What can trauma patients' experiences and perspectives tell us about the perceived quality of trauma care? a qualitative study set within the UK National Health Service.

The global drive for improvements in the efficiency and quality of healthcare has led to the development of frameworks to assist in defining and measuring 'good quality care'. However, such frameworks lack a systematic or meaningful definition of what 'good quality care' means from the patients' perspective. The present research provides an in-depth analysis of patients' experiences in a hospital setting from a quality of care perspective. Forty-five adults (aged 16-70) hospitalised in one of four UK NHS trusts following an unintentional injury were interviewed about their experiences of care. The findings show variability in perceived quality of care within the same hospital episode which cannot be meaningfully captured by existing frameworks. The context of trauma care (e.g. distressing nature of injury, patient vulnerability, expectations of hospitalisation and participants' interaction with different service providers) defined the care experience and the value of being 'cared for'. Participants identified some aspects of good and care which related to holistic, person-centred and personalised care beyond the medical needs. Participants discussed the value of being understood, staff thinking of their needs beyond hospitalisation, staff trying 'their best' despite constrains of current care, having their emotional needs recognised and addressed and staff competence. Patients reported also poor quality of care and 'not being cared for' by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults' psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care.

A Road Less Travelled: using Experience Based Co-Design to map children's and families' emotional journey following burn injury and identify service improvements.

BACKGROUND: The emotional impact after a child's burn injury is poorly understood. Greater insight into the emotional journey can aid services' ability to meet patients/families' needs. To bridge the gap, this study employed an abbreviated form of Experience Based Co-Design (EBCD) to explore the emotional/experiential aspects of moderate to severe burn injuries in children. METHOD: Following EBCD, parents and health professionals were invited to share their experiences. Interviews were analysed and a short film was produced and shown at a focus group event for health professionals and families. Both positive and negative aspects of the journey were identified along with potential service improvements. RESULTS: Families' journeys could be described by the following five distinct phases: life overturned, dawning reality, riding the emotional roller-coaster, aftershocks and, adapting to a new normal. Key areas for improvements were: communication, isolation, dressing changes and managing expectations. DISCUSSION: EBCD facilitated collaborative discussion between researchers, families and health professionals. Families felt empowered to shape the future of burn care and health professionals felt included. Study challenges were mainly in participant engagement and the scheduling of interviews and the focus event. Overall the study outcome was successful in generating ideas for service improvements, and the production of a training video for healthcare professionals.

Early risk factors for depression, anxiety and post-traumatic distress after hospital admission for unintentional injury: Multicentre cohort study.

OBJECTIVE: To quantify psychological morbidity and identify baseline factors associated with depression, anxiety and post-traumatic distress symptoms up to 12 months post-injury. METHODS: Multicentre cohort study of 668 adults, aged 16 to 70, admitted to 4 UK NHS hospital trusts. Data on injury, socio-demographic characteristics and health status was collected at recruitment. Depression, anxiety and post-traumatic distress were measured at 1, 2, 4 and 12 months post-injury. Multilevel linear regression assessed associations between patient and injury characteristics and psychological outcomes over 12 months follow-up. RESULTS: Depression, anxiety and post-traumatic distress scores were highest 1 month post-injury, and remained above baseline at 2, 4 and 12 months post-injury. Moderate or severe injuries, previous psychiatric diagnoses, higher pre-injury depression and anxiety scores, middle age (45-64 years), greater deprivation and lower pre-injury quality of life (QoL) were associated with higher depression scores post-injury. Previous psychiatric diagnoses, higher pre-injury depression and anxiety scores, middle age, greater deprivation and lower pre-injury QoL were associated with higher anxiety scores post-injury. Traffic injuries or injuries from being struck by objects, multiple injures (≥3), being female, previous psychiatric diagnoses, higher pre-injury anxiety scores and greater deprivation were associated with higher post-traumatic distress scores post-injury. CONCLUSION: A range of risk factors, identifiable shortly after injury, are associated with psychological morbidity occurring up to 12 months post-injury in a general trauma population. Further research is required to explore the utility of these, and other risk factors in predicting psychological morbidity on an individual patient basis.

Psychological morbidity and health-related quality of life after injury: multicentre cohort study.

PURPOSE: To demonstrate the impact of psychological morbidity 1 month post-injury on subsequent post-injury quality of life (HRQoL) in a general injury population in the UK to inform development of trauma care and rehabilitation services. METHODS: Multicentre cohort study of 16-70-year-olds admitted to 4 UK hospitals following injury. Psychological morbidity and HRQoL (EQ-5D-3L) were measured at recruitment and 1, 2, 4 and 12 months post-injury. A reduction in EQ-5D compared to retrospectively assessed pre-injury levels of at least 0.074 was taken as the minimal important difference (MID). Multilevel logistic regression explored relationships between psychological morbidity 1 month post-injury and MID in HRQoL over the 12 months after injury. RESULTS: A total of 668 adults participated. Follow-up rates were 77% (1 month) and 63% (12 months). Substantial reductions in HRQoL were seen; 93% reported a MID at 1 month and 58% at 12 months. Problems with pain, mobility and usual activities were commonly reported at each time point. Depression and anxiety scores 1 month post-injury were independently associated with subsequent MID in HRQoL. The relationship between depression and HRQoL was partly explained by anxiety and to a lesser extent by pain and social functioning. The relationship between anxiety and HRQoL was not explained by factors measured in our study. CONCLUSIONS: Hospitalised injuries result in substantial reductions in HRQoL up to 12 months later. Depression and anxiety early in the recovery period are independently associated with lower HRQoL. Identifying and managing these problems, ensuring adequate pain control and facilitating social functioning are key elements in improving HRQoL post-injury.

The impact of psychological factors on recovery from injury: a multicentre cohort study.

PURPOSE: Unintentional injuries have a significant long-term health impact in working age adults. Depression, anxiety and post-traumatic stress disorder are common post-injury, but their impact on self-reported recovery has not been investigated in general injury populations. This study investigated the role of psychological predictors 1 month post-injury in subsequent self-reported recovery from injury in working-aged adults. METHODS: A multicentre cohort study was conducted of 668 unintentionally injured adults admitted to five UK hospitals followed up at 1, 2, 4 and 12 months post-injury. Logistic regression explored relationships between psychological morbidity 1 month post-injury and self-reported recovery 12 months post-injury, adjusting for health, demographic, injury and socio-legal factors. Multiple imputations were used to impute missing values. RESULTS: A total of 668 adults participated at baseline, 77% followed up at 1 month and 63% at 12 months, of whom 383 (57%) were included in the main analysis. Multiple imputation analysis included all 668 participants. Increasing levels of depression scores and increasing levels of pain at 1 month and an increasing number of nights in hospital were associated with significantly reduced odds of recovery at 12 months, adjusting for age, sex, centre, employment and deprivation. The findings were similar in the multiple imputation analysis, except that pain had borderline statistical significance. CONCLUSIONS: Depression 1 month post-injury is an important predictor of recovery, but other factors, especially pain and nights spent in hospital, also predict recovery. Identifying and managing depression and providing adequate pain control are essential in clinical care post-injury.

The effects of 3,3',4,4',5-pentachlorobiphenyl (PCB 126) on mink (Mustela vison) reproduction and kit survivability and growth.

This study was conducted to determine if dietary exposure to 3,3'4,4',5-pentachlorobiphenyl (PCB 126) would have an adverse effect on the reproductive performance of female mink (Mustela vison) and survivability and growth of their kits. Standard dark, female mink were fed diets containing PCB 126 at concentrations of 0, 0.24, 2.4, and 24 microg PCB 126/kg feed (0, 24, 240 and 2,400 ng 2,3,7,8-tetrachlorodibenzo-p-dioxin [TCDD] toxic equivalents [TEQs]/kg, respectively) from 21 days prior to breeding until weaning of their kits at six weeks of age. There were no significant differences in the number of females that whelped or the average litter size between the control group and the 0.24 microg PCB 126/kg feed group. In addition, kit body weights at birth and at three, six and 28 weeks of age as well as kit survivability through weaning were similar between the two groups. In contrast, female mink fed diets containing 2.4 and 24 microg PCB 126/kg feed that had confirmed matings, failed to whelp. Histological examination of their uterine horns verified fetal implantation sites or placental scars, which indicated partial fetal development. Based on the impaired reproductive performance reported in this study, a no observable adverse effect level (NOAEL) of 0.24 microg PCB 126/kg feed (24 ng TEQs/kg) and a lowest observable adverse effect level (LOAEL) of 2.4 microg PCB 126/kg feed (240 ng TEQs /kg) were determined.

Operating in an eczematous surgical field: don't be rash, delay surgery to avoid infective complications.

Prominent ear correction is a common operation. Complication as a result of infection has been quoted at between 3% and 5% [Calder JC, Nasaan A. Morbidity of otoplasty: a review of 562 consecutive cases. Br J Plast Surg 1994;47:170-4 and Jeffery SLA. Complications following correction of prominent ears: an audit review of 122 cases. Br J Plast Surg 1999;52:588-90.]. We present two cases referred for ear reconstruction following catastrophic post-operative infection at the time of pinnaplasty, leaving each patient with significant helical rim deformities. Both patients displayed evidence of active post-auricular eczema at the time of their primary surgery. Dermatological research has highlighted the increased colonisation of Staphylococcus aureus in particular within areas of atopic eczema in comparison to normal skin. We advise delaying ear surgery in the presence of a rash in view of the potentially devastating complications that may result. This approach may be extended to all cutaneous surgery where treatment of the rash is advocated prior to embarking on an elective surgical procedure.

Assessment of effects in mink caused by consumption of carp collected from the Saginaw River, Michigan, USA.

Polychlorinated hydrocarbons, including polychlorinated biphenyls (PCBs), polychlorinated dibenzo-p-dioxins (PCDDs), and polychlorinated dibenzofurans (PCDFs), are ubiquitous environmental contaminants that bioconcentrate in the food chain. Numerous studies have demonstrated mink (Mustela vison) to be one of the most sensitive species to this group of compounds. In recent studies, a lesion characterized by osteoinvasion of epithelial cells into the mandible and maxilla of young mink fed diets containing 3,3',4,4',5-pentachlorobiphenyl (PCB 126) and 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) was observed. The objective of the present study was to determine if proliferation of maxillary and mandibular squamous epithelia could be induced in ranch mink exposed to environmentally-derived polychlorinated hydrocarbons (PCBs, PCDDs, and PCDFs) in utero, during lactation, and throughout the growth period. Adult female mink were fed diets containing 0, 10, 20, or 30% carp (Cyprinus carpio) collected from the Saginaw River, Bay City, Michigan, USA, that provided 0.03, 0.83, 1.1, and 1.7 mg total PCBs (tPCBs)/kg feed and 2.5, 28, 47, and 73 ng TCDD toxic equivalents (TEQs)/kg feed, respectively, three weeks prior to breeding through weaning of the resulting offspring. Mink kits were maintained on their respective diets for up to 27 weeks of age. At 6 and 27 weeks of age, six to eight mink in each treatment group were necropsied and their jaws examined for evidence of maxillary and mandibular squamous epithelial proliferation. Results indicated that inclusion of up to 30% carp in the diet (1.7 mg tPCBs/kg feed, 73 ng TEQs/kg feed) had no effect on mink reproduction and kit survivability. However, maxillary and mandibular squamous epithelial proliferation was evident in four of the seven 27-week-old juveniles in the 20% carp group (1.1 mg tPCBs/kg feed, 47 ng TEQs/kg feed) and six of the eight juveniles in the 30% carp group (1.7 mg tPCBs/kg feed group, 73 ng TEQs/kg feed). Hepatic concentrations of tPCBs and TEQs increased in both the 6-week-old kits and the 27-week-old juveniles as the percentage of dietary carp increased. The livers of 6-week-old kits were also assessed for the presence of polybrominated diphenyl ethers, which increased as the percentage of Saginaw River carp in the diet increased.

Deposition velocities to Sorbus aria, Acer campestre, Populus deltoides X trichocarpa 'Beaupré', Pinus nigra and X Cupressocyparis leylandii for coarse, fine and ultra-fine particles in the urban environment.

Trees are effective in the capture of particles from urban air to the extent that they can significantly improve urban air quality. As a result of their aerodynamic properties conifers, with their smaller leaves and more complex shoot structures, have been shown to capture larger amounts of particle matter than broadleaved trees. This study focuses on the effects of particle size on the deposition velocity of particles (Vg) to five urban tree species (coniferous and broadleaved) measured at two field sites, one urban and polluted and a second more rural. The larger uptake to conifers is confirmed, and for broadleaves and conifers Vg values are shown to be greater for ultra-fine particles (Dp < 1.0 microm) than for fine and coarse particles. This is important since finer particles are more likely to be deposited deep in the alveoli of the human lung causing adverse health effects. The finer particle fraction is also shown to be transported further from the emission source; in this study a busy urban road. In further sets of data the aqueous soluble and insoluble fractions of the ultra-fines were separated, indicating that aqueous insoluble particles made up only a small proportion of the ultra-fines. Much of the ultra-fine fraction is present as aerosol. Chemical analysis of the aqueous soluble fractions of coarse, fine and ultra-fine particles showed the importance of nitrates, chloride and phosphates in all three size categories at the polluted and more rural location.

Sampling and analyses of colloids at the Drigg low level radioactive waste disposal site.

Water samples have been extracted from inside (from standpipes) and from outside (from boreholes) of the trenches at the low level radioactive waste disposal site at Drigg in Cumbria, UK. The samples were taken anaerobically from between 8.5 and 10.0 m below the surface using a submersible pump at low flow rates to ensure that the waters in the standpipes and boreholes were maintained at constant levels. To ensure representative samples, the Eh, pH. conductivity, temperature, iron and dissolved oxygen concentrations of the waters were taken during initial purging and during sampling. The gross tritium, gross non-tritium beta, gross alpha and gamma activities of each sample were determined using suitable sample preparation and counting techniques. Samples were then anaerobically, sequentially filtered through 12 microm, 1 microm, 30 kDa and 500 Da filter membranes. The filtrates were analysed for gross alpha, gross non-tritium beta and gamma activities. SEM and STEM analyses were used to determine the colloid population. An energy dispersive analyser on the SEM was used to determine the major elements present in the colloids. UV-visible spectrophotometry, fluorescence spectrophotometry and high performance size exclusion liquid chromatography were used to analyse the waters before and after treatment with ion exchange materials to determine whether natural organic matter was present in the waters. Results showed that two major types of colloids (iron containing colloids and silicon containing colloids) were present in the waters. There were also a small number of other colloids that contain, as major elements, aluminium, calcium and chromium. Organic colloids were also present. The majority of the radioactivity in the waters was due to tritium. Waters taken from outside the trenches contained low levels of non-tritium beta activities and alpha activities which were lower than the minimum detectable amount. Waters taken from the trenches contained non-tritium beta activities and low levels of alpha emitters. Filtration of the trench waters showed that some of the alpha activity was retained by the 30 kDa and 500 Da membranes suggesting that this activity was associated with small colloids. Radioactivity was not found to be associated with colloids present in the waters taken from outside the trenches. Possible reasons for this observation could be that radionuclide bearing colloids have not yet reached the far-field or that the radionuclide concentration is diluted to below the minimum detectable amount. After concentrating two of the samples by factors of x20 and x 16 respectively, 2.4+/-0.1 and 0.6+/-0.1 Bq dm(-3) of 137Cs were measured.

Variations in the normal anatomy of the collateral ligaments of the human elbow joint.

The variations which occur in the medial and lateral ligament complexes of the elbow were investigated. These occurred frequently with the standard appearances occurring in no more than half the specimens on the medial side and one quarter of those on the lateral side. Surgeons who regularly perform elbow arthroplasty must be aware of these considerations, especially with the introduction of unconstrained prostheses which rely upon the ligament complex for their postoperative stability.

Urban woodlands: their role in reducing the effects of particulate pollution.

In recent years a substantial research effort has focused on the links between particulate air pollution and poor health. As a result the PM10 value has been set as a measure of such pollutants which can directly cause illness. Due to their large leaf areas relative to the ground on which they stand and the physical properties of their surfaces, trees can act as biological filters, removing large numbers of airborne particles and hence improving the quality of air in polluted environments. The role of vegetation and urban woodlands in reducing the effects of particulate pollution is reviewed here. The improvement of urban air quality achieved by establishing more trees in towns and cities is also illustrated.

Use of trimethoprim-sulfamethoxazole to prevent bacterial infections in children with acute lymphoblastic leukemia.

We assessed the efficacy of prophylactic antibiotics in children receiving intensive chemotherapy for acute lymphoblastic leukemia. The patients were randomized to receive either trimethoprim-sulfamethoxazole (TMP-SMX) or placebo in a double-blind trial. Thirty patients were evaluated in each group. Children receiving TMP-SMX had fewer episodes of bacteremia (0 vs. 5) and otitis media (3 vs. 18). The geometric mean of the neutrophil nadir was 172 in the TMP-SMX group and 287 in controls. However, no increased delay or dose reduction of chemotherapy was observed in the TMP-SMX treated patients. Five patients who received TMP-SMX developed Gram-negative rods resistant to TMP-SMX on surveillance stool cultures. We conclude that TMP-SMX prophylaxis decreased certain bacterial infections in children with acute lymphoblastic leukemia without causing clinically significant toxicity. The emergence of Gram-negative rods resistant to TMP-SMX in treated patients suggests that TMP-SMX prophylaxis should be restricted to patients who are at high risk for developing a bacterial infection or Pneumocystis carinii pneumonia.

Combined activity of minocycline and amphotericin B in vitro against medically important yeasts.

The capacity of minocycline to enhance the activity of amphotericin B against Candida albicans, Torulopsis glabrata, Cryptococcus neoformans, and non-albicans Candida was examined in vitro utilizing a time-killing curve technique. Synergism was apparent at 4 h with 5 of 5 strains of C. albicans, 8 of 8 strains of C. neoformans, and 1 of 12 strains of non-albicans Candida. Synergism was apparent at 24 h with the remaining 11 strains of non-albicans Candida and all 5 strains of T. glabrata. C. neoformans was the most susceptible of the yeasts to the minocycline-amphotericin B combination; seven strains showed a 3-log or greater reduction in colony count in 4 h and all strains showed this reduction in 24 h at amphotericin B concentrations of 0.4 mug/ml or less in the presence of minocycline.

Antifungal activity of four tetracycline analogues against Candida albicans in vitro: potentiation by amphotericin B.

The antifungal activities of four tetracycline analogues in combination with amphotericin B (AmB) were determined against 20 strains of Candida albicans. When a microtiter checkerboard technique was used, minocycline (less than or equal to 10 microgram/ml) acted synergistically with AmB against all strains, whereas doxycycline had a reduced effect, and demeclocycline and tetracycline had no potentiating effect at this concentration. Killing-curve experiments with two strains of C. albicans demonstrated that the combination of minocycline and AmB produced a decrease in number of colony-forming units (cfu) of greater than 2 logs in 4 hr and a 4-log decrease in cfu in 24 hr at concentrations (minocycline, 0.64 microgram/ml; AmB, 0.1 microgram/ml) that were subinhibitory when each agent was used alone and that are readily achieved in human serum and body fluids with conventional doses. The killing-curve technique indicated that doxycycline had an intermediate degree of synergistic activity, whereas tetracycline had no synergistic activity at clinically relevant concentrations.