Making Mercury's Histories: Mercury in Gold Mining's Past and Present.

This article considers the presence and absence of mercury, and why in different social arenas where gold features, mercury can become either pervasive or elusive. To substantiate this argument, the article offers two contrasting examples: (1) presentation strategies at Pacific Seaboard gold rush heritage sites, and (2) the background to the Minamata Bay tragedy and the Minamata Convention's subsequent framing of mercury use in artisanal and small-scale gold mining in the Global South. By unpacking these divergent social histories of mercury use and its consequences, the article identifies the current disconnect between different histories of mercury, and the problematic consequences of this disengagement.

Transporting major trauma patients from the margins of a UK trauma system.

OBJECTIVE: For serious motor vehicle crashes (MVC) occurring in a rural area to quantify: how many occur more than 45 min by road to a major trauma centre (MTC); how many occur more than 45 min by helicopter to an MTC; and how many patients might have to be taken to a local trauma unit if their incident occurs more than 45 min by road from an MTC and when the helicopter cannot fly. METHODS: MVC occurring in Shropshire, in which patients were killed or seriously injured during 2006-9 (inclusive) were analysed using the following parameters: distance from MTC by road; distance from MTC by air; weather and visibility-related factors that affect the operation of a helicopter emergency medical service. RESULTS: 722 serious MVC occurred, of which 626 (87%) occurred more than 45 min by road from the MTC. Of these 626 incidents, 408 occurred in conditions in which the helicopter could fly. There were 218 incidents (30%), which were more than 45 min by road from the MTC and which occurred when the helicopter could not fly. CONCLUSIONS: The transportation of patients from remote and rural areas to MTC remains problematical. Further work is required to develop more efficient systems of retrieval and transfer, and in particular to consider how emergency medical helicopters might operate safely at night.

The effect of specialist neurosciences care on outcome in adult severe head injury: a cohort study.

BACKGROUND: Head injury is the leading cause of death in trauma. UK national guidelines have recommended that all patients with severe head injury (SHI) should be treated in neuroscience centers. The aim of this study was to investigate the effect of specialist neuroscience care on mortality after SHI. METHODS: We conducted a cohort study using prospectively recorded data from the largest European trauma registry, for adult patients presenting with blunt trauma between 2003 and 2009. Mortality and unadjusted odds of death were compared for patients with SHI treated in neuroscience units (NSU) versus nonspecialist centers. To control for confounding, odds of death associated with non-NSU care were calculated using propensity score-adjusted multivariate logistic regression (explanatory covariates: age, Glasgow Coma Score, Injury Severity Score, treatment center). Sensitivity analyses were performed to study possible bias arising from selective enrollment, from loss to follow-up, and from hidden confounders. RESULTS: 5411 patients were identified with SHI between 2003 and 2009, with 1485 (27.4%) receiving treatment entirely in non-NSU centers. SHI management in a non-NSU was associated with a 11% increase in crude mortality (P<0.001) and 1.72-fold (95% confidence interval: 1.52-1.96) increase in odds of death. The case mix adjusted odds of death for patients treated in a non-NSU unit with SHI was 1.85 (95% confidence interval: 1.57-2.19). These results were not significantly changed in sensitivity analyses examining selective enrollment or loss to follow-up, and were robust to potential bias from unmeasured confounders. CONCLUSIONS: Our data support current national guidelines and suggest that increasing transfer rates to NSUs represents an important strategy in improving outcomes in patients with SHI.

A benchmarking study of two trauma centres highlighting limitations when standardising mortality for comorbidity.

INTRODUCTION: A continuous process of trauma centre evaluation is essential to ensure the development and progression of trauma care at regional, national and international levels. Evaluation may be by comparison between pooled datasets or by direct benchmarking between centres. This study attempts to benchmark mortality at two trauma centres standardising this for multiple case-mix factors, which includes the prevalence of individual background pre-existing diseases within the study population. METHODS: Trauma patients with an Injury Severity Score (ISS) >15 admitted to the two centres in 2001 and 2002 were included in the study with the exception of those who died in the emergency department. Patient characteristics were analysed in terms of 18 case-mix factors including Glasgow Coma Scale on arrival, Injury Severity Score and the presence or absence of 9 co-morbidity types, and patient outcome was compared based on in-hospital mortality before and after standardisation. RESULTS: Crude mortality was greater at UHNS (18.2 vs 14.5%) with a non-significant odds ratio of 1.31 prior to adjusting for case-mix (P = 0.171). Adjustment for case mix using logistic regression analysis altered the odds ratio to 1.64, which was not significant (P = 0.069). DISCUSSION: This study did not demonstrate any significant difference in the outcome of patients treated at either hospital during the study period. More importantly it has raised several important methodological issues pertinent to researchers undertaking registry based benchmarking studies. Data at the two registries was collected by personnel with differing backgrounds, in formats that were not completely compatible and was collected for patients that met different admissions criteria. The inclusion of a meaningful analysis of pre-existing disease was limited by the availability of robust data and sample size. We suggest greater communication between trauma research coordinators to ensure equivalent data collection and facilitate future benchmarking studies.

Major trauma & cervical clearance radiation doses & cancer induction.

AIM: To compare the radiation dose of cervical spine clearance and body CT in a cohort of unconscious, major trauma patients for three different protocols, comparing spiral to multislice CT. To quantify the radiation exposure effect of the protocols on the lifetime cancer risk. METHOD: The hospital trauma database was used to find the unconscious (GCS<9), severely injured (Injury Severity Score >15) from 1 January 2001 to 31 December 2003, excluding isolated head injuries. The protocols used for imaging the brain and cervical spine were, including the radiographs performed as a mode: The exposure factors and field of view used were put into the Monte Carlo software, to estimate the CT and radiographic X-ray doses to the body as a whole and the dose to the thyroid associated with each region imaged. The associated nominal additional lifetime cancer risk was assessed. RESULTS: Excluding inter hospital transfers, where data was incomplete, 87 patients survived to be admitted and fulfilled the criteria. In 30 cases, the CT films were missing, the exposure factors were not recorded or no imaging was performed. In a further 21 cases, the X-ray packets were missing. Three patients had brain and cervico-dorsal CT imaging only, leaving 33 cases for evaluation. The effective radiation dose for a spiral CT of the brain using the Toshiba Xpress GX CT scanner was 3.8 mSv. The total effective doses for imaging the brain and cervical spine using the three protocols with the same CT scanner were (S.D. as % of mean): (1) 4.4 mSv (5%), (2) 7.1 mSv (10%) and (3) 8.2 mSv (15%). The corresponding mean thyroid doses were: (1) 8.5 mGy (25%), (2) 48.9 mGy (20%) and (3) 66.5 mSv (20%). The resultant nominal lifetime cancer risks were: (1) 1:4500, (2) 1:2800 and (3) 1:2400. For the Siemens Sensation 16 multislice CT scanner, the total effective doses (S.D. as % of mean) were: (1) 2.3 mSv (10%), (2) 4.3 mSv (25%) and (3) 5.4 mSv (35%). The mean doses to the thyroid were: (1) 5.9 mGy (30%), (2) 36.1 mGy (50%) and (3) 52.4 mGy (40%). The lifetime cancer risks were: (1) 1:8700, (2) 1:4600 and (3) 1:3700. Using the Toshiba spiral CT scanner, the total dose and additional lifetime nominal cancer risk associated with CT of the chest, abdomen and pelvis (CAP) as 16 mSv and 1:1250, respectively. Using the Siemens multislice CT scanner, these were 11.8 mSv and 1:1700. The cancer risk for protocol 1 when combined with a CT scan of the chest, abdomen and pelvis was 1:1000 for the spiral CT scanner and 1:1500 for the multislice CT (MCT) scanner. The cancer risk for protocol 2 with CAP CT using the MCT was 1:1200. The cancer risk for protocol 3 when combined with a CT scan of the chest, abdomen and pelvis was 1:1100 for the multislice CT scanner. Prior to the introduction of the BTS guidelines for cervical clearance, 12% of cases had CT of the body, which increased to 16% post-guidelines. CONCLUSIONS: CT of the trunk (chest, abdomen and pelvis) is associated with the greatest risk of inducing a fatal cancer in the severely injured patient with a GCS less than 9. In our institution the multislice CT protocols expose the patient to less radiation than single slice CT, which is contrary to much of the published work to date. CT scanning the thyroid (or whole cervical spine) still has a marked effect on the cancer risk in cervical clearance. Many centres will relax cervical spinal precautions in unconscious trauma patients if the cervical spine CT with reconstructions is normal. CT of the whole cervical spine may be justified in the unconscious, severely injured patient. In conscious trauma patients, the additional lifetime risk may not justify CT of the whole cervical spine as a routine practice.

Emergency care in facial trauma--a maxillofacial and ophthalmic perspective.

Facial trauma, with or without life- and sight-threatening complications, may arise following isolated injury, or it may be associated with significant injuries elsewhere. Assessment needs to be both systematic and repeated, with the establishment of clearly stated priorities in overall care. Although the American College of Surgeons Advanced Trauma Life Support (ATLS) system of care is generally accepted as the gold standard in trauma care, it has potential pitfalls when managing maxillofacial injuries, which are discussed. Management of facial trauma can arguably be regarded as "facial orthopaedics", as both specialities share common management principles. This review outlines a working approach to the identification and management of life- and sight-threatening conditions following significant facial trauma.

Longitudinal trends in trauma mortality and survival in Stoke-on-Trent 1992-1998.

OBJECTIVES: To identify factors related to mortality and to test the null hypothesis of no longitudinal trend in mortality in patients admitted to the North Staffordshire Hospital (NSH) with an Injury Severity Score (ISS) greater than 15, between April 1992 and March 1998. DESIGN: Longitudinal prospective study of 18 factors, including age, sex, mechanism of injury, anatomical injury scores and year of admission. Outcome, based on mortality at discharge, was analysed in two ways: alive or dead at discharge (mortality) and time to death or discharge (survival). RESULTS: A decreasing trend (P < 0.01 ) in mortality with year of admission was detected on the log-odds scale. The trend could not be explained by a case-mix analysis, which allowed for the 17 other factors. Using multiple logistic regression analysis (mortality) and Cox proportional hazards analysis (survival), eight factors were identified as determinants of outcome: age, head AIS score, chest AIS score, abdominal AIS score, calendar year of admission, external injury AIS score, mechanism of the injury and primary receiving hospital. CONCLUSIONS: The observed improvement in survival in severely injured patients must result from the interplay of factors not controlled in this analysis or improvements in patient care or both.

Survival with an arterial pH of 6.57 following major trauma with exsanguinating haemorrhage associated with traumatic amputation.

We report the survival of a multiply injured patient with exanguinating haemorrhage and an arterial pH of 6.5, following a road vehicle crash. The previously healthy 38 years old male driver veered off the motorway and collided with a tree. The ambulance arrived at the scene 9 min after being called by an eyewitness and, following rapid extrication from the wreckage; the patient arrived in hospital 27 min later (with a GCS of 6), and was immediately intubated. The patient had suffered near-complete amputation of the left leg at upper femoral shaft level, along with multiple distal fractures and open wounds. He also sustained a head injury and closed displaced fractures of left radius and ulna. The patient received 2 l of crystalloids in the pre-hospital phase. Once in hospital the haemorrhage was controlled with a pressure dressing and intra-venous fluids were kept to a minimum until he was taken promptly to theatre. His initial arterial blood sample revealed a pH of 6.57, pCo(2) of 9.18 kPa, a pO(2) of 70.11 kPa and a base excess of -27.5 mmol l(-1). The co-oximeter Hb was 5.8 g dl(-1). Haemorrhage was controlled in theatre where he was transfused a total of 30 U of blood, 1 pack of platelets, 12 U of fresh frozen plasma, 3.5 l of crystalloids and 1.5 l of colloid. Sodium bicarbonate was administered three times. He subsequently remained ventilated in intensive care unit (ICU). Over the following week he survived sepsis, disseminated intravascular coagulation and myoglobinuria (with transient renal failure) attributable to rhabdomyolysis secondary to muscle necrosis. He later underwent diversion colostomy and disarticulating amputation of the left femur after several debridements. After 6 weeks on ICU he made an excellent recovery will full return of his mental abilities. In this case, the serial arterial blood samples obtained were reliable. The lactic acidosis observed was the result of profound tissue hypo-perfusion and its rate of clearance seems to have greater prognostic value than its peak or initial value. Several factors may have contributed to the patient's survival: rapid retrieval from the scene; early intubation with excellent subsequent oxygenation (thus avoiding the dangerous combination of hypoxia and acidosis with synergistic influence on cardiac depression) and limited initial fluid resuscitation in the emergency department with prompt surgical intervention and vigorous restoration of organ perfusion after surgical haemostasis. Immediate operative haemostasis, coupled with restricted fluid administration beforehand and vigorous restoration of organ perfusion afterwards is now replacing the old resuscitation paradigm. Perhaps this shift in practice has helped this patient to survive.

Relación Comunal en el Desarrollo Sanitario: Distrito Caranavi / sss

El presente documento tiene el objetivo central de la cogestión de los servicios de salud entre los profesionales de la salud y las personas locales o población, vía una estructura de organización popular. La idea de cogestión vinó del pedido de un nuevo acercamiento, pero no fue recibida con gran entusiasmos en todos los circulos.

Intervención de la comunidad en el desarrollo sanitario : examen de los aspectos esenciales / Peter Oakley / Community involvement in health development : an examination of the critical issues

Este libro presenta un examen crítico del gran número de cuestiones conceptuales y prácticas que es necesario comprender para que el concepto de intervención de la comunidad en el desarrollo sanitario pueda pasar de la teoría a la práctica. Teniendo en cuenta la convicción general de que un desarrollo eficaz requiere la participación de la comunidad, el libro invita a los lectores a preguntarse por qué este concepto ha sido adoptado tan pocas veces como principio fundamental de la atención sanitaria oficial. A lo largo del libro se presentan ejemplos de experiencias en diferentes países para mostrar la forma en que la intervención de la comunidad, bien comprendida, planeada y aplicada, puede contribuir a acelerar el desarrollo sanitario. La parte principal del libro contiene un análisis pormenorizado de los problemas prácticos que es probable que se planteen cuando un servicio de salud trata de conseguir el apoyo de la comunidad como principio fundamental para sus actividades de desarrollo sanitario. Entre los aspectos examinados figuran las características de las comunidades que pueden influir en la eficacia de su intervención en actividades de salud, las repercusiones de los diferentes mecanismos de apoyo tanto en el plano nacional como en el local, y las radicales modificaciones que es necesario efectuar en la formación del personal de salud cuando se toma en serio la decisión de conseguir la participación de la comunidad. También se presenta a los lectores un examen de los métodos útiles para fomentar la intervención de la comunidad en la salud en determinadas situaciones, seguido de un estudio de los indicadores que cabe utilizar para la evaluación y la vigilancia. En el último capítulo se expone a grandes rasgos un programa para el desarrollo futuro de la intervención de la comunidad en salud, incluido un resumen de las condiciones que es necesario satisfacer para fomentar la adopción en mayor escala de esta estrategia de salud fundamental

L' engagement communautaire pour le développement sanitaire : analyse des principaux problèmes / Peter Oakley / Community involvement in health development : an examination of the critical issues

Cet ouvrage constitue une analyse critique des nombreux concepts et des problèmes pratiques qu'il importe de bien comprendre pour pouvoir appliquer le concept théorique d'engagement communautaire au développement sanitaire. Constatant que le principe selon lequel le développement doit reposer sur la participation communautaire est généralement admis, l'ouvrage incite le lecteur à se demander pourquoi on en a si rarement fait un principe fondamental dans la prestation des soins de santé. Des exemples d'expériences menées dans différents pays servent à illustrer la façon dont l'engagement communautaire bien compris, planifié et mis en oeuvre, permet d'accélérer le développement sanitaire

Community involvement in health development : an examination of the critical issues / Peter Oakley / L' engagement communautaire pour le dv̌eloppement sanitaire : analyse des principaux problm̈es / Intervencin̤ de la comunidad en el desarrollo sanitario : examen de los aspectos esenciales

A critical examination of the many conceptual and practical issues that need to be understood before the concept of community involvement in health development can move from theory into practice. Noting the widespread conviction that successful development requires community participation, the book challenges readers to consider why the concept has so very rarely been translated into a fundamental principle of formal health care. Throughout the book, examples of experiences in different countries are used to show how community involvement, when properly understood, planned, and implemented, can work to accelerate health development. The book opens with an historical overview of changing theories of the development process that led to the view that participatory development is the most reliable route to better health for all. Readers are also given a list of the main reasons why previous development strategies, linked to the notion of community involvement, met with so little success. The main part of the book is devoted to a step-by-step analysis of practical problems that are likely to arise when a health service seeks to enlist community support as a fundamental principle of its health development activities. Points covered include characteristics of communities that can influence their successful involvement in health activities, the impact of different support mechanisms at both national and local levels, and the sweeping changes in health service training required when the commitment to community involvement is taken seriously. Readers are also given a review of methods for developing community involvement in health in particular situations, followed by a discussion of indicators that can be used in evaluation and monitoring. The final chapter outlines an agenda for the future development of community involvement in health, including a summary of conditions that must be met in order to foster the adoption of this essential health strategy on a larger scale