Determining the appropriate use of Technology Enabled Care Services (TECS) to manage upper-limb trauma injuries during the COVID-19 pandemic: A multicentre retrospective observational study.

BACKGROUND: The COVID-19 pandemic created a unique opportunity to explore the use of Technology Enabled Care Services (TECS), which remains novel for many service providers. This study assesses the factors that affect adaptation to remote monitoring of patients after upper-limb trauma injury. A standardised risk-stratified screening tool is further developed here to support clinical staff in both the determination of appropriate use of TECS and the optimisation of patient care. OBJECTIVES: 1: To explore the patient and injury factors that determine the appropriate use of TECS for patients with upper-limb injury. 2: To use these findings to refine a standardised screening tool for the appropriate choice of follow-up format. METHODS: A retrospective review of patient management was undertaken across three NHS upper-limb trauma units during the first UK COVID-19 lockdown. Data were collected, and themes were analysed across a number of predetermined categories. This was underpinned by a review of contemporary policy guidance and literature. RESULTS: A total of 85% of patients were offered an appropriate format of follow-up; this was defined by the ability to achieve desired patient-clinician goals and lack of complications. Key factors in determining appropriate follow-up included extent of injury, mental health considerations, and the need for face-to-face (F2F) assessment and treatment. CONCLUSION: Study findings demonstrate consistency between units in the factors determining the appropriate use of TECS. The refined screening tool provides a risk-stratified, standardised approach to the choice of follow-up format, F2F or TECS. It is hoped that this will support future clinical decision-making processes to ensure optimal patient care.

Defining clinical decision making in the provision of audio-visual outpatient care for acute upper limb trauma services: A review of practice.

The Covid-19 pandemic has accelerated the widespread adoption of technology-enabled care in the NHS.1 Moving into phase two of the response, the continuing use of audio-visual technology is expected, where appropriate, to be integral in the provision of safe, quality patient care.2 A clinical need therefore exists to identify when care can be safely delivered remotely using audio-visual technology and when there is a need for in-person contact.  At Salisbury Foundation Trust (SFT), during phase one of the NHS response to Covid-19, the decision to treat upper limb trauma patients in-person or remotely was made using clinical screening criteria. For many patients, audio-visual appointments offered a practical, time efficient way of accessing their reconstructive team for assessment, advice and post-operative care. However, a subset of patients was identified by the team as requiring at least one in-person consultation to minimize perceived clinical risk and to optimize quality outcomes.  In order to understand more fully the challenges and successes of technology-enabled care to date, a national survey of practice across hand units in the UK was conducted. We present here some of our key findings and propose the need to develop nationally agreed screening criteria to determine how and when technology enabled outpatient care can be used in the management of acute upper limb trauma. The results of this survey forms part of a series of projects currently underway looking at the efficacy of audio-visual care in upper limb trauma, including a multicentre observational study.

The quality of life of 790 patients with photodermatoses.

BACKGROUND: Polymorphic light eruption and erythropoietic protoporphyria (EPP) have been demonstrated to have a moderate and large impact on the quality of life (QoL) of patients, respectively. However, there is little information available about the impact of other photodermatoses on QoL. OBJECTIVES: To assess and compare the impact of all forms of photodermatoses on patients' QoL using the standard 1-week Dermatology Life Quality Index (DLQI) questionnaire and a modified questionnaire to assess the impact over the previous year. METHODS: All patients with photodermatoses seen between 2001 and 2005 at five U.K. photobiology centres were contacted by post on the same day during a forecasted sunny week across the U.K. and asked to complete DLQI questionnaires. RESULTS: A total of 1877 patients were contacted. Seven hundred and ninety-seven (42%) patients replied, with a range from 30% to 48% for the five individual centres. Nearly two-thirds of patients with actinic prurigo (AP) and more than one-third of patients with photoaggravated dermatoses (PAD), chronic actinic dermatitis, EPP and solar urticaria had a DLQI of > 10, confirming a very large effect of the disorders on QoL. Of the cutaneous porphyrias, both variegate porphyria (median DLQI 3) and porphyria cutanea tarda (median DLQI 1.5) had a much lower impact on QoL than EPP. CONCLUSION: This is the first large-scale study to attempt to measure the impact of a range of photodermatoses on QoL. Photodermatoses have a major impact on QoL. This impact is highest in AP and PAD.

Reliability testing of a sun exposure questionnaire for the Northern Ireland population.

BACKGROUND: Sunbathing and other types of exposure to ultraviolet radiation are the major preventable risk factors for skin cancer. Due to the continued increase in incidence of melanoma in Northern Ireland, we have conducted a questionnaire survey in an attempt to gather information about sunbathing habits and other forms of ultraviolet light exposure amongst the Northern Ireland population. AIM: The aim of this study was to examine the test-retest reliability of a questionnaire used in a large-scale cross-sectional population survey pertaining to sunbathing habits, use of sun screen, skin types, and frequencies of sunburn and to assess the responses given by the subjects to determine the nature of their sun-related behaviour. METHODS: Thirty control subjects were randomly selected from a population control sample participating in a large case-control study investigating melanoma in the Northern Ireland population. All participants completed the interview questionnaire on two occasions, with a median of 15 days (range, 12-42 days) between interviews. We randomly chose control subjects who had been visited by the same research nurse, thus ruling out interobserver bias in the analyses. We used the test-retest method. Kappa statistics were used to calculate the association between test and retest scores of all the individual items. If the items contained within the questionnaire are reliable, then repeated measurement after a fairly short period of time should result in high within-subject repeatability. RESULTS: Questions pertaining to hours spent in the sun and sun bed usage showed high reliability (kappa > 0.7). Questions about sunscreen usage showed moderately high reliability (kappa > 0.6) in all but one of the 10-year age bands and complete agreement (kappa = 1) in one age category (>50 years). CONCLUSION: This questionnaire is a reliable method of assessing sun-associated behaviour identifying high-risk sun-related behaviour and misconceptions about tanning, which can be targeted for improvement in public health.

Physical friction is under-recognized as an irritant that can cause or contribute to contact dermatitis.

BACKGROUND: The role of physical friction as an irritant in the causation of contact dermatitis is under-recognized. Frictional dermatitis is defined as an eczematous process in which physical frictional trauma contributes to the induction of a dermatitis process. OBJECTIVES: To examine the clinical background of patients in whom friction was contributing to dermatitis. METHODS: Over a 30-month period during which 2700 new patients were seen, frictional irritancy was identified as playing a role in the dermatosis in 31 cases: in 27 of these, case notes were evaluated for a range of parameters. RESULTS: Physical friction was identified as causing or contributing to the dermatitis in 18 men and nine women, mean age at onset 42 years. The hands, usually the fingers of the dominant hand, were affected in all but two cases. Occupational frictional activities were found in 25 cases: commonly handling small metal components, paper, cardboard or fabric, and driving. Potential frictional activities in hobbies were noted in 12 cases. Wet work irritancy contributed in four cases (15%). Patch testing showed relevant contact allergies as cofactors in seven of 25 subjects tested (26%). Psoriasis was a cofactor in four (15%), and atopic dermatitis in 11. The study was selective, being based in a teaching hospital clinic with a special interest in contact dermatitis. Frictional irritancy is often one of several factors contributing to dermatitis. CONCLUSIONS: The contribution of friction to contact dermatitis is under-recognized probably because dermatologists do not think about the potential for physical forces to induce eczematous changes in the skin.

Improved survival for melanoma in Northern Ireland: a comparison of two 5-year periods (1984-88 and 1994-98).

BACKGROUND: The incidence of cutaneous malignant melanoma has been rising steadily in Caucasian populations for several decades, with a doubling time of 10-14 years. An increase in incidence of about 5% per year has been reported in most Caucasian populations since the early 1960s. OBJECTIVES: This study was designed to determine the changing incidence of primary cutaneous malignant melanoma in Northern Ireland and to examine changes in survival rates from cutaneous malignant melanoma in two 5-year periods, 1984-88 and 1994-98. METHODS: One thousand three hundred and twenty-six patients with invasive primary cutaneous melanoma were included in the study. RESULTS: The age standardized rate of melanoma rose from 4.3 per 100,000 population per year in men and 8.6 per 100,000 population per year in women to 7.7 and 11.8, respectively, per 100,000 population per year in the 1994-98 period. Overall, the absolute 5-year survival for the 1984-88 period was 71.0% [95% confidence interval (CI) 66.9-75.1%] and 77.4% (95% CI 73.4-81.4%) for the 1994-98 period. Women consistently showed better survival at all ages and within almost all categories of thickness of primary tumour. Younger patients of both sexes showed better survival rates. CONCLUSIONS: When survival rates between the 1984-88 and 1994-98 periods were compared using multivariate analysis, we found that patients diagnosed in the second period had a one-third lower risk of dying than those in the earlier period. Much of this reduction was explained by changes in the number of melanomas of thin Breslow depth and ulcerated melanomas.

Association between long-term acitretin therapy and osteoporosis: no evidence of increased risk.

Osteoporosis has been observed with chronic hypervitaminosis A, leading some authors to hypothesize that systemic retinoids may have an effect on bone mineral density. Two previous small studies identified osteoporosis in patients who received long-term therapy with etretinate. Etretinate has now been superceeded by acitretin in clinical use. We hypothesized that bone mineral density is lower in patients taking long-term acitretin than control cases who had never taken acitretin. Thirty Caucasian patients receiving acitretin for a median of 3.6 years for a variety of dermatoses were studied. Bone mineral density measurements were determined using DEXA scanning at two standard sites, the lumbar spine and Ward's triangle. We did not find an association between daily dose of acitretin, total dose administered or overall duration of treatment and risk of osteopenia or osteoporosis. Acitretin appears to be safe for long-term use in patients with chronic dermatoses.

Environmental tobacco smoke exposure patterns: a subanalysis of the Canadian Human Time-Activity Pattern Survey.

This subanalysis of the Canadian Human Activity Pattern Survey examines environmental tobacco smoke (ETS) exposure in non-smoking respondents relative to age, sex, socioeconomic status and prevalence of asthma. 2,381 respondents (response rate 64.5%) from Toronto, Vancouver, Edmonton and Saint John completed a 24-hour recall time-activity diary. For each activity and location, respondents were asked, "was there any smoking during the activity?" Among non-smoking adults, youth, children and asthmatics, the rates of ETS exposure were 32%, 34%, 30% and 42% respectively. Regarding the location of exposure, adults reported ETS exposure in various locations (work, bars and restaurants), including home. Children experienced the most exposure at home, primarily between 4 p.m. and midnight. Adults reported ETS mainly in the living room (16%) and vehicles (13%); for children, the living room (22%) and the bedroom (13%) were the most common locations. Determining characteristic time and location patterns for ETS exposure underpins educational strategies to help non-smokers avoid ETS exposure.

Dental amalgam and multiple sclerosis: a case-control study in Montreal, Canada.

BACKGROUND: The aetiology of multiple sclerosis (MS) remains poorly understood. Dental amalgams containing mercury have recently been suggested as a possible risk factor for MS. METHODS: In a case-control study conducted between 1991 and 1994, we interviewed a total of 143 MS patients and 128 controls, to obtain information on socio-demographic characteristics and the number of dental amalgams and the time since installation based on dentists' records. RESULTS: Neither the number nor the duration of exposure to amalgams supported an increased risk of MS. After adjustment for age, sex, smoking, and education those who had more than 15 fillings had an odds ratio (OR) of 2.57 (95% CI: 0.78-8.54) compared to those who had none; for individuals whose first amalgam was inserted more than 15 years prior to the study, we found an OR of 1.34 (95% CI: 0.38-4.72). CONCLUSIONS: Although a suggestive elevated risk was found for those individuals with a large number of dental amalgams, and for a long period of time, the difference between cases and controls was not statistically significant.

Pharmacokinetics of benzo[a]pyrene in the rat.

Groups of 4 male Wistar rats were dosed intravenously with 14C-labeled benzo[a]pyrene dissolved in an Emulphor/water vehicle at 3 different dose levels and killed at 1 of 15 specific time intervals from 5 min to 32 h after dosing. 14C-Radiolabel concentration-time data were obtained for blood, brain, adipose, heart, kidney, liver, lung, spleen, and testes. Benzo[a]pyrene concentration-time data were obtained for blood, adipose, kidney, liver, and lung. Appropriate mathematical models were fitted to these data and to the data for metabolites derived as the residuals from 14C-radiolabel minus benzo[a]pyrene difference, where applicable. Nonlinear kinetics were found for 14C-radiolabel in liver, while the data from lung for both 14C-radiolabel and for benzo[a]pyrene per se supported the binding of benzo[a]pyrene in that tissue.

Childhood discoid lupus erythematosus: a report of two cases.

Discoid lupus erythematosus (DLE) is an uncommon disease in childhood. We present two patients initially diagnosed as impetigo and photosensitive eczema with impetigo, respectively, who failed to respond to topical and systemic antistaphylococcal agents and in whom a diagnosis of discoid lupus erythematosus subsequently became apparent.

Parental reporting of childrens' coughing is biased.

Assessment of cough in the clinical setting as well as in community-based studies of respiratory epidemiology has relied on self-reports. To examine the accuracy and potential for systematic bias in reported cough during a field study, questionnaires administered to parents about their childrens' coughing were compared to overnight cough recordings performed in 145 homes in the community of Wallaceburg, Canada. Percentage agreement between reported and recorded coughing was low, with kappa statistics ranging from 0.02-0.10. Compared to non-smoking parents, smokers under-reported their childrens' coughing (p = 0.01). The association found between parental smoking and recorded coughing was biased towards the null when reported coughing was substituted for recorded coughing: the odds ratio between parental smoking and recorded coughing was 3.1 (95% CI: 1.1-8.8) whereas for reported coughing it was 0.6 (95% CI: 0.2-1.7), the difference in the odds ratios being significant at p = 0.03. When carrying out field surveys, consideration should be given to measuring cough in a subsample of the population in order to estimate the degree of bias inherent in the questionnaire-based results.

Indoor air quality and health: validity and determinants of reported home dampness and moulds.

BACKGROUND: Questionnaire-based surveys from several countries have consistently detected adverse health associated with home dampness and mould growth. METHODS: To test the validity of questions commonly used to indicate the presence of indoor mould, questionnaires were administered in 403 homes where dust samples were taken for viable fungi and air samples for ergosterol. RESULTS: Geometric mean concentrations of the total viable fungi were 255 (SE 116) x 10(3) CFU/g when mouldy odours were reported and 155 (SE 55) when odours were not reported (P = 0.01). Similarly, reported water damage was associated with a 50% increase (P = 0.06). Geometric mean concentrations of the predominantly indoor-source fungi, Aspergillus plus Penicillium, were twice as high when mould or mildew was reported than when not mentioned (P = 0.01). The presence of reported mould or water damage was unrelated to the presence of detectable levels of ergosterol. There was evidence for reporting bias: in the presence of low concentrations of viable fungi in dust, respondents reporting allergies were more likely to report visible mould growth (odds ratio [OR] = 1.8, 95% confidence interval [CI]: 0.9-3.5, P = 0.10. In the presence of elevated concentrations of dust fungi, respondents who smoked were less likely to report visible mould growth, (OR = 0.4, 95% CI: 0.2-0.7, P = 0.005). CONCLUSIONS: Reported mould, water damage, and mouldy odours were associated with elevated levels of indoor fungi. However, inaccuracy was high and there was evidence of a systematic reporting bias. Future research should concentrate on developing accurate objective measures of exposure to fungi, and then use this information to develop valid questionnaires. Currently, objective measures not questionnaires, are recommended to clarify the health effects of indoor fungi.