that it is possible to observe differences between different pump designs during in vitro testing that might translate to clinical performance. This study demonstrates the importance of developing standard in vitro total blood damage methods against which device developers could use to modify design to reduce complication risk long before implantation.

Mechanical assist devices for acute cardiogenic shock.

BACKGROUND: Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra-aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer-term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long-term VAD. OBJECTIVES: To assess whether mechanical assist devices improve survival in people with acute cardiogenic shock. SEARCH METHODS: We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions. SELECTION CRITERIA: Randomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra-aortic balloon pump and inotropic support. DATA COLLECTION AND ANALYSIS: We performed data collection and analysis according to the published protocol. Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow-up), dialysis-dependent (30 days/end of follow-up), length of hospital stay and length of intensive care unit stay and major adverse events. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS: The search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta-analysis was performed only to assess the 30-day survival as there were insufficient data to perform any further meta-analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30-day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain. Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting. We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing. AUTHORS' CONCLUSIONS: There is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.

Generalisation and specialisation in hoverfly (Syrphidae) grassland pollen transport networks revealed by DNA metabarcoding.

Pollination by insects is a key ecosystem service and important to wider ecosystem function. Most species-level pollination networks studied have a generalised structure, with plants having several potential pollinators, and pollinators in turn visiting a number of different plant species. This is in apparent contrast to a plant's need for efficient conspecific pollen transfer. The aim of this study was to investigate the structure of pollen transport networks at three levels of biological hierarchy: community, species and individual. We did this using hoverflies in the genus Eristalis, a key group of non-Hymenopteran pollinators. We constructed pollen transport networks using DNA metabarcoding to identify pollen. We captured hoverflies in conservation grasslands in west Wales, UK, removed external pollen loads, sequenced the pollen DNA on the Illumina MiSeq platform using the standard plant barcode rbcL, and matched sequences using a pre-existing plant DNA barcode reference library. We found that Eristalis hoverflies transport pollen from 65 plant taxa, more than previously appreciated. Networks were generalised at the site and species level, suggesting some degree of functional redundancy, and were more generalised in late summer compared to early summer. In contrast, pollen transport at the individual level showed some degree of specialisation. Hoverflies defined as "single-plant visitors" varied from 40% of those captured in early summer to 24% in late summer. Individual hoverflies became more generalised in late summer, possibly in response to an increase in floral resources. Rubus fruticosus agg. and Succisa pratensis were key plant species for hoverflies at our sites Our results contribute to resolving the apparent paradox of how generalised pollinator networks can provide efficient pollination to plant species. Generalised hoverfly pollen transport networks may result from a varied range of short-term specialised feeding bouts by individual insects. The generalisation and functional redundancy of Eristalis pollen transport networks may increase the stability of the pollination service they deliver.

Ovine Leukocyte Microparticles Generated by the CentriMag Ventricular Assist Device In Vitro.

Ventricular assist devices (VADs) are a life-saving form of mechanical circulatory support in heart failure patients. However, VADs have not yet reached their full potential due to the associated side effects (thrombosis, bleeding, infection) related to the activation and damage of blood cells and proteins caused by mechanical stress and foreign materials. Studies of the effects of VADs on leukocytes are limited, yet leukocyte activation and damage including microparticle generation can influence both thrombosis and infection rates. Therefore, the aim was to develop a multicolor flow cytometry assessment of leukocyte microparticles (LMPs) using ovine blood and the CentriMag VAD as a model for shear stress. Ovine blood was pumped for 6 h in the CentriMag and regular samples analyzed for hemolysis, complete blood counts and LMP by flow cytometry during three different pump operating conditions (low flow, standard, high speed). The high speed condition caused significant increases in plasma-free hemoglobin; decreases in total leukocytes, granulocytes, monocytes, and platelets; increases in CD45+ LMPs as well as two novel LMP populations: CD11bbright /HLA-DR- and CD11bdull /HLA-DR+ , both of which were CD14- /CD21- . CD11bbright /HLA-DR- LMPs appeared to respond to an increase in shear magnitude whereas the CD11bdull /HLA-DR+ LMPs significantly increased in all pumping conditions. We propose that these two populations are released from granulocytes and T cells, respectively, but further research is needed to better characterize these two populations.

The effect of multitasking on the communication skill and clinical skills of medical students.

BACKGROUND: Mental workload is an abstract concept that perceives cognition as the brain having a small and finite capacity to process information, with high levels of workload associated with poor performance and error. While an individual may be able to complete two different tasks individually, a combination of tasks may lead to cognitive overload and poor performance. In many high-risk industries, it is common to measure mental workload and then to redesign tasks until cognitive overload is avoided. This study aimed to measure the effect of multitasking on the mental workload and performance of medical students completing single and combined clinical tasks. METHODS: Medical students who had completed basic clinical skills training in a single undergraduate Medical School completed four standardised tasks for a total of four minutes each, consisting of: inactivity, listening, venepuncture and a combination of listening and venepuncture. Task performance was measured using standard binary checklists and with mental workload measured using a secondary task method. RESULTS: The tasks were successfully completed by 40 subjects and as expected, mental workload increased with task complexity. Combining the two tasks showed no difference in the associated mental workload and performance at venepuncture (p = 0.082) However, during the combined task, listening appeared to deteriorate (p < 0.001). CONCLUSIONS: If staff are expected to simultaneously complete multiple tasks then they may preferentially shed communication tasks in order to maintain their performance of physical tasks, leading to the appearance of poor communication skills. Although this is a small-scale study in medical students it suggests that the active assessment and management of clinician workload in busy clinical settings may be an effective strategy to improve doctor-patient communication.

Symbiont-mediated RNA interference in insects.

RNA interference (RNAi) methods for insects are often limited by problems with double-stranded (ds) RNA delivery, which restricts reverse genetics studies and the development of RNAi-based biocides. We therefore delegated to insect symbiotic bacteria the task of: (i) constitutive dsRNA synthesis and (ii) trauma-free delivery. RNaseIII-deficient, dsRNA-expressing bacterial strains were created from the symbionts of two very diverse pest species: a long-lived blood-sucking bug, Rhodnius prolixus, and a short-lived globally invasive polyphagous agricultural pest, western flower thrips (Frankliniella occidentalis). When ingested, the manipulated bacteria colonized the insects, successfully competed with the wild-type microflora, and sustainably mediated systemic knockdown phenotypes that were horizontally transmissible. This represents a significant advance in the ability to deliver RNAi, potentially to a large range of non-model insects.

Epilepsy and deprivation, a data linkage study.

OBJECTIVE: To investigate whether the link between epilepsy and deprivation is due to factors associated with deprivation (social causation) or factors associated with a diagnosis of epilepsy (social drift). METHODS: We reviewed electronic primary health care records from 2004 to 2010, identifying prevalent and incident cases of epilepsy and recording linked deprivation scores. Logistic and Poisson regression models were used to calculate odds ratios and incidence rate ratios. The change in deprivation was measured 10 years after the initial diagnosis of epilepsy for a cohort of people. RESULTS: Between 2004 and 2010, 8.1 million patient-years of records were reviewed. Epilepsy prevalence and incidence were significantly associated with deprivation. Epilepsy prevalence ranged from 1.13% (1.07-1.19%) in the most deprived decile to 0.49% (0.45-0.53%) in the least deprived decile (adjusted odds ratio 0.92, p < 0.001). Epilepsy incidence ranged from 40/100,000 per year in the most deprived decile to 19/100,000 per year in the least deprived decile (adjusted incidence rate ratio 0.94, p < 0.001). There was no statistically significant change in deprivation index decile 10 years after a new diagnosis of epilepsy (mean difference -0.04, p = 0.85). SIGNIFICANCE: Epilepsy prevalence and incidence are strongly associated with deprivation; the deprivation score remains unchanged 10 years after a diagnosis of epilepsy. These findings suggest that increasing rates of epilepsy in deprived areas are more likely explained by social causation than by social drift. The nature of the association between incident epilepsy and social deprivation needs further exploration.

Evaluation of 2 novel devices for calculation of fluid requirements in pediatric burns.

OBJECTIVES: The Parkland formula for maintenance and resuscitation fluid requirements in the first 24 hours after pediatric burns is widely used, but calculation errors frequently occur. Two different novel aids to calculation, a dedicated electronic device and a mechanical disc calculator, are described and compared with the conventional method of calculation (pen and paper, assisted by a general purpose calculator). METHODS: In a blinded randomized volunteer study, 21 participants performed a total of 189 calculations using simulated patient data to compare the accuracy and speed of 3 different methods for calculating resuscitation fluid requirements based on the pediatric Parkland formula. Bespoke software generated the simulated patient data and recorded accuracy and speed of all participant responses. RESULTS: Sixty-five percent of calculations with the electronic device, 35% using the disc and 44% using the pen/paper methods were within ±5% of the correct value and considered "correct" for clinical purposes. The method used strongly affected the tendency to make errors (logistic regression). With thresholds of error magnitude classed as very small (>5%), small (>25%), medium (>50%) and large (>100%) of the correct value respectively, the electronic method produced fewer errors than both disc and pen/paper methods at all error thresholds. Disc produced more errors than pen/paper at the greater than 5% threshold but fewer at the greater than 25%, greater than 50%, and greater than 100% thresholds. CONCLUSIONS: Both novel devices provide safer and faster alternatives to conventional methods for calculation of fluid requirements in pediatric burns.

Multi-decadal range changes vs. thermal adaptation for north east Atlantic oceanic copepods in the face of climate change.

Populations may potentially respond to climate change in various ways including moving to new areas or alternatively staying where they are and adapting as conditions shift. Traditional laboratory and mesocosm experiments last days to weeks and thus only give a limited picture of thermal adaptation, whereas ocean warming occurring over decades allows the potential for selection of new strains better adapted to warmer conditions. Evidence for adaptation in natural systems is equivocal. We used a 50-year time series comprising of 117 056 samples in the NE Atlantic, to quantify the abundance and distribution of two particularly important and abundant members of the ocean plankton (copepods of the genus Calanus) that play a key trophic role for fisheries. Abundance of C. finmarchicus, a cold-water species, and C. helgolandicus, a warm-water species, were negatively and positively related to sea surface temperature (SST) respectively. However, the abundance vs. SST relationships for neither species changed over time in a manner consistent with thermal adaptation. Accompanying the lack of evidence for thermal adaptation there has been an unabated range contraction for C. finmarchicus and range expansion for C. helgolandicus. Our evidence suggests that thermal adaptation has not mitigated the impacts of ocean warming for dramatic range changes of these key species and points to continued dramatic climate induced changes in the biology of the oceans.

Comparison of three techniques using the Parkland Formula to aid fluid resuscitation in adult burns.

We performed a randomised study to compare the accuracy and speed of three different techniques (pen and paper, electronic calculator and a novel graphic device: 'nomogram') for calculation of resuscitation fluid requirements for adults in the first 24 h of burn injury, based on the Parkland Formula. We also assessed acceptability of each technique using visual analogue scores and qualitative analysis of free text responses. 28 participants performed 252 calculations using a series of computer generated simulated patient data. For nomogram, electronic calculator, pen and paper: Magnitude of error [low (≥25%), medium (≥50%), high (≥75%)]: [6.0%, 1.2%, 0%], [17.9%, 14.3%, 8.3%], [25%, 16.7%, 9.5%]; p<0.002. Calculation time: [sec: mean (SD)]: 94(34), 73(31), 214(103); p<0.001. The mean (SD) of the difficulty scores for each method were 23(17), 17(14) and 70(21) out of 100. Of the 28 participants 15 preferred the calculator, 12 preferred the nomogram and 1 scored the calculator and nomogram equally (table 3). The nomogram was significantly more accurate at all levels, almost as fast as an electronic calculator, and deemed easy to use. It is low cost and robust, and provides a rapid means of detecting and preventing the large errors that we have shown can occur when an electronic device is used as the only method of calculation. We therefore suggest that the Parkland Formula nomogram is a suitable method for calculation of resuscitation fluid requirements in adult burns. Fluid requirement should, however, be reviewed frequently, and adjusted to ensure adequate organ perfusion.

Embedding retrieval practice in undergraduate biochemistry teaching using PeerWise.

Retrieval practice is an evidence-based approach to teaching; here, we evaluate the use of PeerWise for embedding retrieval practice into summative assessment. PeerWise allows anonymous authoring, sharing, answering, rating, and feedback on peer-authored multiple choice questions. PeerWise was embedded as a summative assessment in a large first-year introductory biochemistry module. Engagement with five aspects of the tool was evaluated against student performance in coursework, exam, and overall module outcome. Results indicated a weak-to-moderate positive but significant correlation between engagement with PeerWise and assessment performance. Student feedback showed PeerWise had a polarizing effect; the majority recognized the benefits as a learning and revision tool, but a minority strongly disliked it, complaining of a lack of academic moderation and irrelevant questions unrelated to the module. PeerWise can be considered a helpful learning tool for some students and a means of embedding retrieval practice into summative assessment.

Risk factors for burn contractures: A cross-sectional study in a lower income country.

Risk factors for burn contractures require further study, especially in low and middle-income countries (LMICs); existing research has been predominantly conducted in high income countries (HICs). This study aimed to identify risk factors for burn contractures of major joints in a low-income setting. Potential risk factors (n = 104) for burn contracture were identified from the literature and a survey of clinicians with extensive experience in low and middle-income countries (LMIC). An observational cross-sectional study of adult burn survivors was undertaken in Bangladesh to evaluate as many of these risk factors as were feasible against contracture presence and severity. Forty-eight potential risk factors were examined in 48 adult patients with 126 major joints at risk (median 3 per participant) at a median of 2.5 years after burn injury. Contractures were present in 77% of participants and 52% of joints overall. Contracture severity was determined by measurement of loss of movement at all joints at risk. Person level risk factors were defined as those that were common to all joints at risk for the participant and only documented once, whilst joint level risk factors were documented for each of the participant's included joints at risk. Person level risk factors which were significantly correlated with loss of range of movement (ROM) included employment status, full thickness burns, refusal of skin graft, discharged against medical advice, low frequency of follow up and lack of awareness of contracture development. Significant joint level risk factors for loss of ROM included anatomical location, non-grafted burns, and lack of pressure therapy. This study has examined the largest number of potential contracture risk factors in an LMIC setting to date. A key finding was that risk factors for contracture in low-income settings may differ substantially from those seen in high income countries, which has implications for effective prevention strategies in these countries. Better whole person and joint outcome measures are required for accurate determination of risk factors for burn contracture. Recommendations for planning and reporting on future contracture risk factor studies are made.

Using the Traditional Ex Vivo Whole Blood Model to Discriminate Bacteria by Their Inducible Host Responses.

Whole blood models are rapid and versatile for determining immune responses to inflammatory and infectious stimuli, but they have not been used for bacterial discrimination. Staphylococcus aureus, S. epidermidis and Escherichia coli are the most common causes of invasive disease, and rapid testing strategies utilising host responses remain elusive. Currently, immune responses can only discriminate between bacterial 'domains' (fungi, bacteria and viruses), and very few studies can use immune responses to discriminate bacteria at the species and strain level. Here, whole blood was used to investigate the relationship between host responses and bacterial strains. Results confirmed unique temporal profiles for the 10 parameters studied: IL-6, MIP-1α, MIP-3α, IL-10, resistin, phagocytosis, S100A8, S100A8/A9, C5a and TF3. Pairwise analysis confirmed that IL-6, resistin, phagocytosis, C5a and S100A8/A9 could be used in a discrimination scheme to identify to the strain level. Linear discriminant analysis (LDA) confirmed that (i) IL-6, MIP-3α and TF3 could predict genera with 95% accuracy; (ii) IL-6, phagocytosis, resistin and TF3 could predict species at 90% accuracy and (iii) phagocytosis, S100A8 and IL-10 predicted strain at 40% accuracy. These data are important because they confirm the proof of concept that host biomarker panels could be used to identify bacterial pathogens.

Putative prognostic epithelial-to-mesenchymal transition biomarkers for aggressive prostate cancer.

Prostate cancer is the second most frequently diagnosed cancer worldwide and is the sixth leading cause of cancer deaths in men, yet it varies greatly in its aggressiveness. Currently, it is not possible to adequately differentiate between patients whose tumors will remain indolent and those patients whose disease will progress, resulting in unnecessary aggressive treatment. Consequently, there is an urgent need to identify markers of prostate cancer progression, invasiveness and metastasis to more accurately predict prognosis. The aim of this study was to assess the ability of key epithelial-to-mesenchymal transition molecules in identifying prostate cancer patients who are likely to develop aggressive tumors. Using 215 archival patient tissue samples, immunohistochemistry was applied to examine the expression and sub-cellular localization of E-Cadherin, Snail, Slug, Twist, Vimentin, BMP-2 and BMP-7. Of the seven markers assessed, a significantly increased expression of Snail protein was observed within the nucleus of prostate cancer cells and was strongly associated with increasing Gleason score and clinical stage. In addition, loss of E-Cadherin expression at the cellular membrane of prostate cancer cells was also significantly associated with increasing Gleason score, clinical stage, and additionally, a reduction in survival.

Comparison of three techniques for calculation of the Parkland formula to aid fluid resuscitation in paediatric burns.

CONTEXT: Inadequate fluid resuscitation of acute burns may result in hypovolaemic shock. Excessive fluid resuscitation may result in fluid overload. A nomogram which uses the popular Parkland formula and '4-2-1' regime has been recently described to facilitate the calculation of fluid requirements in children during the first 24 h following burn injury. OBJECTIVE: To compare the accuracy and speed of calculation of three different methods (pen and paper, electronic calculator and nomogram), which all use the Parkland formula and '4-2-1' regime to calculate maintenance and resuscitation fluid requirements for children in the first 24 h after burn injury. DESIGN: A randomised volunteer study using computer-generated simulated patient data. SETTING: Welsh Centre for Burns, ABM University Local Health Board, Swansea, UK. Data were collected between February 2011 and October 2011. PARTICIPANTS: The group consisted of 36 volunteers including trainee and consultant surgeons and anaesthetists. INTERVENTION: Thirty-six participants performed 318 calculations, using each of the three methods of calculation up to three times. MAIN OUTCOME MEASURES: Accuracy, speed and acceptability of the different methods. RESULTS: For nomogram, calculator and pen and paper: magnitude of error [low (≥25%), medium (≥50%) and high (≥75%)]: [5.7, 4.7 and 3.8%], [12.1, 12.1 and 7.5%], [28.6, 21.9 and 16.2%]; [P <0.001, P = 0.001 and P = 0.006]. Calculation time: [s; mean (SD)]: 121 (48), 109 (52) and 240 (140); P <0.001. The mean (SD) of the difficulty scores were 17.3 (13), 20.6 (13.4) and 62.2 (23.4); P <0.001. CONCLUSION: The nomogram was the most accurate method of calculating fluid requirements using the Parkland formula, was only slightly slower than the electronic calculator and was deemed the easiest to use. The nomogram is also low cost, robust, and provides a rapid means of detecting and preventing the large errors that we have shown can occur when an electronic device is used as the primary method of resuscitation fluid calculation. We, therefore, suggest that the nomogram is a suitable method for the calculation of the Parkland formula to guide resuscitation and maintenance fluid requirements in the first 24 h of paediatric burns or for cross-checking the results obtained by other means of calculation.

What is the best clinical test for Achilles tendinopathy?

BACKGROUND: Differential diagnosis of Achilles pathology is demanding. This study evaluates the diagnostic accuracy of clinical tests identified for a chronic mid body Achilles tendinopathy. Ultrasound scanning provides the reference standard. METHODS: Twenty-one participants with, and without, an Achilles tendinopathy, had an ultrasound scan followed immediately by the application of ten clinical tests. The accuracy and reproducibility of each test was determined. RESULTS: The most valid tests are; pain on palpation of the tendon (sensitivity 84%, specificity 73%, kappa 0.74-0.96) and the subjective reporting of pain 2-6 cm above the insertion into the calcaneum (sensitivity 78%, specificity 77%, kappa 0.75-0.81). CONCLUSION: Only location of pain and pain on palpation were found to be sufficiently reliable and accurate, to be recommended for use.

The association of anxiety disorders and depression with facial scarring: population-based, data linkage, matched cohort analysis of 358 158 patients.

BACKGROUND: Estimates suggest that 1 in 100 people in the UK live with facial scarring. Despite this incidence, psychological support is limited. AIMS: The aim of this study was to strengthen the case for improving such support by determining the incidence and risk factors for anxiety and depression disorders in patients with facial scarring. METHOD: A matched cohort study was performed. Patients were identified via secondary care data sources, using clinical codes for conditions resulting in facial scarring. A diagnosis of anxiety or depression was determined by linkage with the patient's primary care general practice data. Incidence was calculated per 1000 person-years at risk (PYAR). Logistic regression was used to determine risk factors. RESULTS: Between 2009 and 2018, 179 079 patients met the study criteria and were identified as having a facial scar, and matched to 179 079 controls. The incidence of anxiety in the facial scarring group was 10.05 per 1000 PYAR compared with 7.48 per 1000 PYAR for controls. The incidence of depression in the facial scarring group was 16.28 per 1000 PYAR compared with 9.56 per 1000 PYAR for controls. Age at the time of scarring, previous history of anxiety or depression, female gender, socioeconomic status and classification of scarring increased the risk of both anxiety disorders and depression. CONCLUSIONS: There is a high burden of anxiety disorders and depression in this patient group. Risk of these mental health disorders is very much determined by factors apparent at the time of injury, supporting the need for psychological support.

Functional outcome and patient satisfaction with a 'self-care' protocol for minimally displaced distal radius fractures : a service evaluation.

AIMS: We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. METHODS: All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted. RESULTS: Overall 71/101 patients completed the telephone consultation; no patients required surgery, and the mean and median PRWE scores were 23.9/100 (SD 24.9) and 17.0/100 (interquartile range (IQR) 0 to 40), respectively. Mean patient satisfaction with treatment was 34.3/40 (SD 9.2), and 65 patients (92%) were satisfied or highly satisfied. In total there were 16 contact calls, 12 requests for a consultant review, no formal complaints, and 15 minor adjustment suggestions to improve patient experience. A relationship was found between intra-articular injuries and lower patient satisfaction scores (p = 0.025), however no relationship was found between PRWE scores and the nature of the fracture. Also, no relationship was found between the type of immobilization and the functional outcome or patient satisfaction. Cost analysis of the self-care pathway V traditional pathway showed a cost savings of over £13,500 per year with the new self-care model compared to the traditional model. CONCLUSION: Our study supports a VFC self-care pathway for patients with minimally displaced distal radius fractures. The pathway provides a good level of patient satisfaction and function. To improve the service, we will make minor amendments to our patient information sheet.Cite this article: Bone Jt Open 2022;3(9):726-732.