The impact of a new regional air ambulance service on a large general hospital

Background: Helicopter air ambulance crews are influenced in their selection of the destination hospital for their patients by several factors including: distance from the scene; facilities, on site specialties, and senior cover of the receiving hospital; and the proximity of the helicopter landing area to the emergency department (ED). Only a limited number of hospitals have landing sites adjacent to the ED from which patients can be taken directly into the department (primary landing sites). Helicopter crews will often elect to over fly hospitals that do not have primary landing sites because secondary land transfers will add delays in delivering patients. Birmingham Heartlands Hospital has an elevated helideck adjacent to the ED. In October 2003, the Warwickshire and Northamptonshire Air Ambulance (WNAA) service was launched; the hospital sits on the western periphery of the area served by the service. Methods: Prospective data was collated on all patients brought by WNAA to Heartlands Hospital between 1 October 2003 and 31 August 2004. Results: In the 10 month period after the launch of the service, the helicopter delivered 83 patients to the ED; 74 of these were "off patch". This additional workload generated 163 ward days, 19 operative procedures, and 85 intensive care unit, high dependency unit, or coronary care unit days. The direct costs of this additional workload approached £160 000. Conclusions: In future discussions on the cost effectiveness of air ambulances, it will be important to consider both the direct and indirect costs to the receiving hospitals arising from the redistribution of emergency workload. Abbreviations: ED, emergency department; HDU, high dependency unit; HEMS, helicopter emergency medical service; ICU, intensive care unit; ISS, injury severity score; WNAA, Warwickshire and Northamptonshire Air Ambulance; WMCAA, West Midlands County Air Ambulance

CO2 laser waveguiding in proton implanted GaAs

Surface layers capable of supporting optical modes at 10.6 microns have been produced in n-type GaAs wafers through 300 keV proton implantation. The dominant mechanism for this effect appears to be free carrier compensation. Characterization of the implanted layers by analysis of infrared reflectivity spectra and synchronous coupling at 10.6 microns produced results in good agreement with elementary models. These results of sample characterization by infrared reflectivity and by CO2 laser waveguiding as implanted are presented and evaluated

Delivering organisational adaptation through legislative mechanisms: Evidence from the Adaptation Reporting Power (Climate Change Act 2008)

There is increasing recognition that organisations, particularly in key infrastructure sectors, are potentially vulnerable to climate change and extreme weather events, and require organisational responses to ensure they are resilient and adaptive. However, detailed evidence of how adaptation is facilitated, implemented and reported, particularly through legislative mechanisms is lacking. The United Kingdom Climate Change Act (2008), introduced the Adaptation Reporting Power, enabling the Government to direct so-called reporting authorities to report their climate change risks and adaptation plans. We describe the authors' unique role and experience supporting the Department for Environment, Food and Rural Affairs (Defra) during the Adaptation Reporting Power's first round. An evaluation framework, used to review the adaptation reports, is presented alongside evidence on how the process provides new insights into adaptation activities and triggered organisational change in 78% of reporting authorities, including the embedding of climate risk and adaptation issues. The role of legislative mechanisms and risk-based approaches in driving and delivering adaptation is discussed alongside future research needs, including the development of organisational maturity models to determine resilient and well adapting organisations. The Adaptation Reporting Power process provides a basis for similar initiatives in other countries, although a clear engagement strategy to ensure buy-in to the process and research on its long-term legacy, including the potential merits of voluntary approaches, is required

The impact of transport infrastructure projects on sustainable development within a major logistics gateway in North West England

In the North West of England the issue of a perceived infrastructure gap is of increasing concern. Investment needs to be made to improve the transport infrastructure of the region if it is to be expected to promote the development of its own regional logistics gateway. Funding tools have been set up to address the challenges arising from the imbalance in infrastructure development that exists between regions in the north of the United Kingdom and those in the south. For regions with well developed economies the outlook is promising as the availability of modern transport infrastructure looks set to improve. However, some sources believe that the development of new transport infrastructure will have a negative impact upon sustainable development. It is expected that this will occur in a range of both direct and indirect ways. As a result, it is critical that planning for the creation of new intermodal transport infrastructure, or the upgrading of that which already exists, takes into account the impact that these developments will have on the sustainable development of the host region. A scenario based development methodology is proposed in this paper. It was developed to provide a way to identify potential scenarios that may arise within a given region as a result of transport infrastructure projects. To create significant scenarios the methodology is dependent on the availability of a sufficient quantity of quality data. For this paper that data was collected through a focus group composed of stakeholders from the region in question. This was further supported by the performance of an impact survey using the same group of stakeholders

O-mannosylation in Candida albicans enables development of interkingdom biofilm communities

Peer reviewedPublisher PD

Transcriptome analysis of <i>Streptococcus gordonii </i>Challis DL1 indicates a role for the biofilm-associated <i>fruRBA </i>operon in response to <i>Candida albicans</i>

Multiple levels of interkingdom signaling have been implicated in maintaining the ecological balance between Candida albicans and commensal streptococci to assure a state of oral health. To better understand the molecular mechanisms involved in the initial streptococcal response to the presence of C. albicans that can initiate oral surface colonization and biofilm formation, hypha-forming cells were incubated with Streptococcus gordonii cells for 30 minutes to assess the streptococcal transcriptome response. A genome wide microarray analysis and quantitative PCR validation of S. gordonii transcripts identified a number of genes, the majority of which were involved in metabolic functions that were differentially expressed in the presence of hyphae. The fruR, fruB and fruA genes encoding the transcriptional regulator, fructose-1-phosphate kinase, and fructose-specific permease, respectively, of the phosphoenolpyruvate-dependent fructose phosphotransferase system, were consistently up-regulated. An S. gordonii mutant in which these genes were deleted by allelic replacement, formed an architecturally-distinct, less robust biofilm with C. albicans than did parental strain cells. Complementing the mutant with plasmid borne fruR, fruB and fruA genes caused phenotype reversion, indicating that the genes in this operon played a role in dual species biofilm formation. This genome wide analysis of the S. gordonii transcriptional response to C. albicans has identified several genes that have potential roles in interkingdom signaling and responses

Double reading in breast cancer screening : cohort evaluation in the CO-OPS trial

Purpose: To investigate the effect of double readings by a second radiologist on recall rates, cancer detection and characteristics of cancers detected in the National Health Service Breast Screening Program in England. Materials and Methods: In this retrospective analysis we evaluated 805,206 women through screening and diagnostic test results by extracting one year of routine data from 33 English breast screening centers. Centers used double reading of digital mammograms, with arbitration if there were discrepant reads. Information on reader decisions, with results of follow-up tests, were used to explore the effect of the second reader. The statistical tests used were the test for equality of proportions, the χ2 test for independence and the t-test. Results: The first reader recalled 4·76%, (38295/805206, 95% CI 4·71%-4·80%) of women. Two readers recalled 6·19% in total, (49857/805206, 95% CI 6·14%- 6·24%), but arbitration of discordant reads reduced recall rate to 4·08%, (32863/805206, 95% CI 4·04%-4·12%, p<0.001). 7055 cancers were detected of which 627 (8·89%, 95% CI 8·22%-9·55%, p<0.001) were detected by the second reader only. These additional cancers were more likely to be ductal carcinoma in situ, (30·5% (183/600) vs 22.0% (1344/6114), p<0.001); and additional invasive cancers were smaller (mean 14·2mm vs 16·7mm, p<0.001), had fewer involved nodes, and were likely to be lower grade. Conclusion: Double reading with arbitration reduces recall and increases cancer detection compared to single reading. Cancers detected only by the second reader were smaller, lower grade, and had less nodal involvement

Metastasis-inducing proteins are widely expressed in human brain metastases and associated with intracranial progression and radiation response

Background:Understanding the factors that drive recurrence and radiosensitivity in brain metastases would improve prediction of outcomes, treatment planning and development of therapeutics. We investigated the expression of known metastasis-inducing proteins in human brain metastases.Methods:Immunohistochemistry on metastases removed at neurosurgery from 138 patients to determine the degree and pattern of expression of the proteins S100A4, S100P, AGR2, osteopontin (OPN) and the DNA repair marker FANCD2. Validation of significant findings in a separate prospective series with the investigation of intra-tumoral heterogeneity using image-guided sampling. Assessment of S100A4 expression in brain metastatic and non-metastatic primary breast carcinomas.Results:There was widespread staining for OPN, S100A4, S100P and AGR2 in human brain metastases. Positive staining for S100A4 was independently associated with a shorter time to intracranial progression after resection in multivariate analysis (hazard ratio for negative over positive staining=0.17, 95% CI: 0.04-0.74, P=0.018). S100A4 was expressed at the leading edge of brain metastases in image guided sampling and overexpressed in brain metastatic vs non-brain metastatic primary breast carcinomas. Staining for OPN was associated with a significant increase in survival time after post-operative whole-brain radiotherapy in retrospective (OPN negative 3.43 months, 95% CI: 1.36-5.51 vs OPN positive, 11.20 months 95% CI: 7.68-14.72, Log rank test, P<0.001) and validation populations.Conclusions:Proteins known to be involved in cellular adhesion and migration in vitro, and metastasis in vivo are significantly expressed in human brain metastases and may be useful biomarkers of intracranial progression and radiosensitivity

The Lagrange and Markov spectra from the dynamical point of view

This text grew out of my lecture notes for a 4-hours minicourse delivered on October 17 \& 19, 2016 during the research school "Applications of Ergodic Theory in Number Theory" -- an activity related to the Jean-Molet Chair project of Mariusz Lema\'nczyk and S\'ebastien Ferenczi -- realized at CIRM, Marseille, France. The subject of this text is the same of my minicourse, namely, the structure of the so-called Lagrange and Markov spectra (with an special emphasis on a recent theorem of C. G. Moreira).Comment: 27 pages, 6 figures. Survey articl

Allostatic load as a predictor of grey matter volume and white matter integrity in old age: The Whitehall II MRI study

The allostatic load index quantifies the cumulative multisystem physiological response to chronic everyday stress, and includes cardiovascular, metabolic and inflammatory measures. Despite its central role in the stress response, research of the effect of allostatic load on the ageing brain has been limited. We investigated the relation of mid-life allostatic load index and multifactorial predictors of stroke (Framingham stroke risk) and diabetes (metabolic syndrome) with voxelwise structural grey and white matter brain integrity measures in the ageing Whitehall II cohort (N = 349, mean age = 69.6 (SD 5.2) years, N (male) = 281 (80.5%), mean follow-up before scan = 21.4 (SD 0.82) years). Higher levels of all three markers were significantly associated with lower grey matter density. Only higher Framingham stroke risk was significantly associated with lower white matter integrity (low fractional anisotropy and high mean diffusivity). Our findings provide some empirical support for the concept of allostatic load, linking the effect of everyday stress on the body with features of the ageing human brain