Patient and informal carer experience of hip fracture: A qualitative study using interviews and observation in acute orthopaedic trauma

Objectives The time taken for older people to recover from hip fracture can be extensive. The aim of this study was to gain an understanding of patient and informal carer experience of recovery in the early stage, while in acute care. Design A phenomenological (lived experience) approach was used to guide the design of the study. Interviews and observation took place between March 2016 and December 2016 in acute care. Setting Trauma wards in a National Health Service Foundation Trust in the South West of England. Participants A purposive sample of 25 patients were interviewed and observation taking 52 hours was undertaken with 13 patients and 12 staff. 11 patients had memory loss, 2 patients chose to take part in an interview and observation. The age range was 63-91 years (median 83), 10 were men. A purposive sample of 25 informal carers were also interviewed, the age range was 42-95 years (mean 64), 11 were men. Results The results identified how participants moved forward together after injury by sharing the journey. This was conveyed through three themes: (1) sustaining relationships while experiencing strong emotions and actively helping, (2) becoming aware of uncertainty about the future and working through possible outcomes, (3) being changed, visibly looking different, not being able to walk, and enduring indignity and pain. Conclusion This study identified the experience of patients and informal carers as they shared the journey during a challenging life transition. Strategies that support well-being and enable successful negotiation of the emotional and practical challenges of acute care may help with longer term recovery. Research should focus on developing interventions that promote well-being during this transition to help provide the foundation for patients and carers to live fulfilled lives.Fil: Tutton, Elizabeth. University of Oxford; Reino UnidoFil: Saletti, Lorena. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Córdoba. Centro de Investigaciones y Estudios sobre Cultura y Sociedad. Universidad Nacional de Córdoba. Centro de Investigaciones y Estudios sobre Cultura y Sociedad; ArgentinaFil: Lanstaff, Debbie. University of Oxford; Reino UnidoFil: Wright, Julie. University of Oxford; Reino UnidoFil: Grant, Richard. University of Oxford; Reino UnidoFil: Willett, Keith. University of Oxford; Reino Unid

Laserska desorpcijsko–ionizacijska masena spektroskopija potpomognuta sa C60

An application of C60-assisted laser desorption/ionization mass spectrometry of two organic samples including insulin (5734 Da), bovine albumin (66 000 Da) and a heteropoly inorganic system: phosphotungstic acid H3PO4(WO3)12×H2O, is presented. A nitrogen laser (337 nm) on a linear tandem time-of-flight mass spectrometer is used for the observation of the laser-power dependence of mass spectra.Opisuje se primjena laserske desorpcijsko–ionizacijske masene spektroskopije sa dva organska pripravka, insulin (5734 Da) sa crijevnim albuminom (66 000 Da), te heteropolni anorganski sistem od fosforovolframske kiseline, H3PO4(WO3)12×H2O. Primijenjen je dušikov laser pri linearnom tandem masenom spektrometru s mjerenjem vremena proleta i proučavana je ovisnost masenih spektara o snazi laserskog snopa. Pokazano je da se tehnika slojeva sa C60 kao substratom za desorpciju organskih ili neorganskih molekula, može primijeniti kao alternativna dobro poznatoj MALDI metodi

Protocol for a randomised controlled trial of standard wound management versus negative pressure wound therapy in the treatment of adult patients with an open fracture of the lower limb : UK wound management of open lower limb fractures (UK WOLFF)

Introduction: Patients who sustain open lower limb fractures have reported infection risks as high as 27%. The type of dressing applied after initial debridement could potentially affect this risk. In this trial, standard dressings will be compared with a new emerging treatment, negative pressure wound therapy, for patients with open lower limb fractures. Methods and analysis: All adult patients presenting with an open lower limb fracture, with a Gustilo and Anderson (G&A) grade 2/3, will be considered for inclusion. 460 consented patients will provide 90% power to detect a difference of eight points in the Disability Rating Index (DRI) score at 12 months, at the 5% level. A randomisation sequence, stratified by trial centre and G&A grade, will be produced and administered by a secure web-based service. A qualitative substudy will assess patients’ experience of giving consent for the trial, and acceptability of trial procedures to patients and staff. Patients will have clinical follow-up in a fracture clinic up to a minimum of 12 months as per standard National Health Service (NHS) practice. Functional and quality of life outcome data will be collected using the DRI, SF12 and EQ-5D questionnaires at 3, 6, 9 and 12 months postoperatively. In addition, information will be requested with regards to resource use and any late complications or surgical interventions related to their injury. The main analysis will investigate differences in the DRI score at 1 year after injury, between the two treatment groups on an intention-to-treat basis. Tests will be two sided and considered to provide evidence for a significant difference if p values are less than 0.05. Ethics and dissemination: Ethical approval was given by NRES Committee West Midlands—Coventry & Warwickshire on 6/2/2012 (ref: 12/WM/0001). The results of the trial will be disseminated via peer-reviewed publications and presentations at relevant conferences

Tranexamic acid use in severely injured civilian patients and the effects on outcomes

Objective: To characterize the relationship between tranexamic acid (TXA) use and patient outcomes in a severely injured civilian cohort, and to determine any differential effect between patients who presented with and without shock. Background: TXA has demonstrated survival benefits in trauma patients in an international randomized control trial and the military setting. The uptake of TXA into civilian major hemorrhage protocols (MHPs) has been variable. The evidence gap in mature civilian trauma systems is limiting the widespread use of TXA and its potential benefits on survival. Methods: Prospective cohort study of severely injured adult patients (Injury severity score > 15) admitted to a civilian trauma system during the adoption phase of TXA into the hospital's MHP. Outcomes measured were mortality, multiple organ failure (MOF), venous thromboembolism, infection, stroke, ventilator-free days (VFD), and length of stay. Results: Patients receiving TXA (n = 160, 42%) were more severely injured, shocked, and coagulopathic on arrival. TXA was not independently associated with any change in outcome for either the overall or nonshocked cohorts. In multivariate analysis, TXA was independently associated with a reduction in MOF [odds ratio (OR) = 0.27, confidence interval (CI): 0.10-0.73, P = 0.01] and was protective for adjusted all-cause mortality (OR = 0.16 CI: 0.03-0.86, P = 0.03) in shocked patients. Conclusions: TXA as part of a major hemorrhage protocol within a mature civilian trauma system provides outcome benefits specifically for severely injured shocked patients

Tranexamic acid use in severely injured civilian patients and the effects on outcomes

Objective: To characterize the relationship between tranexamic acid (TXA) use and patient outcomes in a severely injured civilian cohort, and to determine any differential effect between patients who presented with and without shock. Background: TXA has demonstrated survival benefits in trauma patients in an international randomized control trial and the military setting. The uptake of TXA into civilian major hemorrhage protocols (MHPs) has been variable. The evidence gap in mature civilian trauma systems is limiting the widespread use of TXA and its potential benefits on survival. Methods: Prospective cohort study of severely injured adult patients (Injury severity score > 15) admitted to a civilian trauma system during the adoption phase of TXA into the hospital's MHP. Outcomes measured were mortality, multiple organ failure (MOF), venous thromboembolism, infection, stroke, ventilator-free days (VFD), and length of stay. Results: Patients receiving TXA (n = 160, 42%) were more severely injured, shocked, and coagulopathic on arrival. TXA was not independently associated with any change in outcome for either the overall or nonshocked cohorts. In multivariate analysis, TXA was independently associated with a reduction in MOF [odds ratio (OR) = 0.27, confidence interval (CI): 0.10-0.73, P = 0.01] and was protective for adjusted all-cause mortality (OR = 0.16 CI: 0.03-0.86, P = 0.03) in shocked patients. Conclusions: TXA as part of a major hemorrhage protocol within a mature civilian trauma system provides outcome benefits specifically for severely injured shocked patients

Platelet rich plasma injection for acute Achilles tendon rupture: PATH-2 randomised, placebo controlled, superiority trial

Objective To determine whether an injection of platelet rich plasma improves outcomes after acute Achilles tendon rupture. Design Randomised, placebo controlled, two arm, parallel group, participant and assessor masked, superiority trial. Setting Secondary care trauma units across 19 hospitals in the United Kingdom’s health service. Participants Recruitment commenced in July 2015 and follow-up was completed in March 2018. 230 adults aged 18 years and over were included, with acute Achilles tendon rupture presenting within 12 days of injury and managed with non-surgical treatment. Exclusions were injury at the insertion or musculotendinous junction, major leg injury or deformity, diabetes mellitus, platelet or haematological disorder, systemic corticosteroids, anticoagulation treatment, and other contraindicating conditions. Interventions Participants were randomised 1:1 to platelet rich plasma (n=114) or placebo (dry needle; n=116) injection. All participants received standard rehabilitation care (ankle immobilisation followed by physiotherapy). Main outcomes and measures Primary outcome was muscle tendon function at 24 weeks, measured objectively with the limb symmetry index (injured/uninjured×100) in maximal work done during the heel rise endurance test (an instrumented measure of repeated single leg heel rises until fatigue). Secondary outcomes included patient reported function (Achilles tendon rupture score), quality of life (short form 12 version 2®), pain (visual analogue scale), goal attainment (patient specific functional scale), and adverse events. A central laboratory analysed the quality and content of platelet rich plasma. Analyses were by modified intention to treat. Results Participants were 46 years old on average, and 57 (25%) of 230 were female. At 24 weeks, 202 (88%) participants completed the heel rise endurance test and 216 (94%) the patient reported outcomes. The platelet rich plasma was of good quality, with expected growth factor content. No difference was detected in muscle tendon function between participants receiving platelet rich plasma injections and those receiving placebo injections (limb symmetry index, mean 34.7% (standard deviation 17.7%) v 38.5% (22.8%); adjusted mean difference −3.9% (95% confidence interval −10.5% to 2.7%)) or in any secondary outcomes or adverse event rates. Complier average causal effect analyses gave similar findings. Conclusions There is no evidence to indicate that injections of platelet rich plasma can improve objective muscle tendon function, patient reported function, or quality of life after acute Achilles tendon rupture compared with placebo, or that they offer any patient benefit. Trial registration isrctn.com identifier: ISRCTN54992179</p

Vehicle to Grid Demonstration Project

This report summarizes the activities and accomplishments of a two-year DOE-funded project on Grid-Integrated Vehicles (GIV) with vehicle to grid power (V2G). The project included several research and development components: an analysis of US driving patterns; an analysis of the market for EVs and V2G-capable EVs; development and testing of GIV components (in-car and in-EVSE); interconnect law and policy; and development and filing of patents. In addition, development activities included GIV manufacturing and licensing of technologies developed under this grant. Also, five vehicles were built and deployed, four for the fleet of the State of Delaware, plus one for the University of Delaware fleet

Endocrine Disruptors and Obesity: An Examination of Selected Persistent Organic Pollutants in the NHANES 1999–2002 Data

Recent evidence suggests that endocrine disrupting chemicals (EDCs) may cause perturbations in endogenous hormonal regulation that predispose to weight gain. Using data from NHANES (1999–2002), we investigated the association between body mass index (BMI), waist circumference (WC) and selected persistent organic pollutants (POPs) via multiple linear regressions. Consistent interaction was found between gender, ln oxychlordane and ln p,p’ DDT. Also, we found an association between WC and ln oxychlordane and ln hpcdd in subjects with detectable levels of POPs, whereas an association between WC and ln p,p’ DDT was observed in all subjects. Furthermore, ln Ocdd showed an increase with higher WC and BMI, whereas, ln trans-nonachlor decreased with higher BMI. Hence, BMI and WC are associated with POPs levels, making the chemicals plausible contributors to the obesity epidemic

Must . . . stay . . . strong!

This is the fourth installment in our trilogy of papers on epistemic modality.It is a recurring matra that epistemic must creates a statement that is weaker than the corresponding flat-footed assertion: It must be raining vs. It’s raining. Contrary to classic discussions of the phenomenon such as by Karttunen, Kratzer, and Veltman, we argue that instead of having a weak semantics, must presupposes the presence of an indirect inference or deduction rather than of a direct observation. This is independent of the strength of the claim being made. Epistemic must is therefore quite similar to evidential markers of indirect evidence known from languages with rich evidential systems. We work towards a formalization of the evidential component, relying on a structured model of information states (analogous to some models used in the belief dynamics literature). We explain why in many contexts, one can perceive a lack of confidence on the part of the speaker who uses must