Clinical outcomes and cost-effectiveness of three different compression systems in newly-diagnosed venous leg ulcers in the UK.

OBJECTIVE: To assess clinical outcomes and cost-effectiveness of using a two-layer cohesive compression bandage (TLCCB; Coban 2) compared with a two-layer compression system (TLCS; KTwo) and a four-layer compression system (FLCS; Profore) in treating newly-diagnosed venous leg ulcers (VLUs) in clinical practice in the UK, from the perspective of the NHS. METHOD: This was a retrospective cohort analysis of the case records of patients with newly-diagnosed VLUs randomly extracted from The Health Improvement Network (THIN) database (a nationally representative database of clinical practice among patients registered with general practitioners in the UK) who were treated with either TLCCB (n=200), TLCS (n=200) or FLCS (n=200). The clinical outcomes and cost-effectiveness of the alternative compression systems were estimated over six months after starting treatment. RESULTS: Patients' mean age was 72 years and 58% were female. Time from wound onset to the start of compression was a mean of two months, and when starting compression the wound size was a mean of 45 cm2. The distribution of healing was significantly different between the three groups; 76% of wounds in the TLCCB group healed by six months compared with 70% and 64% in the TLCS and FLCS groups, respectively (p=0.006). Time to healing was significantly less in the TLCCB group compared with the two other groups (p=0.003). Patients in the TLCCB group experienced better health-related quality of life over six months (0.413 quality-adjusted life years (QALYs) per patient), compared with the TLCS and FLCS groups (0.404 and 0.396 QALYs per patient, respectively). The mean six-month NHS management cost was £3045, £3842 and £4480 per patient in the TLCCB, TLCS and FLCS groups, respectively. CONCLUSION: Real-world evidence demonstrates that treating newly-diagnosed VLUs with TLCCB, compared with the other two compression systems, affords a more cost-effective use of NHS-funded resources in clinical practice since it resulted in an increased healing rate, better health-related quality of life and a reduction in NHS management cost.

Long-term trends in particulate matter from wood burning in the United Kingdom: Dependence on weather and social factors.

Particulate matter from wood burning emissions (Cwood) was quantified at five locations in the United Kingdom (UK), comprising three rural and two urban sites between 2009 and 2021. The aethalometer method was used. Mean winter Cwood concentrations ranged from 0.26 µg m-3 (in rural Scotland) to 1.30 µg m-3 (London), which represented on average 4% (in rural environments) and 5% (urban) of PM10 concentrations; and 8% of PM2.5. Concentrations were greatest in the evenings in winter months, with larger evening concentrations in the weekends at the urban sites. Random-forest (RF) machine learning regression models were used to reconstruct Cwood concentrations using both meteorological and temporal explanatory variables at each site. The partial dependency plots indicated that temperature and wind speed were the meteorological variables explaining the greatest variability in Cwood, with larger concentrations during cold and calm conditions. Peaks of Cwood concentrations took place during and after events that are celebrated with bonfires. These were Guy Fawkes events in the urban areas and on New Year's Day at the rural sites; the later probably related to long-range transport. Time series were built using the RF. Having removed weather influences, long-term trends of Cwood were estimated using the Theil Sen method. Trends for 2015-2021 were downward at three of the locations (London, Glasgow and rural Scotland), with rates ranging from -5.5% year-1 to -2.5% year-1. The replacement of old fireplaces with lower emission wood stoves might explain the decrease in Cwood especially at the urban sites The two rural sites in England observed positive trends for the same period but this was not statistically significant.

The performance of the World Rugby Head Injury Assessment Screening Tool: a diagnostic accuracy study.

BACKGROUND: Off-field screening tools, such as the Sports Concussion Assessment Tool (SCAT), have been recommended to identify possible concussion following a head impact where the consequences are unclear. However, real-life performance, and diagnostic accuracy of constituent sub-tests, have not been well characterized. METHODS: A retrospective cohort study was performed in elite Rugby Union competitions between September 2015 and June 2018. The study population comprised consecutive players identified with a head impact event undergoing off-field assessments with the World Rugby Head Injury Assessment (HIA01) screening tool, an abridged version of the SCAT3. Off-field screening performance was investigated by evaluating real-life removal-from-play outcomes and determining the theoretical diagnostic accuracy of the HIA01 tool, and individual sub-tests, if player-specific baseline or normative sub-test thresholds were strictly applied. The reference standard was clinically diagnosed concussion determined by serial medical assessments. RESULTS: One thousand one hundred eighteen head impacts events requiring off-field assessments were identified, resulting in 448 concussions. Real-life removal-from-play decisions demonstrated a sensitivity of 76.8% (95% CI 72.6-80.6) and a specificity of 86.6% (95% CI 83.7-89.1) for concussion (AUROC 0.82, 95% CI 0.79-0.84). Theoretical HIA01 tool performance worsened if pre-season baseline values (sensitivity 89.6%, specificity 33.9%, AUROC 0.62, p < 0.01) or normative thresholds (sensitivity 80.4%, specificity 69.0%, AUROC 0.75, p < 0.01) were strictly applied. Symptoms and clinical signs were the HIA01 screening tool sub-tests most predictive for concussion; with immediate memory and tandem gait providing little additional diagnostic value. CONCLUSIONS: These findings support expert recommendations that clinical judgement should be used in the assessment of athletes following head impact events. Substitution of the tandem gait and 5-word immediate memory sub-tests with alternative modes could potentially improve screening tool performance.

PM2.5 on the London Underground.

INTRODUCTION: Despite the London Underground (LU) handling on average 2.8 million passenger journeys per day, the characteristics and potential health effects of the elevated concentrations of metal-rich PM2.5 found in this subway system are not well understood. METHODS: Spatial monitoring campaigns were carried out to characterise the health-relevant chemical and physical properties of PM2.5 across the LU network, including diurnal and day-to-day variability and spatial distribution (above ground, depth below ground and subway line). Population-weighted station PM2.5 rankings were produced to understand the relative importance of concentrations at different stations and on different lines. RESULTS: The PM2.5 mass in the LU (mean 88 µg m-3, median 28 µg m-3) was greater than at ambient background locations (mean 19 µg m-3, median 14 µg m-3) and roadside environments in central London (mean 22 µg m-3, median 14 µg m-3). Concentrations varied between lines and locations, with the deepest and shallowest submerged lines being the District (median 4 µg m-3) and Victoria (median 361 µg m-3 but up to 885 µg m-3). Broadly in agreement with other subway systems around the world, sampled LU PM2.5 comprised 47% iron oxide, 7% elemental carbon, 11% organic carbon, and 14% metallic and mineral oxides. Although a relationship between line depth and air quality inside the tube trains was evident, there were clear influences relating to the distance from cleaner outside air and the exchange with cabin air when the doors open. The passenger population-weighted exposure analysis demonstrated a method to identify stations that should be prioritised for remediation to improve air quality. CONCLUSION: PM2.5 concentrations in the LU are many times higher than in other London transport Environments. Failure to include this environment in epidemiological studies of the relationship between PM2.5 and health in London is therefore likely to lead to a large exposure misclassification error. Given the significant contribution of underground PM2.5 to daily exposure, and the differences in composition compared to urban PM2.5, there is a clear need for well-designed studies to better understand the health effects of underground exposure.

Fulminant descending mediastinitis secondary to infectious mononucleosis.

Descending mediastinitis is a rare, life-threatening condition caused by contiguous spread of oropharyngeal or cervical infection into the mediastinum. Infectious mononucleosis generally results in a self-limited illness characterized by fever, pharyngitis and lymphadenopathy. We present an exceptional case of an 18-year-old with infectious mononucleosis complicated by progressive bacterial superinfection and fulminant descending mediastinitis. After resuscitation, broad spectrum antibiotics, critical care support and definitive surgical management, they made a full recovery.

Sport concussion assessment tool-Third edition normative reference values for professional Rugby Union players.

OBJECTIVES: To establish normative reference data for the SCAT3 in professional Rugby Union players. DESIGN: A cross sectional study in professional Rugby Union players competing in national and international professional competitions between 2015 and 2016. METHODS: The SCAT3 was administered pre-season or prior to tournaments. Data was collected electronically using a custom tablet application. SCAT3 subcomponents distributions were described and normative ranges determined using percentile cut-offs for average, unusually low/high, and extremely low/high scores. The association between player characteristics and performance in SCAT3 subcomponents was also investigated in exploratory analyses. RESULTS: A total of 3611 professional Rugby Union players were included. The most common baseline symptom was fatigue (14%). The symptom score median (md) was 0 (interquartile range (IQR)=0-1). Symptom severity md was 0 (IQR=0-1). The md of the SAC score was 28 (IQR=26-29). The md of the MBESS was 2 (IQR=0-4). The Tandem gait md was 11.1s (IQR=10.0-12.7s). Upper limb coordination was normal in 98.4%. Younger age and lower educational level were associated with worse performance on delayed recall and reverse month sub-components of the SCAT3 (p<0.0001). No statistically significant differences in SCAT3 subcomponents were evident across gender. CONCLUSIONS: Representative normative reference values for the SCAT3 among professional Rugby Union players are provided. Baseline performance on concentration and delayed recall tests may be lower in younger athletes or in those with lower educational level.

The accuracy and reproducibility of video assessment in the pitch-side management of concussion in elite rugby.

OBJECTIVES: To investigate the accuracy and reliability of side-line video review of head impact events to aid identification of concussion in elite sport. DESIGN: Diagnostic accuracy and inter-rater agreement study. METHODS: Immediate care, match day and team doctors involved in the 2015 Rugby Union World Cup viewed 20 video clips showing broadcaster's footage of head impact events occurring during elite Rugby matches. Subjects subsequently recorded whether any criteria warranting permanent removal from play or medical room head injury assessment were present. The accuracy of these ratings were compared to consensus expert opinion by calculating mean sensitivity and specificity across raters. The reproducibility of doctor's decisions was additionally assessed using raw agreement and Gwets AC1 chance corrected agreement coefficient. RESULTS: Forty rugby medicine doctors were included in the study. Compared to the expert reference standard overall sensitivity and specificity of doctors decisions were 77.5% (95% CI 73.1-81.5%) and 53.3% (95% CI 48.2-58.2%) respectively. Overall there was raw agreement of 67.8% (95% CI 57.9-77.7%) between doctors across all video clips. Chance corrected Gwets AC1 agreement coefficient was 0.39 (95% CI 0.17-0.62), indicating fair agreement. CONCLUSIONS: Rugby World Cup doctors' demonstrated moderate accuracy and fair reproducibility in head injury event decision making when assessing video clips of head impact events. The use of real-time video may improve the identification, decision making and management of concussion in elite sports.

Intervention assessments in the control of PM10 emissions from an urban waste transfer station.

While vehicle emissions present the most widespread cause of breaches of EU air quality standards in urban areas of the UK, the greatest PM10 concentrations are often recorded close to small industrial sites with significant and long-term public exposure within close proximity. This is particularly the case in London, where monitoring in densely populated locations, adjacent to waste transfer stations (WTS), routinely report the highest PM10 concentrations in the city. This study aims to assess the impact of dust abatement measures taken at a WTS in west London and, in so doing, develop analysis techniques transferrable to other similar industrial situations. The study was performed in a 'blinded fashion', i.e., no details of operating times, activities or remediation measures were provided prior to the analysis. The study established that PM10 concentrations were strongly related to the industrial area's working hours and atmospheric humidity. The primary source of local particulate matter during working hours was found to be from the industrial area itself, not from the adjacent road serving the site. CUSUM analysis revealed a strong, sustained change point coinciding with a number of modifications at the WTS. Analysis suggested that introducing a vehicle washer bay, leading to a less dry and dusty yard, and ceasing stock piling and waste handling activities outside of the open shed had the greatest effect on PM10 concentrations. The techniques developed in this study should empower licensing authorities to more effectively characterise and mitigate particulate matter generated by urban industrial activities, thereby improving the health and quality of life of the local population.

Physicians and administrators can work together.

This article describes the working relationship between the administration and medical staff of the Mid-Maine Medical Center which is comprised of two separate modern hospitals. The authors advocate the philosophy that "a hospital which harnesses the medical staff's considerable talent and expertise through sound organizational input will be a stronger institution." They explain that patient care is becoming increasingly complex and that management decisions impact heavily on the care provided. In 1973, the Medical Center changed from its traditional organizational form of having a full-time medical director and an administrator report to the board of directors, to a modified corporate model designed to increase physician involvement. In the new organization, the vice president of finance and a part-time chief of staff (acting as vice president for medical affairs) report to the president (former medical director) who, in turn, is responsible to the board of trustees. The authors attribute the success of the reorganization to the CEO's willingness to delegate and share authority, not to the CEO's physician background. Planning at the institution involves a committee of six physicians, four administrators, and one full-time planner. A budgeting committee of three physicians and three administrators is responsible for the review of the budget as well as for making recommendations for the executive board for the expected volume of services. It is concluded that there is no perfect way to run a hospital, but the involvement of doctors in hospital decisions is necessary.

Appraisal of collection techniques and storage temperatures on turkey plasma cholinesterase levels and blood glutathione concentrations.

The effects of different blood collection procedures, various storage temperatures and durations of storage on the levels of plasma cholinesterase and whole blood glutathione in turkeys were investigated. Collection of blood through vacutainers yielded satisfactory results. Whereas the plasma cholinesterase activity remained unchanged even after three weeks of storage at -17.8 degrees C., blood glutathione concentration was unaffected only when the samples were stored at -28.9 degrees C for the three weeks. The range of mean activity was from 4.64 to 4.71 DeltapH/hour x 10 for cholinesterase and from 44.85 to 47.91 mgm/100 ml for glutathione.