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BACKGROUND: Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016. METHODS: An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death. RESULTS: Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001). CONCLUSION: Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.

ANTECEDENTES: Se han demostrado mejoras significativas en la mortalidad tras la implementación de las redes de trauma en Inglaterra. El traslado a tiempo de pacientes con lesiones graves para el tratamiento definitivo es un indicador clave del rendimiento de la red de traumatismos. Este estudio evaluó los plazos de tiempo desde la activación del servicio de emergencia (emergency service,EMS) hasta el tratamiento definitivo entre 2013 y 2016. MÉTODOS: Se realizó un estudio observacional en base a los datos obtenidos de la auditoría clínica nacional del Reino Unido de la atención de traumatismos graves en pacientes con puntuación de gravedad de lesiones superior a 15. Los resultados incluyeron los intervalos de tiempo entre la activación del EMS hasta la llegada a una Unidad de Trauma (Trauma Unit, TU) o a un centro de traumatismos graves (Major Trauma Center, MTC), la práctica de una tomografía computarizada (computerised tomography, CT), la práctica de cirugía de urgencia, y la mortalidad. RESULTADOS: El traslado secundario se asoció con un aumento en el tiempo hasta la cirugía urgente (7,23 h (rango intercuartílico, RIQ 5,48-9,28 versus 4,37 (3,00-6,57), P < 0,001)) y un aumento de la mortalidad cruda (19,6% (i.c. del 95% 16,9-22,3) versus 15,7% (14,7-16,7)). La CT y la cirugía urgente se efectuaron con mayor rapidez en los centros MTC que TU (2,00 h (RIQ 1,55-2,73) versus 3,15 h (RIQ 2,17-4,63) y 4,37 h (RIQ 3,00-6,57) versus 5,37 h (RIQ 3,50-7,65), respectivamente (P < 0,001)). El tiempo de traslado y el tiempo hasta la práctica de la CT aumentaron entre 2013 y 2016 (P < 0,001). El tiempo de traslado, el tiempo hasta la práctica de la CT y el tiempo hasta la práctica de cirugía urgente variaron significativamente entre las redes regionales (P < 0,001). CONCLUSIÓN: El traslado secundario se asoció de forma significativa con el retraso en las imágenes radiológicas, retraso en la cirugía y aumento de la mortalidad. Las intervenciones clave se realizaron más rápidamente en centro MTC que en centros TU.

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BACKGROUND: Climate change is anticipated to have profound effects on mental health, particularly among populations that are simultaneously ecologically and economically vulnerable to its impacts. Various pathways through which climate change can impact mental health have been theorised, but the impacts themselves remain understudied. PURPOSE: In this article we applied psychological methods to examine if climate change is affecting individuals' mental health in the Small Island Developing State of Tuvalu, a Pacific Island nation regarded as exceptionally vulnerable to climate change. We determined the presence of psychological distress and associated impairment attributed to two categories of climate change-related stressors in particular: 1) local environmental impacts caused or exacerbated by climate change, and 2) hearing about global climate change and contemplating its future implications. METHODS: The findings draw on data collected in a mixed-method study involving 100 Tuvaluan participants. Data were collected via face-to-face structured interviews that lasted 45 min on average and were subjected to descriptive, correlational, and between-group analyses. RESULTS: The findings revealed participants' experiences of distress in relation to both types of stressor, and demonstrated that a high proportion of participants are experiencing psychological distress at levels that reportedly cause them impairment in one or more areas of daily life. CONCLUSIONS: The findings lend weight to the claim that climate change represents a risk to mental health and obliges decision-makers to consider these risks when conceptualizing climate-related harms or tallying the costs of inaction.

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BACKGROUND: Antibiotic-associated diarrhoea (AAD) is a frequent complication of systemic antibiotic therapy and Clostridium difficile-associated diarrhoea (CDAD) is its most serious form due to associated morbidity and mortality. AIM: This trial aimed to investigate whether the probiotic VSL#3 prevents AAD and CDAD in average-risk hospital patients. METHODS: Adult hospital inpatients exposed to systemic antibiotics were recruited to this multicentre, randomized, double-blind, placebo-controlled trial. One sachet of VSL#3 or placebo was given twice daily for the length of the antibiotics course and for seven days thereafter. Primary outcomes were AAD and CDAD. FINDINGS: Patients randomized to active (N = 117) and placebo (N = 112) groups were well-matched for baseline demographic patient data. No cases of CDAD were detected. The rate of AAD was significantly lower in the active group on per protocol analysis (0% active vs 11.4% placebo; P = 0.006). On intention-to-treat analysis the difference in AAD incidence (4.3% active vs 8.9% placebo; P = 0.19) was not significant. CONCLUSIONS: VSL#3 is associated with a significant reduction in the incidence of AAD in average-risk hospital inpatients exposed to systemic antibiotics. As the incidence of CDAD has fallen sharply, no cases of CDAD were found. Probiotic administration as prophylaxis for CDAD may not be indicated in average-risk hospital patients.

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Taxometric research methods were developed by Paul Meehl and colleagues to distinguish between categorical and dimensional models of latent variables. We have conducted a comprehensive review of published taxometric research that included 177 articles, 311 distinct findings and a combined sample of 533 377 participants. Multilevel logistic regression analyses have examined the methodological and substantive variables associated with taxonic (categorical) findings. Although 38.9% of findings were taxonic, these findings were much less frequent in more recent and methodologically stronger studies, and in those reporting comparative fit indices based on simulated comparison data. When these and other possible confounds were statistically controlled, the true prevalence of taxonic findings was estimated at 14%. The domains of normal personality, mood disorders, anxiety disorders, eating disorders, externalizing disorders, and personality disorders (PDs) other than schizotypal yielded little persuasive evidence of taxa. Promising but still not definitive evidence of psychological taxa was confined to the domains of schizotypy, substance use disorders and autism. This review indicates that most latent variables of interest to psychiatrists and personality and clinical psychologists are dimensional, and that many influential taxonic findings of early taxometric research are likely to be spurious.

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BACKGROUND: Psychiatry and clinical psychology are the two dominant disciplines in mental health research, but the structure of scientific influence and information flow within and between them has never been mapped. METHOD: Citations among 96 of the highest impact psychiatry and clinical psychology journals were examined, based on 10 052 articles published in 2008. Network analysis explored patterns of influence between journal clusters. RESULTS: Psychiatry journals tended to have greater influence than clinical psychology journals, and their influence was asymmetrical: clinical psychology journals cited psychiatry journals at a much higher rate than the reverse. Eight journal clusters were found, most dominated by a single discipline. Their citation network revealed an influential central cluster of 'core psychiatry' journals that had close affinities with a 'psychopharmacology' cluster. A group of 'core clinical psychology' journals was linked to a 'behavior therapy' cluster but both were subordinate to psychiatry journals. Clinical psychology journals were less integrated than psychiatry journals, and 'health psychology/behavioral medicine' and 'neuropsychology' clusters were relatively peripheral to the network. CONCLUSIONS: Scientific publication in the mental health field is largely organized along disciplinary lines, and is to some degree hierarchical, with clinical psychology journals tending to be structurally subordinate to psychiatry journals.

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BACKGROUND: Visuospatial working memory (VSWM) deficits have not been investigated specifically in children with dysthymic disorder (DD), although they are associated with impairments in attention that commonly occur in DD. This study investigates VSWM impairment in children with DD. METHOD: A cross-sectional study of VSWM in 6- to 12-year-old children with medication-naive DD (n=26) compared to an age-, gender- and 'performance IQ' (PIQ)-matched healthy control group (n=28) was completed. RESULTS: The DD group demonstrated impairment in VSWM, including impairment in the spatial span and strategy components of VSWM. Furthermore, the VSWM impairment remained after controlling for spatial span. Inattentive symptoms were significantly associated with the VSWM impairment. CONCLUSIONS: This study of children with DD found deficits in performance on VSWM tasks, suggesting that fronto-striatal-parietal neural networks that underlie processes of attention and the executive component of VSWM are dysfunctional in children with DD. These findings further our understanding of DD and suggest more specific interventions that might improve functioning.

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OBJECTIVE: Many anti-stigma programmes use the 'mental illness is an illness like any other' approach. This review evaluates the effectiveness of this approach in relation to schizophrenia. METHOD: The academic literature was searched, via PsycINFO and MEDLINE, to identify peer-reviewed studies addressing whether public espousal of a biogenetic paradigm has increased over time, and whether biogenetic causal beliefs and diagnostic labelling are associated with less negative attitudes. RESULTS: The public, internationally, continues to prefer psychosocial to biogenetic explanations and treatments for schizophrenia. Biogenetic causal theories and diagnostic labelling as 'illness', are both positively related to perceptions of dangerousness and unpredictability, and to fear and desire for social distance. CONCLUSION: An evidence-based approach to reducing discrimination would seek a range of alternatives to the 'mental illness is an illness like any other' approach, based on enhanced understanding, from multi-disciplinary research, of the causes of prejudice.

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Adequate pre-operative analgesia for elderly patients with femoral neck fractures is difficult to assess and is often an overseen aspect of their care. We aimed to assess the efficacy of fascia iliaca blocks inserted via plexus blockade catheters in the pre-operative period. Our simple technique allowed the block to be administered safely without the need for a nerve stimulator. We assessed the effectiveness of the block with a novel objective sitting score and by assessing the degree of passive hip flexion that could be achieved comfortably. Visual analogue scores were also used. We studied 30 consecutive patients, regardless of their mental state. One hour following the block, there was a significant improvement in the sitting scores as well as the passive hip flexion (mean increase 44 degrees ). Visual analogue scores also score improved significantly from 7.2 to 4.6 (S.D. 2.4) in the 18 patients without cognitive impairment. We conclude that fascia iliaca blocks can provide significant benefit in the pre-operative period and allow patients to sit up more comfortably while they await surgery.

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The impact of cricoid pressure on laryngoscopy is unknown. We have developed a quantitative method of recording the laryngoscopic view using a rigid, zero-degree endoscope. We found that an image matching the laryngoscopist's view could be obtained by positioning the endoscope along the laryngoscopist's 'line of sight'. Photographing this image allowed us to measure laryngeal exposure. We set out to define the effect of cricoid pressure on laryngoscopy using this method. In 40 patients undergoing elective surgery, laryngoscopy was performed with cricoid pressures of 0-60 N, increasing by increments of 10 N. We photographed the laryngoscopic view at each force and recorded dynamic images as cricoid pressure was released. The change in laryngoscopic view with increasing cricoid pressure fell into one of four broad patterns: little change (11 subjects); gradual deterioration (10 subjects); improvement at low force (< 20 N) followed by deterioration (9 subjects); improvement at high force (> 30 N) (10 subjects). We identified five subjects with a good initial view (anteroposterior length of the rima glottidis > 5 mm) who showed a marked deterioration in laryngoscopic view as cricoid pressure increased; in three of these subjects this progressed to obscure the larynx completely at a force of 30 N, 40 N and 60 N, respectively. We conclude that the effect of cricoid pressure on laryngoscopy is complex. However, in some individuals, a force close to that currently recommended (30 N) may cause a complete loss of the glottic view.

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Cricoid pressure is frequently used to protect the anaesthetised and paralysed patient from passive regurgitation. Although intragastric pressure (Pga) drives regurgitation, its relevance in the setting of protective cricoid force has been largely ignored. We sought to define the likely range of Pga encountered in the population at risk. We studied 100 consecutive patients presenting for surgery requiring mechanical ventilation. We measured respiratory swings in Pga during mechanical ventilation in the paralysed state following rapid sequence induction (n = 24) and routine induction of anaesthesia (n = 76). Pga (mmHg) in the whole group recorded at end-inspiration (Pga-In) and end-expiration (Pga-Ex) was [mean (SD)]: Pga-In 6.48 (2.60) mmHg and Pga-Ex 3.23 (2.24) mmHg. We found no correlation between Pga and body mass index (r2 = 0.018). These findings have implications for the level of cricoid force required to protect a patient during the induction of anaesthesia.

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A device based on a load cell was constructed to measure the strength of foot dorsiflexion and plantarflexion. Performance of the device was evaluated for both movements. The influence of foot position within the device, its use over a 30-min period at 30-s intervals and the effect of the removal and reapplication of the device on measured force of dorsiflexion and plantarflexion was studied in six volunteers. Both dorsiflexion and plantarflexion are suitable movements on which to base a device to quantify the density of motor block during the onset and offset of neuraxial block. Dorsiflexion has a number of advantages: muscle strength is independent of knee position, and therefore a below-knee device can be constructed; strength of dorsiflexion is less affected by the foot position; we found the device easier to apply using dorsiflexion as the heel tended to self-locate; innervation of the muscles responsible for dorsiflexion involves fewer spinal segments.

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We have investigated the prevalence of positive serology for coeliac disease in pregnant women, using the IgA anti-endomysium antibody test. Five of 216 pregnant women with a haemoglobin less than 11 g/dl were positive, compared to 0/350 with haemoglobin > or = 11 g/dl. Four of these five had low plasma ferritin levels, indicative of iron deficiency anaemia; the fifth was borderline normal. We found no association between positive coeliac disease serology and folate deficiency. None of thirty mothers of children born with neural tube defects were IgA anti-endomysium antibody positive. This study has identified a very high prevalence of occult coeliac disease in pregnancy and a strong association with anaemia. We advise that in cases with a haemoglobin of less than 11 g/dl in pregnancy, coeliac disease should be excluded.

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BACKGROUND: A thrombotic etiology for inflammatory bowel disease (IBD) has been proposed as a result of its association with thromboembolic complications, smoking, the oral contraceptive pill, and the response of ulcerative colitis (UC) patients to heparin. We have previously demonstrated an increased prevalence of the Factor V Leiden mutation in UC and wished to investigate the frequency of the recently discovered prothrombin G20210A gene mutation in IBD. The aim of the study was to investigate the hypothesis that the prothrombic state associated with the prothrombin G20210A gene mutation is involved in the etiology of IBD. PATIENTS AND METHODS: A prospective cohort study of patients attending the Bristol Royal Infirmary and Gloucestershire Royal Hospital's IBD clinics was performed. Thirty-nine patients with IBD (24 with Crohn's disease and 15 with UC) and 100 historical controls were screened for the presence of the prothrombin gene mutation using a heteroduplex-based polymerase chain reaction technique. None of the patients with IBD had a personal history of thromboembolism, while three of them had a family history. RESULTS: No IBD patients had the prothrombin gene mutation compared with four (4%) controls (allelic frequency 2%). CONCLUSION: There does not appear to be an association of the prothrombin gene mutation with IBD and therefore it is unlikely to be involved in the etiology of IBD.

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Seventy-four patients seeking treatment for major depression completed four measures of dependent and autonomous personality and two measures of depressive symptomatology. Relationships among the personality measures were investigated by principal-components analysis, enabling systematic comparison of their composition. Relationships between personality components and symptom dimensions were examined to clarify specific associations that have been proposed but inconsistently obtained in previous research. Neither dependency nor autonomy were unitary constructs, and alternative measures had substantial differences in composition. Some support for symptom specificity was obtained. Dependency and autonomy have distinctive associations with depressive symptoms, but their correspondence to unitary personality dimensions and the equivalence of their alternative scales cannot be assumed.

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