Maternal outcomes of pregnant patients after trauma: a retrospective study of the Trauma Registry of England and Wales.

INTRODUCTION: Trauma accounts for 20% of deaths in pregnant women. Injury characterisation and outcome in pregnant women following trauma is poorly described. To understand and inform optimum care of this key injury population, a study was conducted using the Trauma Audit Research Network (TARN) database. METHODS: In total, 341 pregnant and 26,774 non-pregnant female patients aged 15 to 46 years were identified for comparison from the TARN database. Mortality, cross-sectional imaging, blood product administration and EQ-5D scores were compared between the two groups. Mechanism of injury, Injury Severity Score (ISS) and mortality rate before and after the creation of regional trauma networks were reported for pregnant patients. RESULTS: Pregnancy was recorded in 1.3% (341/27,115) of included patients, with the most common cause of injury being road traffic collisions. A reduction in crude maternal mortality was observed over the course of the study period (7.3% to 2.9%). Baseline mean EQ-5D (0.47) and EQ-VAS (54.08) improved to 0.81 (p < 0.001) and 85.75 (p = 0.001), respectively, at 6 months following injury. CONCLUSION: The incidence of trauma in pregnancy is small and mortality in injured pregnant women decreased over the study period. Pregnant patients have significantly improved patient-reported outcome measures 6 months after injury although this is limited in impact because of poor response rates and outcome reporting. Construction and validation of tools aiding in outcome reporting will help considerably in understanding further gains in the care of pregnant women.

Home Energy Efficiency and Subjective Health in Greater London.

The UK has introduced legislation that requires net-zero greenhouse gas emissions to be achieved by 2050. Improving the energy efficiency of homes is a key objective to help reach this target, and the UK government's Clean Growth Strategy aims to get many homes up to an Energy Performance Certificate (EPC) Band of C by 2035. The relationship between home energy-efficiency and occupant health and wellbeing remains an area of ongoing research. This paper explores the nexus between home energy efficiency, energy consumption and self-reported health-an indicator of the general health and wellbeing of the population. We focus on Greater London through secondary data analysis. Energy-efficiency ratings and air infiltration rates of dwellings, derived from EPCs, were aggregated and matched to local area self-reported health and energy consumption data obtained from the Greater London Authority's (GLA) Lower Layer Super Output Area (LSOA) Atlas database. Our regression model indicates that improving the energy efficiency (SAP) rating by 10 points for a typical home may reduce household gas consumption by around 7% (95% CIs: 2%, 14%). Beta regression finds a positive, but not statistically significant association between median SAP rating and the proportion of the population reporting 'good or very good' health when considering all Greater London LSOAs (z score = 0.60, p value = 0.55). A statistically significant positive association is observed however when repeating the analysis for the lowest income quartile LSOAs (z score = 2.03, p value = 0.04). This indicates that the least well-off may benefit most from home energy efficiency programs. A statistically significant positive association is also observed for the relationship between self-reported health and air infiltration rates (z score = 2.62, p value = 0.01). The findings support existing evidence for the predominantly naturally ventilated UK housing stock, suggesting that home energy efficiency measures provide a co-benefit for occupant health provided that adequate air exchange is maintained.

Assessing urban population vulnerability and environmental risks across an urban area during heatwaves - Implications for health protection.

Heatwaves can lead to a range of adverse impacts including increased risk of illness and mortality; the heatwave in August 2003 has been associated with ~70,000 deaths across Europe. Due to climate change, heatwaves are likely to become more intense, more frequent and last longer in the future. A number of factors may influence risks associated with heat exposure, such as population age, housing type, and location within the Urban Heat Island, and such factors may not be evenly distributed spatially across a region. We simulated and analysed two major heatwaves in the UK, in August 2003 and July 2006, to assess spatial vulnerability to heat exposure across the West Midlands, an area containing ~5 million people, and how ambient temperature varies in relation to factors that influence heat-related health effects, through weighting of ambient temperatures according to distributions of these factors across an urban area. Additionally we present quantification of how particular centres such as hospitals are exposed to the UHI, by comparing temperatures at these locations with average temperatures across the region, and presenting these results for both day and night times. We find that UHI intensity was substantial during both heatwaves, reaching a maximum of +9.6°C in Birmingham in July 2006. Previous work has shown some housing types, such as flats and terraced houses, are associated with increased risk of overheating, and our results show that these housing types are generally located within the warmest parts of the city. Older age groups are more susceptible to the effects of heat. Our analysis of distribution of population based on age group showed there is only small spatial variation in ambient temperature that different age groups are exposed to. Analysis of relative deprivation across the region indicates more deprived populations are located in the warmest parts of the city.

Radiation Exposure and Health Effects - is it Time to Reassess the Real Consequences?

Our acceptance of exposure to radiation is somewhat schizophrenic. We accept that the use of high doses of radiation is still one of the most valuable weapons in our fight against cancer, and believe that bathing in radioactive spas is beneficial. On the other hand, as a species, we are fearful of exposure to man-made radiation as a result of accidents related to power generation, even though we understand that the doses are orders of magnitude lower than those we use everyday in medicine. The 70th anniversary of the detonation of the atomic bombs in Hiroshima and Nagasaki was marked in 2015. The 30th anniversary of the Chernobyl nuclear power plant accident will be marked in April 2016. March 2016 also sees the fifth anniversary of the accident at the Fukushima nuclear power plant. Perhaps now is an opportune time to assess whether we are right to be fearful of the effects of low doses of radiation, or whether actions taken because of our fear of radiation actually cause a greater detriment to health than the direct effect of radiation exposure.

The beliefs and knowledge of patients newly diagnosed with cancer in a UK ethnically diverse population.

AIMS: To compare knowledge about the outcome of cancer treatment and beliefs about the causes of cancer among British South Asian (BSA) cancer patients of predominantly Gujarati origin with the beliefs held by British White (BW) cancer patients. We also wanted to determine if these beliefs impacted upon the patients' mental health. MATERIALS AND METHODS: We administered a questionnaire about cancer beliefs to 94 BSA and 185 BW newly diagnosed cancer patients at the Leicestershire Cancer Centre. Using a Likert seven-item scale, we analysed patients' views on confidentiality, outcome and cancer treatment and 15 items about beliefs about the causes of cancer. Patients also completed the Hospital Anxiety and Depression Scale, Patient Health Questionnaire, Mini-MAC, Distress Thermometer and newly developed Cancer Insight and Denial, and Physician/Patient Trust questionnaires. RESULTS: Most (232/279; 83.2%) believed cancer was curable. However, significantly more BSA (10.6% versus 2.7% BW P=0.001) believed cancer was incurable. Although most (86.4%) agreed that smoking can cause cancer, there was a widespread lack of knowledge of the importance of diet and obesity as contributing causes of cancer. There was, in general, an over-emphasis on pollution, stress and injury as important aetiological agents. There was a strong belief in supernatural involvement in the development of cancer among a minority of BSA patients. Twenty per cent of this sample believed that treatment, especially surgery, caused the cancer to spread and this was associated with significant depression in BSAs (P=0.019) and anxiety in both BW (P=0.006) and BSA (P=0.0134) patients. CONCLUSION: Our results show that there is a continual need for education about the causes of cancer both in BW and BSA patients.

Measuring trust in healthcare professionals--a study of ethnically diverse UK cancer patients.

AIM: To assess the effect of patient physician trust on how British South Asian (BSA) and British White (BW) patients cope when diagnosed with cancer. MATERIALS AND METHODS: We administered a questionnaire incorporating domains of fidelity, honesty, competence, confidentiality and global trust. The patient-physician relationship most preferred by the patient was tested by a further five questions. Five other questionnaires were completed, including the Brief Illness Perception Questionnaire and mini-MAC. In total, 94 BSA patients and 185 BW patients were recruited in the Leicestershire Cancer Centre by an English-speaking nurse or two radiographers who between them spoke English, Gujarati, Hindi and Urdu. RESULTS: In all the five domains of trust, BW and BSA patients rated doctors in the Leicestershire Cancer Centre consistently high or very high; 97.4% (BW 97.2%, BSA 95.7%) were satisfied with the medical care received and 94.4% completely trusted the hospital doctor; 9.3% were concerned that 'the NHS would not give the best possible care'. Fewer (80.2%) showed a high degree of trust in general practitioners, particularly in BSA patients (BW 81.4%, BSA 78%, P<0.027). More BSA patients, however, preferred to receive sensitive information from their general practitioner (BSA 62.5% versus 32.6%; P<0.0005 or from 'someone of the similar religion or background to me' (BSA 38.1% versus BW 7.4%; P<0.0001). Confidentiality (P=0.0005), faith in treatment (P=0.011) and understanding of cancer (P=0.011) plus a low detrimental effect of the illness on lives (P=0.0005) were strong predictors of trust in this sample. CONCLUSION: Trust in both the hospital, general practitioners and the National Health Service in general is very high among BSA and BW cancer patients in Leicestershire. Greater partnership between the hospital and general practitioners is desirable for some sections of our population.

Substantial improvement in UK cervical cancer survival with chemoradiotherapy: results of a Royal College of Radiologists' audit.

AIMS: To compare survival and late complications between patients treated with chemoradiotherapy and radiotherapy for locally advanced cervix cancer. MATERIALS AND METHODS: A Royal College of Radiologists' audit of patients treated with radiotherapy in UK cancer centres in 2001-2002. Survival, recurrence and late complications were assessed for patients grouped according to radical treatment received (radiotherapy, chemoradiotherapy, postoperative radiotherapy or chemoradiotherapy) and non-radical treatment. Late complication rates were assessed using the Franco-Italian glossary. RESULTS: Data were analysed for 1243 patients from 42 UK centres. Overall 5-year survival was 56% (any radical treatment); 44% (radical radiotherapy); 55% (chemoradiotherapy) and 71% (surgery with postoperative radiotherapy). Overall survival at 5 years was 59% (stage IB), 44% (stage IIB) and 24% (stage IIIB) for women treated with radiotherapy, and 65% (stage IB), 61% (stage IIB) and 44% (stage IIIB) for those receiving chemoradiotherapy. Cox regression showed that survival was significantly better for patients receiving chemoradiotherapy (hazard ratio=0.77, 95% confidence interval 0.60-0.98; P=0.037) compared with those receiving radiotherapy taking age, stage, pelvic node involvement and treatment delay into account. The grade 3/4 late complication rate was 8% (radiotherapy) and 10% (chemoradiotherapy). Although complications continued to develop up to 7 years after treatment for those receiving chemoradiotherapy, there was no apparent increase in overall late complications compared with radiotherapy alone when other factors were taken into account (hazard ratio=0.94, 95% confidence interval 0.71-1.245; P=0.667). DISCUSSION: The addition of chemotherapy to radiotherapy seems to have improved survival compared with radiotherapy alone for women treated in 2001-2002, without an apparent rise in late treatment complications.

Concomitant and neoadjuvant chemotherapy for cervical cancer.

In the past, women with early-stage cervical cancer have been treated with radical radiotherapy or radical surgery, and women with locally advanced disease with radical radiotherapy, each offering a good chance of cure. Numerous trials have investigated whether giving cytotoxic chemotherapy alongside radiotherapy or before local treatment could augment the established benefits of these therapies. There is a strong basis for the use platinum-based chemoradiotherapy, the current standard of care, but little convincing evidence as to the therapeutic benefits of using concomitant hydroxyurea. Chemoradiotherapy based on other non-platinum agents may offer alternatives. The effect of chemoradiotherapy seems to vary according to the stage of disease, but all types of women benefit. Neoadjuvant chemotherapy before radiotherapy could jeopardise survival and should be avoided unless perhaps a 'quick', dose-intense regimen is used. Neoadjuvant chemotherapy before surgery may be beneficial, but the approach will remain controversial until it is tested against platinum-based chemoradiotherapy. Future studies many include combinations of other cytotoxics, such as topotecan, with cisplatin-based concomitant chemoradiotherapy or the addition of agents targeted against specific receptors, such as epidermal growth factor receptor.

Anaemia is associated with poor overall survival but not with inferior local control in patients with muscle invasive bladder carcinoma treated by radical external beam radiotherapy. A retrospective study.

AIMS: The treatment of muscle invasive transitional cell carcinoma of the bladder with radiotherapy allows organ preservation and is frequently used in the UK, especially in patients not medically fit for cystectomy. Anaemia is known to be an indicator of a poor response to radiotherapy in head and neck and cervical carcinomas. Here we describe the prevalence and type of anaemia in patients with transitional cell carcinoma of the bladder and determine the effect anaemia has on treatment outcome. MATERIALS AND METHODS: A retrospective review of notes was carried out on patients treated radically between 1992 and 1997. Potential patient, tumour and treatment prognostic indicators were reported. Patients were labelled as being anaemic if their pre-treatment haemoglobin level was below the normal range (below 13.5 g/dl for men and below 11.5 g/dl for women). The time to local failure, metastases and overall survival were recorded. Recurrence-free survival and overall survival actuarial estimations were carried out using the Kaplan-Meier method and compared by Log-rank testing. A multivariate analysis was carried out using the Cox regression method. RESULTS: Data on 100 patients were available for analysis. Most of the patients were not adequately staged by today's standards. Fifty-two patients were anaemic, with 75% of them having a normochromic, normocytic anaemia. The univariate analysis showed no significant difference in the time to local recurrence, a trend towards a shorter time to metastases and a significant reduction in overall survival in anaemic patients (P = 0.001). Two-year survival was 43% and 22% for non-anaemic and anaemic patients, respectively. A multivariate analysis using the covariates tumour stage, grade and serum creatinine found anaemia to be a poor prognostic indicator for overall survival (P = 0.005). CONCLUSION: Anaemia is highly prevalent in patients with bladder cancer. This retrospective study showed anaemic patients to have a worse outcome with radiotherapy treatment than patients with a normal haemoglobin level. This was not accounted for by a difference in local control, which may be expected from hypoxic radiobiological principles. Anaemia may be indicative of more aggressive malignancy or subclinical metastases.

EMAP-II-dependent lymphocyte killing is associated with hypoxia in colorectal cancer.

Endothelial-monocyte-activating polypeptide-II (EMAP-II) is a novel multifunctional polypeptide with proinflammatory activity. We have previously shown that the recombinant and native forms of EMAP-II can induce apoptosis in mitogen-stimulated lymphocytes, and that the release of this protein into the extracellular milieu is enhanced by hypoxia. We hypothesised that hypoxia may lead to death of tumour-infiltrating lymphocytes (TILs) via an EMAP-II-dependent mechanism, thereby assisting tumours to evade the immune system. In this study, we used immunohistochemistry to detect EMAP-II, active caspase-3 and cleaved Poly (ADP-ribose) Polymerase (PARP) as indicators of apoptosis in TILs, and carbonic anhydrase IX (CA IX) as a surrogate marker of hypoxia. EMAP-II expression is associated with regions of hypoxia, and furthermore there is a significant association between TILs apoptosis and the presence of hypoxia. Using a coculture model of colorectal cancer cell/lymphocyte interactions, we were also able to demonstrate lymphocyte apoptosis induced by tumour cells, with concomitant caspase-3 activity. Lymphocyte killing was enhanced by direct cell-cell contact, particularly by tumour cells exposed to hypoxic conditions. Our data support the hypothesis that hypoxia plays a role in immune evasion by tumour cells, through EMAP-II-dependent lymphocyte killing.