Predictors of psychological distress following major trauma.

AIM: The aim of this study was to identify variables that may predict later psychological distress in patients following admission to a Major Trauma Centre (MTC) and to determine whether a psychological screening tool, the Posttraumatic Adjustment Screen (PAS), administered on admission was able to contribute to this. METHODS: Patients referred to the MTC clinical psychology service completed the PAS during their inpatient stay over an eight-month period. Following discharge from hospital, patients were telephoned (1 month, 3 months and 6 months post injury) by a member of the clinical psychology team and asked two validated questionnaires; the Impact of Events Scale revised (IES-R) (measure of posttraumatic stress symptoms) and the CORE-10 (measure of global psychological distress). In addition, patients' data from the local Trauma Audit & Research Network (TARN) database was reviewed to identify information related to injury and other demographic data. Patients were divided into groups for comparison based upon their PAS scores using previously described severity cut offs for posttraumatic stress symptoms and depression. Receiver Operator Characteristic and Multiple Linear Regression analysis was used to examine for significant baseline predictors of psychological distress during follow up according to the IES and CORE-10 scores. RESULTS: One hundred and fourteen patients completed the PAS over the study period. Follow-up psychological data was available for 63 (56%) of patients. Except for the patient's home address, no baseline parameter examined in this study regarding patient demographics, injury or treatment was associated with reported psychological symptoms in the first six months post injury as measured by the IES-R or CORE-10 scores. Multiple linear regression analysis revealed that both PAS-P and PAS-D were significant predictor variables for patients reporting significant symptoms of posttraumatic stress and global psychological distress (according to IES-R and CORE-10 scores) in the first six months post injury. CONCLUSIONS: Psychological screening on admission may be helpful in identifying patients admitted to MTCs who are at risk at developing posttraumatic stress symptoms and psychological distress following major trauma.

Symptomatic venous thromboembolism following circular frame treatment for tibial fractures.

INTRODUCTION: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following tibial fractures. The risk is as high as 77% without prophylaxis and around 10% with prophylaxis. Within the current literature there are no figures reported specifically for those individuals treated with circular frames. Our aim was to evaluate the VTE incidence within a single surgeon series and to evaluate potential risk factors. METHODS: We retrospectively reviewed our consecutive single surgeon series of 177 patients admitted to a major trauma unit with tibial fractures. All patients received standardised care, including chemical thromboprophylaxis within 24h of injury until independent mobility was achieved. We comprehensively reviewed our prospective database and medical records looking at demographics and potential risk factors. RESULTS: Seven patients (4.0% ± 2.87%) developed symptomatic VTE during the course of frame treatment; three deep vein thrombosis (DVTs) and four pulmonary embolisms (PEs). Those with a VTE event had significantly increased body mass index (BMI) (p = 0.01) when compared to those without symptomatic VTE. No differences (p > 0.05) were observed between the groups in age, gender, smoking status, fracture type (anatomical allocation or open/closed), delay to frame treatment, weight bearing status post-frame, inpatient stay or total duration of frame treatment. CONCLUSION: This study suggests that increased BMI is a statistically significant risk factor for VTE, as reported in current literature. In addition, we calculated the true risk of VTE following circular frame treatment for tibial fracture in our series is from 1.13% to 6.87%, which is at least comparable to other forms of treatment.

Hormone-releasing contraceptive implants: our experience of complex removals using preoperative ultrasound.

A known complication of hormone-releasing contraceptive implants is a nonpalpable device at time of intended removal. We report a preprocedure outpatient assessment that includes an ultrasound scan and surface marking. This technique, with avoidance of local infiltration anesthesia, facilitates implant removal and negates the need for concomitant imaging on the day of surgery. The cases we present were referred to our upper limb clinic after previous failed attempts at removal.

Craniospinal radiotherapy for medulloblastoma in a man with severe kyphoscoliosis.

Medulloblastoma is an uncommon tumour in the adult population. Maximum surgical resection followed by craniospinal irradiation with a posterior fossa boost is the standard treatment. We report the case history of an adult with medulloblastoma and severe kyphoscoliosis. The unusual anatomy of the patient posed a technical challenge to the oncologist and the physicist in planning the craniospinal radiotherapy. A shaped spinal field matched to a parallel opposed pair of shaped head fields was used. The technique used in treating this patient was made possible with the use of a multileaf collimation and verification with an electronic portal imaging device. The patient remains well with no sign of relapse 4 years after treatment.

Calibration of pre-cut iridium-192 wires for low dose rate interstitial brachytherapy using a Farmer-type ionization chamber.

A technique, originally developed for calibrating small low activity caesium sources, which uses a Farmer-type ionization chamber, has been further developed for use with iridium wires. Correction factors have been generated to account for the finite source and detector sizes, and attenuation in the source carriers. The air kerma calibration factor for heavily filtered 280 kV X-rays was used for reference back to the National Standard. The results of this calibration method have been compared with the calibration figures given by the manufacturers over a 5 year period for the emissions from 50 batches of wires of varying strengths. Agreement to within +/- 3.2% was achieved in all cases, establishing that the method is satisfactory for acceptance testing purposes. The mean agreement was good to within 0.2%, but the possibility of a systematic error of between 1% and 3% existing both in this method and in the method used by the manufacturer is discussed.

Investigation of dose homogeneity in paediatric anthropomorphic phantoms for a simple total body irradiation technique.

The technique for treating total body irradiation patients used at the centre involves no compensation for the inhomogeneity of patient shape. Dose is prescribed to the lung, and monitor units are derived from standard data depending on the external dimensions of the patient at nipple level. Dose measurements were made during standard treatments on three paediatric anthropomorphic phantoms representing children of 5, 10 and 15 years of age. The results confirmed that the measured dose to the lung was within 4% of the prescribed dose, and dose homogeneity was within +/- 5%, excluding the neck, where the higher measured doses were still within tissue tolerance.