Civilian penetrating neck trauma at a level I trauma centre: A five-year retrospective case note review.

OBJECTIVES: To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of correlation between clinical signs of injury, operative findings and radiological reports. DESIGN: Retrospective case note review. SETTING: UK level I trauma centre April 2012-November 2017. PARTICIPANTS: Three hundred ten cases of PNT were drawn from electronic patient records. Data were extracted on hard and soft signs of vascular or aerodigestive tract injury, clinical management, radiological imaging and patient outcomes. MAIN OUTCOME MEASURES: Patient demographics, mechanism of injury, morbidity and mortality. The correlation between clinical signs, and radiological reports to internal injury on surgical exploration. RESULTS: Two hundred seventy-one (87.4%) male and 39 (13.6%) female patients with a mean age of 36 years (16-87) were identified. The most common causes of injury were assault 171 (55.2%) and deliberate self-harm 118 (38%). A knife was the most common instrument 240 (77.4%). Past psychiatric history was noted in 119 (38.4%), and 60 (19.4%) were intoxicated. 50% were definitively managed in theatre with a negative exploration rate of 38%, and 50% were managed in ED. Pre-operative radiological reports correlated with operative reports in 62% of cases with venous injury the most common positive and negative finding. Multivariate correlation was r = 0.89, p = 0.045, between hard signs plus positive radiology findings and internal injury on neck exploration. CONCLUSIONS: Management of PNT by clinical and radiological signs is safe and effective, and can be streamlined by a decision-making algorithm as proposed here.

A systematic review of remote otological assessment using video-otoscopy over the past 10 years: reliability and applications.

PURPOSE: This systematic review describes and evaluates the current literature on remote otological assessment using video-otoscopy with regards to reliability and potential applications. METHODS: Systematic review was conducted in accordance with the PRISMA statement. There was heterogeneity of included studies, so a descriptive analysis was undertaken. RESULTS: Seventeen studies were included for analysis conducted across a variety of healthcare settings. Overall, there was a trend towards acquisition of adequate images for diagnosis by non-otolaryngology-specialist facilitators with reasonable agreement between asynchronous images and controls; however, there was significant variation between the studies. CONCLUSION: Remote otological assessment using video-otoscopy shows potential as a safe and effective method for detecting the presence of ear disease in a wide range of healthcare settings. Barriers to the acquisition of adequate images include the presence of obstructing cerumen, and strategies to deal with this should be considered. Further work is required to evaluate endoscope-based systems to assess whether they will allow the acquisition of higher quality images.

Discrimination between benign, primary and secondary malignancies in lymph nodes from the head and neck utilising Raman spectroscopy and multivariate analysis.

BACKGROUND: The potential use of Raman spectroscopy (RS) for the detection of malignancy within lymph nodes of the head and neck was evaluated. RS measures the presence of biomolecules by the inelastic scattering of light within cells and tissues. This can be performed in vivo in real-time. METHODS: 103 lymph nodes were collected from 23 patients undergoing surgery for suspicious lymph nodes. Five pathologies, defined by consensus histopathology, were collected including reactive nodes (benign), Hodgkin's and non-Hodgkin's lymphomas, metastases from both squamous cell carcinomas and adenocarcinomas. Raman spectra were measured with 830 nm excitation from numerous positions on each biopsy. Spectral diagnostic models were constructed using principal component analysis followed by linear discriminant analysis (PCA-LDA), and by partial least squares discriminant analysis (PLS-DA) for comparison. Two-group models were constructed to distinguish between reactive and malignant nodes, and three-group models to distinguish between the benign, primary and secondary conditions. RESULTS: Results were validated using a repeated subsampling procedure. Sensitivities and specificities of 90% and 86% were obtained using PCA-LDA, and 89% and 88% using PLS-DA, for the two-group models. Both PCA-LDA and PLS-DA models were also found to be very successful at discriminating between pathologies in the three-group models achieving sensitivities and specificities of over 78% and 89% for PCA-LDA, and over 81% and 89% for PLS-DA for all three pathology groups. CONCLUSION: Raman spectroscopy and chemometric techniques can be successfully utilised in combination for discriminating between different cancerous conditions of lymph nodes from the head and neck.

Carer involvement with drug services: a qualitative study.

BACKGROUND: Empirical research suggests that involving carers brings benefits to families and services. Consequently, drug-related policy and guidance has increasingly encouraged drug services to involve carers at all levels of service provision. OBJECTIVE: To explore the purpose and scope of carer involvement with adult drug services in North-east Scotland. DESIGN, SETTING AND PARTICIPANTS: A total of 82 participants (20 informal carers, 43 service providers and 19 policy makers) were purposively selected to take part in a qualitative study. Eight focus groups and 32 interviews were conducted between 2007 and 2008. FINDINGS: Three themes were identified through thematic coding: 'Current levels of involvement', 'Use of the term carer' and 'Opportunities for change?' Carer involvement was described as limited, unplanned and unstructured, and consisted largely of information and advice, practical and emotional support, and signposting of services. Although use of the term 'carer' was contested within and across the groups, caring in a drug context was considered the 'same but different' from caring in other contexts. Carers remained sceptical that services actually wanted to involve them in supporting their relative or to offer carers support in their own right. Many service providers and policy makers regarded carer involvement as an aspiration. CONCLUSION: Encouraging carers, service providers and policy makers to reach a shared understanding of caring in a drug context may help translation of policy into practice. However, there is also a fundamental need for drug services to widen the level and type of involvement activities on offer to carers.

The Downrange Acoustic Toolbox: An Active Solution for Combat-Related Acute Acoustic Trauma.

Frontline military personnel are at high risk of acute acoustic trauma (AAT) caused by impulse noise, such as weapon firing or blast. This can result in anatomic disruption of the tympanic membrane and damage to the middle and inner ear, leading to conductive, sensorineural, or mixed hearing loss that may be temporary or permanent. AAT reduces warfighters' operational effectiveness and has implications for future quality of life. Hearing protection devices can mitigate AAT but are not completely protective. Novel therapeutic options now exist; therefore, identification of AAT as soon as possible from point of injury is vital to ensure optimal treatment and fulfillment of the duty of care. Early recognition and treatment of frontline AAT can maintain the deployed team's capabilities, avoid unnecessary case evacuation (CASEVAC), and raise awareness of military occupational AAT. This will help prioritize hearing preservation, maintain the fighting force, and ultimately retain personnel in service. The UK Defence hearWELL research collaboration has developed a frontline protocol for the assessment of AAT utilizing future-facing technology developed by the US Department of Defense: the Downrange Acoustic Toolbox (DAT). The DAT has been operationally deployed since 2019 and has successfully identified AAT requiring treatment, thereby improving casualties' hearing and reducing unnecessary repatriation.

Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: A comparison of treatment at US and United Kingdom medical treatment facilities.

INTRODUCTION: The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan. METHODS: The US and UK combat trauma registries were scrutinized for patients with penetrating neck injury (PNI) at deployed coalition MTF between March 2003 and October 2011. A multivariate mixed effects logistic regression model (threshold, p < 0.05) was used stratified by MTF location and year of injury. The dependent variable was fatality on leaving Role 3, and the independent variables were ISS on arrival, nationality, MTF nationality, and presence of head and neck surgeon. RESULTS: A total of 3,357 (4.9%) of 67,586 patients who arrived alive at deployed military MTF were recorded to have sustained neck injuries; of which 2,186 (83%) were PNIs and the remainder were blunt injuries. When service members killed in action were included, the incidence of neck injury rose from 4.9% to 10%. Seven hundred nine (32%) of 2,186 patients with PNI underwent neck exploration; 555 patients were recorded to have sustained cervical vascular injury, 230 (41%) of 555 underwent vascular ligation or repair. Where it was recorded, PNI directly contributed to death in 64 (28%) of 228 of patients. Fatality status was positively associated with ISS on arrival (odds ratio, 1.05; 95% confidence interval, 1.04-1.06; p < 0.001) and the casualty being a local national (odds ratio, 1.74; 95% confidence interval, 1.28-2.38; p < 0.001). CONCLUSION: Significant differences in the treatment and survival of casualties with PNI were identified between nations in this study; this may reflect differing cervical protection, management protocols, and surgical capability and is worthy of further study. In an era of increasing specialization within surgery, neck exploration remains a skill that must be retained by military surgeons deploying to Role 2 and Role 3 MTF. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Vibrational spectroscopy: a clinical tool for cancer diagnostics.

Vibrational spectroscopy techniques have demonstrated potential to provide non-destructive, rapid, clinically relevant diagnostic information. Early detection is the most important factor in the prevention of cancer. Raman and infrared spectroscopy enable the biochemical signatures from biological tissues to be extracted and analysed. In conjunction with advanced chemometrics such measurements can contribute to the diagnostic assessment of biological material. This paper also illustrates the complementary advantage of using Raman and FTIR spectroscopy technologies together. Clinical requirements are increasingly met by technological developments which show promise to become a clinical reality. This review summarises recent advances in vibrational spectroscopy and their impact on the diagnosis of cancer.

Secondary prevention interventions for young drug users: a systematic review of the evidence.

This paper reviews the international scientific evidence on the effectiveness of secondary prevention interventions for young drug users. The review provides insight into the effectiveness of interventions that have been evaluated using moderately strong research designs. Most of the studies included are from the United States of America. Some interventions are effective in reducing drug use and associated problems while others have no or mixed effect. Those successful in reducing drug use include behavior therapy, Minnesota 12-step programs, residential care, and general drug treatment. Those with either no effect or mixed effect include schools interventions. Involving parents and other agencies may enhance an intervention's effect. There is a lack of good quality studies outside the USA. Future interventions should focus on either low- or high-risk groups of young drug users. Future research should be conducted on a wider range of services for young people and include non-medical outcomes such as communication skills, schooling, employment, family relations, and economic costs.

Therapeutic ratio of hydrofluoroalkane and chlorofluorocarbon formulations of fluticasone propionate.

OBJECTIVES: To compare the therapeutic ratio of chlorofluorocarbon (CFC) and hydrofluoroalkane-134a (HFA) formulations of fluticasone propionate (FP). METHODS: We performed a randomized, placebo-controlled, crossover study comparing 6 weeks of treatment with FP using 500 micro g/d and 1,000 microg/d formulations of CFC and HFA. The primary end points were provocative dose of methacholine causing a 20% fall in FEV1 (PD20) and overnight urinary cortisol/creatinine excretion. RESULTS: Eighteen patients with mild-to-moderate asthma and geometric mean (SEM) PD20 of 82.3 micro g (19.2 micro g) completed the study. All treatments significantly improved PD20 values and morning peak expiratory flow vs placebo, while 1,000 microg/d was significantly better than 500 microg/d for the CFC formulation of FP (CFC-FP) but not the HFA formulation of FP (HFA-FP). Only 1,000 microg/d of CFC-FP caused significant suppression of overnight urinary cortisol/creatinine compared to placebo. There were no differences between formulations at either dose. CONCLUSIONS: The increased airway benefit with CFC-FP > 500 microg/d was offset by greater systemic effects. Although HFA-FP had fewer systemic effects than CFC-FP at 1,000 microg/d, there was no benefit to increasing HFA-FP to > 500 microg/d.

Promoting family-focused approaches within adult drug services: the potential of the 'Senses Framework'.

BACKGROUND: Policies across countries promote family-focused engagement with adult drugs services however this is rarely offered routinely and relationships with carers are often poor. Research in mental health and older people's services suggests that improving the relationships between carers and service providers is fundamental to enhancing the quality of services. One example is the Senses Framework which assesses the extent to which services are relationship-centred and provides deeper insight into the areas that require further improvement. The aim of this paper is to establish the extent to which relationship-centred care, as defined by the Senses Framework, is expressed in the interactions between carers, services providers and policy makers in adult drug service settings. METHODS: A qualitative study, involving 8 focus groups and 32 individual interviews, was undertaken to explore carers', service providers' and policy makers' experiences and understandings of family and carer involvement with drug services in Scotland, United Kingdom. RESULTS: Tensions exist between carers, service providers and policy makers however there are also areas of commonality in which participants shared experiences and understandings of family and carer involvement with services. Our findings go beyond existing research which focuses largely on describing of the poor quality of relationships between carers, service providers and policy makers by providing a deeper theoretical insight into the nature of these relationships. In so doing, by focusing on the senses of belonging, continuity, security, achievement, purpose and significance, we present the possibility of resolving such tensions. CONCLUSIONS: We think that implementing relationship-centred approaches to care, such as that in the Senses Framework, would provide a greater sense of therapeutic and strategic direction for those delivering and commissioning adult drug services in many countries.

Relationship between changes in quality of life and measures of lung function and bronchial hyper-responsiveness during high-dose inhaled corticosteroid treatment in uncontrolled asthma.

OBJECTIVE: To examine the relationship between changes in quality of life and measures of lung function and bronchial hyper-responsiveness (BHR) during treatment with high-dose inhaled corticosteroids in patients with uncontrolled asthma. METHODS: Thirty patients with uncontrolled asthma currently receiving inhaled corticosteroids (median dose 550 microg/day) were treated with beclomethasone dipropionate (BDP) dry powder 2000 microg/day for 4 weeks. Patients completed the Asthma Quality of Life Questionnaire (AQLQ), underwent bronchial challenge with methacholine and spirometry, and made entries in asthma diary cards at baseline and after treatment with beclomethasone dipropionate. RESULTS: The mean change in overall AQLQ score improved significantly (p < 0.05) during the 4-week period by 0.57 (95% CI 0.29-0.84, p < 0.05), representing a minimal important difference, with similar improvements in individual domains. Change in overall AQLQ score correlated significantly with FEV(1) (p < 0.001), forced mid-expiratory flow between 25-75% of vital capacity (FEF(25-75)) [p < 0.05] and morning PEF (p < 0.05), but not with methacholine PD(20) i.e. the provocative dose of methacholine causing a 20% fall in FEV(1). CONCLUSIONS: Quality-of-life scores related to changes in lung function but not BHR during short-term high-dose inhaled corticosteroid therapy for uncontrolled asthma.

An evaluation of short-term corticosteroid response in perennial allergic rhinitis using histamine and adenosine monophosphate nasal challenge.

AIMS: To evaluate the role of AMP nasal challenge as a measure of short-term treatment response in patients receiving intranasal corticosteroids. Adenosine monophosphate (AMP) challenge has been shown to be a good inflammatory surrogate in the lower airways, but it has not been properly evaluated as a nasal challenge test. METHODS: Fourteen patients with perennial allergic rhinitis (PAR) were randomized to receive 2 weeks treatment with placebo (PL) or 200 microg intranasal mometasone furoate (MF) once daily in a randomized single-blind crossover study. AMP (25-800 mg ml-1) and histamine (0.25-8 mg ml-1) nasal challenge testing were performed after each treatment period with 30% decrease in minimal cross-sectional area (MCA). Domiciliary symptom data were collected. RESULTS: There was a significant (P < 0.05) improvement in PC30 MCA and nasal volume with AMP but not with histamine comparing MF vs PL. This amounted to a 2.8 (95% CI 1.5, 4.0) and 0.7 (95% CI -0.5, 1.9) doubling-dose change for AMP and histamine challenges, respectively. There were significant (P < 0.05) improvements in nasal symptoms and quality of life. CONCLUSIONS: AMP nasal challenge using acoustic rhinometry may be a useful test to assess short-term treatment response in patient with PAR.