Anogenital injury following sexual assault and consensual sexual intercourse: a systematic review and meta-analysis.

Background: Sexual violence is a grave human rights violation and a serious global public health challenge. Rates of reporting of sexual violence and subsequent passage of cases through the criminal justice system are poor all over the world. The presence or absence of anogenital injury following sexual assault may influence survivors in their willingness to report a crime, and law enforcement officers and jurors in their decision making regarding the laying of charges and/or conviction of offenders. The aim of this systematic review was to compare rates of identification of anogenital injury (AGI) in women following sexual assault and consensual sexual intercourse using the same examination techniques. Methods: In this systematic review and meta-analysis, Medline, Embase and Google Scholar were searched for relevant studies (in any language, with no age or sex criteria) published between February 25, 1993, and February 25, 2023, that directly compared AGI between individuals after either sexual assault or consensual sexual intercourse. Abstracts, conference proceedings, and case reports were excluded. The primary outcome of interest was any form of detected AGI. The Mantel-Haenszel method was used for meta-analysis using random effects modelling to determine the risk ratio (RR) of AGI between sexual assault and consensual sexual intercourse. Quality assessment was undertaken using the Newcastle-Ottawa scale tool. The I2 statistic was used to determine heterogeneity among studies. An I2 >75% was considered high heterogeneity. Funnel plots were used to assess the risk of publication bias, by determining any visually apparent asymmetry. This analysis is registered with PROSPERO, CRD42023402468. Findings: We included 10 studies, accounting for 3165 study participants. All participants were female. AGI was detected in 901 (48%) of 1874 participants following sexual assault and 394 (31%) of 1291 participants following consensual sexual intercourse. Meta-analysis of all included studies demonstrated that the presence of AGI was significantly more likely for participants following sexual assault than consensual sexual intercourse (RR 1.59 (95% CI 1.21, 2.09); p < 0.001). There was a significant heterogeneity among studies and funnel plots suggest that this RR may be an over-estimation. Subgroup analysis including only high-quality studies showed no significant difference between groups. Interpretation: Although AGI was significantly more likely to be detected after sexual assault than consensual sexual intercourse, more than half of survivors of sexual assault have no detectable injuries. The presence of AGI, therefore, does not prove there has been sexual violence and absence of injury does not refute that sexual assault has occurred. Funding: The University of Birmingham.

Improvements over time for patients following liver trauma: A 17-year observational study.

Background: Centralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre. Methods: All patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V). Results: There were 600 patients; the median age was 33 (IQR 22-52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively). Conclusions: Outcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.

Injuries among children attributed to violence and social funding: a 10-year observational study.

BACKGROUND: Mechanisms and patterns of injury in children are changing, with violent mechanisms becoming more prevalent over time. Government funding of services for children and young people has reduced nationally over the last decade. We aimed to investigate the trends in admissions of injured children to a Major Trauma Centre (MTC) and examine the relationship between injuries sustained by violent mechanisms and local authority funding of children and youth services within the same catchment area. METHODS: A 10-year observational study included all patients aged<18 years treated at a regional MTC between April 2012 and April 2022. Number of admissions with violent trauma, mechanism of injury, requirement for operative intervention and mortality were compared with published annual local authority expenditure reports. RESULTS: 1126 children were included; 71.3% were boys, with median age 11 years (IQR 3-16). There were 154/1126 (14%) children who were victims of violent trauma; they were more likely to be boys than children injured by non-violent mechanisms (84% vs 69%). The proportion of injuries attributed to violence increased over the study period at the same time as reductions in local authority funding of services for the early years, families and youth services. However, there were insufficient data to formally assess the interdependency between these factors. CONCLUSIONS: The proportion of injuries attributed to violence has increased over time, and government spending on specific children and young people's services has decreased over the same time period. Further work is needed to examine the interdependency between spending and violent injuries in children, and public health interventions to target violence-related injuries should take into account youth service funding.

One size does not fit all: Impact of hand size on ease of use of instruments for minimally invasive surgery.

BACKGROUND: Consideration of ergonomic factors is important for the practice of safe and efficient minimally invasive surgery (MIS). Surgeons with smaller glove sizes have previously been reported to have increased difficulties with some minimally invasive instruments. We aim to investigate hand anthropometrics and their relationship to surgeon comfort when using MIS instruments. METHODS: Male and female surgeons from two centres were surveyed on their experience of handling MIS instruments and images obtained of the dorsal and palmar aspects of their dominant hand. Photographs of hands were transformed to calibrated coordinates to enable anthropometric measurements of finger length and width as well as palm width and hand span photogrammetrically. Surgeon-perceived discomfort, fatigue, pressure points and techniques to mitigate difficulty handling instruments were compared to hand measurements. RESULTS: Questionnaires were completed by 58 surgeons; 20 (34%) were consultants, 17 (29%) were women. Glove size ranged from 6 to 8 (median 7.5). Male participants had significantly larger hands than females in all measured dimensions. Female surgeons and those with smaller finger and hand dimensions were significantly more likely to experience difficulty or discomfort across a range of variables when using MIS instruments. CONCLUSIONS: Surgeons with smaller hands reported increased problems handling MIS instruments. This represents an issue of equity in surgery, with women being more significantly affected than men. Hand size varies greatly between surgeons and anthropometric variability should be considered in design of MIS instruments.

Injury by knife crime amongst children is associated with socioeconomic deprivation: an observational study.

PURPOSE: Children who live in areas of socioeconomic deprivation may be at higher risk of being victims of violent crime such as knife wounds. The current study investigated whether socioeconomic disparity was associated with higher risk of knife crime. METHODS: An observational study included patients aged ≤ 17 years at a UK Major Trauma Centre injured by knife trauma from 2016 to 2022. Indices of deprivation were recorded according to the zip code of residence and compared with those of all of England. These included Index of Multiple Deprivation (IMD); income; employment; education and skills; health and disability; crime; barriers to housing and services; living environment; and Income Deprivation Affecting Children Index (IDACI). RESULTS: There were 139 patients (96% male) with median age of 16 years. When compared with the whole of England, patients had worse indices of IMD (p = 0.021); income (p < 0.001); employment (p < 0.001); education and skills (p < 0.001); health and disability; and IDACI (p < 0.001). There were no significant differences in indices of crime, barriers to housing and services or living environment. CONCLUSIONS: Paediatric knife injury was associated with poor socioeconomic status in multiple domains. Focussed efforts to address socioeconomic disparities should be a priority as a public health measure for vulnerable children.

Weaning Humidified High Flow Oxygen Therapy among Paediatric Patients: An Integrative Review of Literature.

PROBLEM: The paucity of up-to-date recommendations and evidence-based models, whether it is physician-initiated or initiated by other healthcare professionals, for humidified high flow oxygen therapy among children. ELIGIBILITY CRITERIA: The inclusion criteria included the following: 1) use of high flow oxygen therapy (≥15 L/min); 2) published studies from the year 2000 and onwards; 3) research article in a peer-reviewed journal; 4) studies conducted in a hospital setting involving paediatric patients <18 years old; 5) availability of full article online. SAMPLE: From March to April 2018, electronic databases such as PubMed, Cumulative Index of Nursing and Allied Health Literature, Excerpta Medica Database, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, SCOPUS, Ovid, Informit, and Google Scholar were accessed. The systematic search initially yielded 41 studies. RESULTS: Eventually, three eligible studies were reviewed and appraised. Overarching themes were identified: 1) the lack of weaning standards; 2) the limited focus on young population in intensive care settings; and 3) the paucity of weaning models. CONCLUSION: The lack of studies suggested that this is a fertile area for research. In this light, this paper challenged researchers, clinicians, and experts to develop evidence-based standards and models of weaning towards efficient and better quality of care. IMPLICATION: This review may lead to the development of nurse-led or nurse-initiated weaning protocols to enable timely weaning intervention for children and thus reduce the need for prolonged oxygen use. Furthermore, this may also instigate an economic evaluation of a nurse-lead weaning against current models of medically lead weaning.

Optimal neoadjuvant chemotherapy duration in Wilms tumour with intravascular thrombus: A literature review and evidence from SIOP WT 2001 trial.

INTRODUCTION: Preoperative chemotherapy is recommended for children with Wilms tumour with intravascular extension. Extended chemotherapy may improve resectability, but increase tumour adherence to vascular endothelium, precluding complete resection. To evaluate the optimal length of preoperative treatment, we report a two-part review comprising systematic review of the literature and investigation of patients treated in the International Society of Paediatric Oncology (SIOP) WT 2001 trial. METHODS: Studies were identified using Medline and Embase databases from 1996 to present. English language titles reporting management of intravascular Wilms tumour were analysed. Patients with Wilms tumour and thrombus were identified from the SIOP WT 2001 trial. Overall survival (OS) and event-free survival (EFS), tumour regression, completeness of resection and cavectomy were investigated. RESULTS: The search retrieved 43 articles documenting 498 children. Note that 72% of the patients received neoadjuvant chemotherapy: 101 received standard course (4-6 weeks, standard course neoadjuvant chemotherapy [StC]) and 62 extended course (> 6 weeks, extended course neoadjuvant chemotherapy [EC]). There was no significant difference between the groups in terms of thrombus regression or completeness of resection. EFS was greater in the StC group (78 vs 54%; P = .04). Of 4511 patients registered in the SIOP WT 2001 trial, 166 had thrombus. Note that 97% of the patients received neoadjuvant chemotherapy: 63 StC and 67 EC. There was no significant difference between the groups with regard to tumour regression, complete resection, or cavectomy. Survival was significantly higher in those receiving StC than EC (OS: 95% vs 82%, P = .025; EFS: 88% vs 72%, P = .047). CONCLUSION: There is no evidence that prolonged courses of neoadjuvant chemotherapy beyond the recommended protocols confer any additional benefit in treating intravascular extension of Wilms tumour.

Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study.

PURPOSE: To review the management of patients >16 years with blunt splenic injury in a single, UK, major trauma centre and identify whether the following are associated with success or failure of non-operative management with selective use of arterial embolization (NOM ± AE): age, Injury Severity Score (ISS), head injury, haemodynamic instability, massive transfusion, radiological hard signs [contrast extravasation or pseudoaneurysm on the initial computed tomography (CT) scan], grade, and presence of intraparenchymal haematoma or splenic laceration. METHODS: Retrospective, cross-sectional study undertaken between April 2012 and October 2015. Paediatric patients, penetrating splenic trauma, and iatrogenic injuries were excluded. Follow-up was for at least 30 days. RESULTS: 154 patients were included. Median age was 38 years, 77.3% were male, and median ISS was 22. 14/87 (16.1%) patients re-bled following NOM in a median of 2.3 days (IQR 0.8-3.6 days). 8/28 (28.6%) patients re-bled following AE in a median of 2.0 days (IQR 1.3-3.7 days). Grade III-V injuries are a significant predictor of the failure of NOM ± AE (OR 15.6, 95% CI 3.1-78.9, p = 0.001). No grade I injuries and only 3.3% grade II injuries re-bled following NOM ± AE. Age ≥55 years, ISS, radiological hard signs, and haemodynamic instability are not significant predictors of the failure of NOM ± AE, but an intraparenchymal or subcapsular haematoma increases the likelihood of failure 11-fold (OR 10.9, 95% CI 2.2-55.1, p = 0.004). CONCLUSIONS: Higher grade injuries (III-V) and intraparenchymal or subcapsular haematomas are associated with a higher failure rate of NOM ± AE and should be managed more aggressively. Grade I and II injuries can be discharged after 24 h with appropriate advice.

Cardiac torsion-strain relationships in fatigued primary biliary cirrhosis patients show accelerated aging: a pilot cross-sectional study.

The autoimmune liver disease primary biliary cirrhosis (PBC) is associated with life-altering fatigue in ∼50% of patients. Previous work suggests that fatigued PBC subjects have evidence of autonomic dysfunction and may be at a higher risk of sudden cardiac death. The manifestation of this risk is not clear. This pilot study investigated whether alterations in cardiac torsion and strain could be detected in fatigued or nonfatigued early-stage PBC patients. We performed cardiac tissue tagging and anatomical cine-imaging in 13 early-stage PBC patients (including 7 with significant fatigue) and 10 control subjects to calculate cardiac torsion and strain throughout systole and diastole. From the cardiac tagging, we calculated the torsion-to-shortening ratio (TSR), a measure of subepicardial torsion exerting mechanical advantage over subendocardial shortening. Autonomic function testing was performed to evaluate baroreceptor effective index on standing. TSR was markedly increased in the fatigued PBC patients (0.70 ± 0.13) compared with both controls (0.46 ± 0.11, P = 0.002) and nonfatigued PBC patients (0.44 ± 0.12, P = 0.003). Decreased baroreceptor effective index on standing strongly correlated with increased TSR within the whole PBC group (r = -0.71, P = 0.007). Fatigued PBC patients demonstrate a redistribution of myocardial strain characteristic of a reduced relative contribution to contraction from the subendocardium. This is analogous to the changes found in healthy aging for subjects ∼16 yr older than the fatigued PBC patients. Hence the hearts of fatigued PBC patients may be subject to processes of accelerated aging.

How primary care dentists perceive and are influenced by research.

INTRODUCTION: Little is understood as to how primary care dentists alter their clinical practice. AIM: To develop an understanding of how primary care dentists view and use research to inform their clinical practice. METHODS: An iterative approach was followed using two methods of data collection. A focus group was undertaken with dentists and researchers who had been involved in primary care dental research. Subsequently phased, qualitative interviews were undertaken with primary care dentists with a range of research experiences. Focus group and interviews were audio-recorded and transcribed verbatim. Six people participated in the focus group. Eighteen dentists participated in the interviews. Interviews were undertaken in four phases until saturation was achieved. Data were analysed using constant comparison. FINDINGS: Evidence-based dentistry was considered the ideal. However, the research base for primary care dentistry was thought to lag behind clinical services, to focus on incorrect endpoints, to disregard the patients' voice and failed to consider the impact of conducting research on dental practices. Dentists modified their clinical practice based upon research, colleagues' opinions, courses and ad hoc personal evaluation. Uptake of research was affected by the ethos of the practice, which determined whether the dentists were early or late adopters of research and financial viability of new interventions. CONCLUSION: Dentists wanted concise, timely evidence-based guidance to aid their management of patients. Further research needs to be undertaken to understand how to develop an evidence-based culture in primary dental care.

Molecular epidemiology of multiresistant Streptococcus pneumoniae with both erm(B)- and mef(A)-mediated macrolide resistance.

Of a total of 1043 macrolide-resistant Streptococcus pneumoniae isolates collected from 24 countries as part of PROTEKT 1999-2000, 71 isolates tested positive for both the mef(A) and erm(B) genes. Of 69 isolates subjected to further molecular investigations, all were resistant to tetracycline, 63 (91.3%) were resistant to penicillin, and 57 (82.6%) were resistant to trimethoprim-sulfamethoxazole. One isolate was also fluoroquinolone resistant, and another was resistant to quinupristin-dalfopristin. The ketolide telithromycin retained activity against all of the isolates. Of the 69 of these 71 isolates viable for further testing, 46 were from South Korea, 13 were from the United States, 8 came from Japan, and 1 each came from Mexico and Hungary. One major clonal complex (59 [85.5%] of 69 isolates) was identified by serotyping (with 85.5% of the isolates being 19A or 19F), pulsed-field gel electrophoresis, and multilocus sequence typing. The remaining isolates were less clonal in nature. Representative isolates were shown to carry the mobile genetic elements Tn1545 and mega, were negative for Tn1207.1, had tetracycline resistance mediated by tet(M), and contained the mef(E) variant of mef(A). All isolates were positive for mel, a homologue of the msr(A) efflux gene. These clones are obviously very efficient at global dissemination, and hence it will be very important to monitor their progress through continued surveillance. Telithromycin demonstrated high levels of activity (MIC for 90% of the strains tested, 0.5 micro g/ml; MIC range, 0.06 to 1 micro g/ml) against all isolates.

Descriptive evaluation of Alione hydrocapillary dressing.

It is widely recognized that a moist wound environment enhances epithelial migration and resurfacing, as well as promoting autolytic debridement of necrotic tissue, reducing pain, infection and scarring (Russell, 2002). However, an imbalance in the level of moisture can lead to delayed healing, or even wound extension (Kindlen and Morison, 1999). The type of wound itself can be influential in relation to the level of exudate produced. With such a diverse array of wound management products now available, the healthcare professional faces a constant dilemma in deciding what dressing is suitable for maintaining an optimal level of humidity in the wound environment. Alione, a new hydrocapillary dressing, manufactured by Coloplast, appears to overcome this impasse by being sufficiently versatile to manage varying levels of exudate in all types of wounds.

Clinical practice benchmarking: implications for tissue viability.

Healthcare provision has been described as a 'lottery', reflecting a deficiency in equity of care (Ellis, 2000). Recent Department of Health (DoH, 1998, 1999) attempt to overcome this disparity and assure quality care by quality assessment and continuous quality improvement (Ellis and Morris, 1997). These documents advocate clinical benchmarking as a means to supporting this practice. This article provides an overview of the benchmarking process, with particular focus being applied to the pressure ulcer element. It reflects on the coalescence that appears to exist between implementing clinical benchmarking and the characteristics of specialist practice. It also analyses the effects of establishing the process on an existing tissue viability service.