Improvements in National Code Red transfusion practice in Scotland after adoption of recommendations from the Scottish National Code Red 2015 review.

AIMS: The Scottish Transfusion and Laboratory Support in Trauma Group (TLSTG) previously reviewed all National Code Red activations between June 1st 2013 and October 31st 2015, generating a number of recommendations to be adopted to optimise the transfusion support given to patients following major trauma in Scotland. A repeat National survey was undertaken for all patients for whom Code Red was activated between 1st November 2015 and 31st December 2017. METHODS: A clinical and transfusion lead for each centre entered anonymised data onto a secure electronic database (REDCap). RESULTS: During the study period there were 66 activations (24 South-East of Scotland, 32 West, 10 East). Mean age was 45 years and 88% were male. Mean Injury Severity Score (ISS) was 28 with 75% blunt trauma. 93% (62/66) of Code Red patients received blood components with a 300% increase in pre-hospital transfusion (48 vs 16 patients; p<0.001). Median time from 999 call to Code Red activation reduced significantly to 37 min from 70 min (p = 0.01) giving the hospital more time to prepare transfusion components. 78% patients received pre-hospital tranexamic acid (TXA; improved from 70%, p = 0.67, ns). Concentrated Red Cell (CRC): Fresh Frozen Plasma (FFP) ratio was always less than 2:1 and below 1.4:1 at 90 min, compared to 2013-15 when CRC: FFP ratios did not drop to below 2:1 until 150 min after arrival in the ED. Mean time for Full Blood Count (FBC; 46 mins versus 81; p = 0.004) and clotting (53 mins versus 119; p<0.001) result was reduced. Survival to hospital discharge was unchanged (66% versus 63%; p = 1.00 ns). CONCLUSIONS: Code Red practice has improved in several ways since our last survey with earlier Code Red activation, more patients receiving pre-hospital transfusion and improved CRC:FFP ratios. Interventions such as earlier on scene Code Red activation, provision of pre-hospital TXA, Emergency Department (ED) resuscitation room pre-thawed FFP and point-of-care viscoelastic coagulation testing have all contributed to these improvements in transfusion practice in Scotland.

Lipopolysaccharide reduces gonadotrophin-releasing hormone (GnRH) gene expression: role of RFamide-related peptide-3 and kisspeptin.

RFamide-related peptide (RFRP)-3 reduces luteinising hormone (LH) secretion in rodents. Stress has been shown to upregulate the expression of the RFRP gene (Rfrp) with a concomitant reduction in LH secretion, but an effect on expression of the gonadotrophin-releasing hormone (GnRH) gene (Gnrh1) has not been shown. We hypothesised that lipopolysaccharide (LPS)-induced stress affects expression of Rfrp, the gene for kisspeptin (Kiss1) and/or Gnrh1, leading to suppression of LH levels in rats. Intracerebroventricular injections of RFRP-3 (0.1, 1, 5 nmol) or i.v. LPS (15µgkg-1) reduced LH levels. Doses of 1 and 5 nmol RFRP-3 were then administered to analyse gene expression by in situ hybridisation. RFRP-3 (5 nmol) had no effect on Gnrh1 or Kiss1 expression. LPS stress reduced GnRH and Kiss1 expression, without affecting Rfrp1 expression. These data indicate that LPS stress directly or indirectly reduces Gnrh1 expression, but this is unlikely to be due to a change in Rfrp1 expression.

Sex differences in predictors of violent and non-violent juvenile offending.

In response to concerns regarding the rise in female juvenile violent crime and the dearth of gender-specific research, this study aimed to identify predictors of violent offending in female offenders. Data were extracted from risk assessments of 586 male and female juvenile offenders (aged 11-17 years) conducted between 2005 and 2009 by the Youth Offending Service in Gloucestershire, an English county. Information regarding the young people's living arrangements, family and personal relationships, education, emotional/mental health, thinking and behavior, and attitudes to offending was recorded. Comparisons were made between the violent male offenders (N = 185), the violent female offenders (N = 113), the non-violent male offenders (N = 150), and the non-violent female offenders (N = 138) for these variables. These were followed by a multinomial logistic regression analysis. The findings indicated that engaging in self-harm was the best predictor of being a female violent offender, with the predictors of giving into pressure from others and attempted suicide nearing significance. Furthermore, non-violent females were significantly less likely to lose control of their temper and more likely to give in to pressure from others than their violent counterparts. Non-violent males were significantly less likely to lose control of their temper and more likely to self-harm and give in to pressure from others than violent males. Although many similarities existed between sexes for predictors of violent offending, the findings of this study indicate that more attention needs to be paid to the mental health of female offenders.

Suspect aggression and victim resistance in multiple perpetrator rapes.

Several research studies have reported an elevated level of aggression in rapes committed by multiple perpetrators compared to rapes committed by lone suspects. Several factors that have been linked to elevated aggression in generic samples of rape were examined for the first time with a sample of multiple perpetrator rapes. Factors that might be associated with victim resistance were also investigated. Victim and offender characteristics, as well as the behaviors displayed by victims and offenders, were extracted from the police files of 89 multiple perpetrator stranger rapes perpetrated against female victims in the United Kingdom. These behaviors were rated for their level of suspect (non-sexual) aggression and victim resistance, respectively. Degree of victim resistance was significantly and positively associated with suspect aggression. Older victims were the recipients of significantly higher levels of suspect aggression. Victims who were incapacitated from drugs and/or alcohol were less likely to be the recipients of suspect aggression. Group leaders displayed more aggression towards the victim than the followers in the groups. The number of perpetrators was significantly related to the degree of resistance displayed by the victim with offences perpetrated by fewer suspects being characterized by more victim resistance. Research regarding cognitive appraisal during criminal interactions and the respective roles of offenders is referred to in considering these relationships.

Leadership in multiple perpetrator stranger rape.

Sexual offences by multiple perpetrators are more violent and involve more severe forms of sexual violation than those perpetrated by a lone offender. Often a clear leader exists within these groups. Questions have been raised as to the relative risk of reoffending and the potentially differing criminogenic needs of leaders and followers. However, a recent study comparing leaders and followers in juvenile multiple perpetrator rapes (t'Hart-Kerkhoffs et al., 2011) failed to find some of the expected differences. It was proposed that this might be due, in part, to the way leaders and followers were classified in the study. Before work can progress in this area, it is important to devise reliable and valid means of identifying leaders and followers in multiple perpetrator rape. This article reports on a study which investigated the utility of two different methods of identifying leadership. The Scale of Influence (Porter & Alison, 2001) was applied to a sample of 256 offenders responsible for 95 multiple perpetrator rapes from the United Kingdom. Following this, the relative number of directives uttered by offenders was used to designate leadership. In 66% of the offences sampled, a leader was designated using the number of directives uttered compared with 80% when using the Scale of Influence. When combining both measures to form a composite measure of leadership, this percentage increased to 89%. Classifications of offenders as leaders, followers, and neither, according to the Scale of Influence, the count of directives, and the composite measure, were compared with classifications made by a practitioner to assess their concordance. The composite measure showed the greatest agreement with practitioner opinion. These findings suggest that the Scale of Influence could be developed to take account of other ways that leadership is displayed during multiple perpetrator rapes.

The emergency surgical team - the way forward in emergency care?

INTRODUCTION: With reduced working hours and shift patterns, surgical training and continuity of patient care is being put at risk. We have devised a system for managing the emergency surgical patients in an effort to counteract these perceived problems. This study describes the emergency surgical team and audits its activity. PATIENTS AND METHODS: The emergency surgery team concept is described in detail. Over a 2-week period, general surgical referral data, patient management and operative activity were audited. RESULTS: A total of 229 patients were referred to the emergency surgical team with 159 treated conservatively, 45 underwent operative intervention and 25 were discharged without admission. Of the emergency surgical team referrals, 58% had gallstone pathology, appendicitis or constipation/non-specific abdominal pain. Average daily number of patients under the care of the emergency surgical team was 26 (range, 10-40). CONCLUSIONS: The consultant-led emergency surgical team look after many of the acutely sick surgical patients. Our system not only provides good teaching opportunities but ensures optimal continuity of patient care in a busy district general hospital. Such an approach to emergency surgical care has been successfully developed to optimise training opportunities and improve patient care in a setting of reduced working hours and shift systems in our hospital.