Supporting research and development in ambulance services: research for better healthcare in prehospital settings

Background This paper discusses recent developments in research support for ambulance trusts in England and Wales and how this could be designed to lead to better implementation, collaboration in and initiation of high-quality research to support a truly evidence-based service. Method The National Ambulance Research Steering Group was set up in 2007 to establish the strategic direction for involvement of regional ambulance services in developing relevant and well-designed research for improving the quality of services to patients. Results Ambulance services have been working together and with academic partners to implement research and to participate, collaborate and lead the design of research that is relevant for patients and ambulance services. Conclusion New structures to support the strategic development of ambulance and prehospital research will help address gaps in the evidence for health interventions and service delivery in prehospital and ambulance care and ensure that ambulance services can increase their capacity and capability for high-quality research

Tolerance of early life stages of Tilapia (Cichlidae: Tilapiini) to metal stress

Ecophysiological indices that characterise animals fitness directly or indirectly measure the components of protein turnover and its associated metabolic costs, Therefore, more likely protein turnover and associated metabolic costs may play a major role in underlying stress tolerance mechanisms. In this thesis a flow-through system was designed and developed to overcome some of the existing basic design flaws in such systems and used to determine responses of different species of' tilapiine fishes (Cichlidae: Tilapiini) under lethal and non-lethal stress using cadmium and copper. A significant variation in tolerance capability between mouth brooding and substrate spawning tilapia yolk sac-fry to lethal cadmium and copper stress was observed. There was concordance between the relative tolerance capabilities of these two groups to the two metals suggesting a general response. Similarly, tolerance capabilities were in concordance with early life-history growth traits and ass associated metabolic costs measured under non-stressed (control) conditions suggesting individuals with higher growth rates and low maintenance metabolic costs are better capable of tolerating metal stress than the individuals with low growth rates and higher maintenance metabolic costs. Lower cadmium body burden levels were observed in the sac-fry of the more tolerant substrate-spawner T zillii than those of in the more sensitive mouth- brooder () niloticus. Variations in growth performances between mouthbrooders and substrate spawners were attributed to the difference in their developmental rates. Therefore, genetically based phenotypic variations for early life history traits translate into variations in stress tolerance. Similarly O niloticus yolk sac-fry originating from small eggs were more tolerant to cadmium stress and had lower body burdens than larger conspecifics originating from large eggs. The early life history growth traits and associated metabolic costs measured under non-stress conditions were in concordance with the tolerance capabilities of the two size groups supporting the correlation between higher tolerance and low maintenance metabolic cost. The size of the yolk sac-fry was influenced by maternal age and size, and hence, by egg size. Therefore, translation of pre-determined phenotypic variations for early life history traits into variations in tolerance capabilities to metal lethal stress was supported. Starvation-induced reductions in metabolic rate of tilapia sac-fry carried a fitness advantage by reducing cadmium uptake under lethal stress. Therefore, post adapted physiological acclimation to one type of stress may carry a fitness advantage over metal stress. In all cases tolerance capability to metal stress was correlated to the metabolic status of yolk sac-fry. Using the most sensitive mouth brooder O niloticus and most tolerant substrate spawner T zillii which demonstrated the largest difference in their lethal tolerance to cadmium and copper, the effects of non-lethal cadmium stress were investigated. Significant differences in stress tolerance between the two species was observed. The effects of cadmium on growth and associated metabolic costs were similar for both species suggesting a general response under non-lethal cadmium stress. I here was evidence that both species showed an increase in protein turnover, and hence, an increase in maintenance metabolic costs. It was found that cadmium did not affect the energy supply, but reduced protein growth which appears to be due to investment of more supplied energy on increased protein turnover, and hence, increased maintenance metabolic cost than deposition as growth energy. Therefore, the predicted fitness advantage for lethal cadmium stress was observed for non-lethal cadmium stress. In conclusion, in tilapia yolk sac-fry there was a general response to lethal as well as non-lethal stress. The tolerance capability have been brought about either by genetically pre-determined or physiologically post-adapted variations in early life history traits of tilapia yolk sac-fry. The observed concordance between the range over which differences in responses occur in terms of more sensitive non-lethal stress indices and lethal tolerance capability of O. niloticus and T. zillii yolk sac-fry suggests there may be a possible link between responses to lethal and non-lethal cadmium stress

Pro/con debate: antifungal prophylaxis is important to prevent fungal infection in patients with acute necrotizing pancreatitis receiving broad-spectrum antibiotics

When critically ill patients with pancreatitis develop infection of the pancreas, the ongoing management of such patients becomes difficult. Sufficient evidence supports the use of broad-spectrum antibiotic prophylaxis to prevent the development of bacterial infection. Since fungal infection is also a relatively common complication of severe pancreatitis--particularly when broad-spectrum antibiotics are used--it seems logical that fungal prophylaxis may be an important component of management. In this issue of Critical Care, two expert groups debate the merits of antifungal prophylaxis in patients with acute necrotizing pancreatitis who are receiving antibiotics

Qualitative interview study of patients', ambulance practitioners' and emergency department clinicians' perceptions of prehospital pain management

Introduction Pre-hospital pain management is increasingly important with most patients (80%) presenting to UK ambulance services in pain and 20% of patients reporting inadequate pain relief. Improving prehospital pain management is important for service quality. Our aim was to investigate perceptions of pain management from patients, ambulance and emergency care staff. Methods Qualitative data were gathered through focus group (5) and interviews (28). Participants were purposively sampled from patients recently transported to hospital in pain, ambulance staff and emergency department clinicians. Interviews were audiotaped and transcribed using thematic analysis to iteratively develop themes supported by data analysis software, MAXQDA. Results Themes emerging from the data included: (a) expectations and beliefs (b) assessment methods (c) drug treatment (d) non-drug treatment and (f) improvement strategies for pain. Patients and staff expected pain to be relieved in the ambulance; instances of refusal of or inadequate analgesia were not uncommon because patients were concerned about drug side effects or, did not want to be transported. Pain was commonly assessed using a verbal pain score; clinical observation was often discordant with subjective experience. Communication difficulties, non-cooperation or influence of alcohol or drugs were found as barriers to pain assessment. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Suggestions to improve prehospital pain management included addressing barriers, modifying the available drugs and developing agreed multi-organisational pain management protocols supported by training for staff. Discussion Patients and practitioners expected pain to be relieved in the ambulance. Suggestions to improve prehospital pain management included addressing identified barriers, modifying the available drugs, using non-drug measures and developing agreed multi-organisational pain management protocols supported by appropriate training for staff. Our findings will inform development of protocols and quality improvement programmes along the pathway of prehospital pain management

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial

Background: Sleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety. Methods and design: This will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 × 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing. Discussion: Previous studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation

Evaluation of Community Resilience Aspects of Sri Lankan Coastal Districts

This research is carried out to evaluate important community resilience aspects of coastal districts in Sri Lanka and to provide suitable recommendations to strengthen them. After carrying out an indepth literature survey and interviewing key personnel who are involved in the field of Disaster Management and Disaster Risk Reduction, existing status of the coastal hazards, multi-hazard assessments, early warning mechanisms, national policies, guidelines and efforts and regional cooperation were identified. During the literature survey, it was observed that Sri Lanka has developed a Hazard profile for the country and has an Early Warning Dissemination System which seems to function quite well by the book. What is more, the country is in the process of orienting the existing national policies and guidelines with the post 2015 global standards such as the Sendai framework and Sustainable Development Goals. Sri Lanka being a member of Indian Ocean Tsunami Warning and Mitigation System (IOTWMS) and Regional Integrated Multi-Hazard Early Warning System for Africa and Asia (RIMES) depicts that the country has a good regional cooperation in terms of Early Warning. Even though Sri Lanka lacks efficient and sustainable resilience mechanisms focused on the coastal communities, national efforts are underway to build up the coastal resilience. Training and public awareness campaigns, efficient funds, properly maintained hierarchy and concern to the coastal ecosystems are some of the enablers identified in this study which are associated in building coastal resilience. Developing and updating a multi-hazard map, improving the interagency cooperation and driving towards a people-centred Multi-Hazard Early Warning System (MHEWS) are some of the recommendations given after the analysi

Anti-Microbial Dendrimers against Multidrug-Resistant P. aeruginosa Enhance the Angiogenic Effect of Biological Burn-wound Bandages.

Multi-drug resistant Pseudomonas aeruginosa has increased progressively and impedes further regression in mortality in burn patients. Such wound infections serve as bacterial reservoir for nosocomial infections and are associated with significant morbidity and costs. Anti-microbial polycationic dendrimers G3KL and G3RL, able to kill multi-drug resistant P. aeruginosa, have been previously developed. The combination of these dendrimers with a class of biological bandages made of progenitor skin cells, which secrete growth factors, could positively impact wound-healing processes. However, polycations are known to be used as anti-angiogenic agents for tumor suppression. Since, neovascularization is pivotal in the healing of deep burn-wounds, the use of anti-microbial dendrimers may thus hinder the healing processes. Surprisingly, we have seen in this study that G3KL and G3RL dendrimers can have angiogenic effects. Moreover, we have shown that a dendrimer concentration ranging between 50 and 100 μg/mL in combination with the biological bandages can suppress bacterial growth without altering cell viability up to 5 days. These results show that antimicrobial dendrimers can be used in combination with biological bandages and could potentially improve the healing process with an enhanced angiogenesis

Analyzing the Contribution of Green Buildings Towards Circular Economy in Sri Lanka

The circular economy concept is crucial in moving forward with sustainable development in any country. It has been identified that implementing CE (Circular Economy) in the built environment has various benefits towards the environment, society as well as the economy. Although this approach has various benefits, its implementation in Sri Lanka is still at a premature stage. Green rating systems are used to qualitatively assess the building’s performance regarding sustainability aspects of the built environment. It remains unclear whether green rating systems in Sri Lanka provide an appropriate guide towards implementing the CE concept. Hence, this paper aims to analyze the contribution provided by green ratings in Sri Lanka towards the implementation of CE. Two pilot case studies and semi-structured interviews were carried out among industry experts who have hands-on experience in green rating systems and work experience in green building projects. Findings indicate that Green building projects have implemented various kinds of sustainable features to obtain a rating. Nevertheless, the practice of these features are not adequately reflecting the implementation CE concept due to numerous barriers to implement CE in Sri Lankan context. The study concludes that in Sri Lanka, the green rating system does not adequately contribute towards the implementation of CE