Non-pharmaceutical interventions to reduce COVID-19 transmission in the UK: a rapid mapping review and interactive evidence gap map

BACKGROUND

Non-pharmaceutical interventions (NPIs) were crucial in the response to the COVID-19 pandemic, although uncertainties about their effectiveness remain. This work aimed to better understand the evidence generated during the pandemic on the effectiveness of NPIs implemented in the UK.

METHODS

We conducted a rapid mapping review (search date: 1 March 2023) to identify primary studies reporting on the effectiveness of NPIs to reduce COVID-19 transmission. Included studies were displayed in an interactive evidence gap map.

RESULTS

After removal of duplicates, 11 752 records were screened. Of these, 151 were included, including 100 modelling studies but only 2 randomized controlled trials and 10 longitudinal observational studies.Most studies reported on NPIs to identify and isolate those who are or may become infectious, and on NPIs to reduce the number of contacts. There was an evidence gap for hand and respiratory hygiene, ventilation and cleaning.

CONCLUSIONS

Our findings show that despite the large number of studies published, there is still a lack of robust evaluations of the NPIs implemented in the UK. There is a need to build evaluation into the design and implementation of public health interventions and policies from the start of any future pandemic or other public health emergency.

Patient and Caregivers Opinions on Receiving Radiology Results before Oncologist Appointments

PURPOSE/OBJECTIVE(S)

With the passing of the Cures Act, patients now have immediate access to radiology reports and can review the results before discussing the findings with a physician. In Oncology, the results of these imaging reports can be especially sensitive as the results can lead to difficult discussions about patient prognosis, or the need for invasive medical, surgical, or radiation therapies. It is unclear whether immediate access may increase anxiety, stress, and confusion before discussions with an oncologist. In this study, we hypothesized that in the oncology setting, immediate access to imaging reports before meeting with their oncologist would be associated with worsened patient anxiety.

MATERIALS/METHODS

Patients and their caregivers were invited to complete an investigator-developed anonymous multiple-choice survey prior to a scheduled follow-up appointment with their radiation oncologist. Survey questions assessed preferences for reviewing the radiology report prior to their oncology visit, their reported level of anxiety before undergoing diagnostic imaging, after directly receiving their results, and after they have the discussion of their results with the oncologist. Additional metrics collected included patient demographics, the time interval between discussing the results with an oncologist, preference for reviewing the images or just the radiology report, satisfaction with having immediate access to the report, and if they would prefer being blinded from the results until after discussing with their oncologist. Survey items were scored descriptively through summary statistics.

RESULTS

In this interim report of 54 individuals surveyed over a two-week period (89% were patients, 11% were caregivers/family members), a combined 33% reported a high level of anxiety before undergoing their scan. Levels of high anxiety decreased to 20% for those who received their report prior to reviewing with their oncologist and further lowered to 13% after reviewing the report and images with their oncologist. 57% of responders reported discussing the results with an oncologist within 2 days of receiving results. 46% preferred reviewing only radiology reports and not the images, 35% favored reviewing both imaging and the report together and 19% had no preference. Only 18.5% of responders preferred viewing the reports before discussing them with their oncologist and only 20% felt it was beneficial having early access to them.

CONCLUSION

Anxiety associated with oncology-related imaging improved after immediate access to the report and after discussions with oncologists. A small proportion of patients preferred having early access to imaging reports and most patients preferred reviewing only the report, not the images. Strategies including shortened intervals between immediate access and discussions with oncologists may minimize anxiety associated with imaging as most patients preferred first discussing the results with their oncologist.

Durvalumab with or without tremelimumab versus the EXTREME regimen as first-line treatment for recurrent or metastatic squamous cell carcinoma of the head and neck: KESTREL, a randomized, open-label, phase III study

BACKGROUND

Patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) have a poor prognosis. The phase III KESTREL study evaluated the efficacy of durvalumab [programmed death-ligand 1 (PD-L1) antibody] with or without tremelimumab [cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antibody], versus the EXTREME regimen in patients with R/M HNSCC.

PATIENTS AND METHODS

Patients with HNSCC who had not received prior systemic treatment for R/M disease were randomized (2 : 1 : 1) to receive durvalumab 1500 mg every 4 weeks (Q4W) plus tremelimumab 75 mg Q4W (up to four doses), durvalumab monotherapy 1500 mg Q4W, or the EXTREME regimen (platinum, 5-fluorouracil, and cetuximab) until disease progression. Durvalumab efficacy, with or without tremelimumab, versus the EXTREME regimen in patients with PD-L1-high tumors and in all randomized patients was assessed. Safety was also assessed.

RESULTS

Durvalumab and durvalumab plus tremelimumab were not superior to EXTREME for overall survival (OS) in patients with PD-L1-high expression [median, 10.9 and 11.2 versus 10.9 months, respectively; hazard ratio (HR) = 0.96; 95% confidence interval (CI) 0.69-1.32; P = 0.787 and HR = 1.05; 95% CI 0.80-1.39, respectively]. Durvalumab and durvalumab plus tremelimumab prolonged duration of response versus EXTREME (49.3% and 48.1% versus 9.8% of patients remaining in response at 12 months), correlating with long-term OS for responding patients; however, median progression-free survival was longer with EXTREME (2.8 and 2.8 versus 5.4 months). Exploratory analyses suggested that subsequent immunotherapy use by 24.3% of patients in the EXTREME regimen arm contributed to the similar OS outcomes between arms. Grade 3/4 treatment-related adverse events (TRAEs) for durvalumab, durvalumab plus tremelimumab, and EXTREME were 8.9%, 19.1%, and 53.1%, respectively.

CONCLUSIONS

In patients with PD-L1-high expression, OS was comparable between durvalumab and the EXTREME regimen. Durvalumab alone, and with tremelimumab, demonstrated durable responses and reduced TRAEs versus the EXTREME regimen in R/M HNSCC.

Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'

Background

It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand.

Methods

We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand.

Results

EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics.

Conclusions

Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00709-2.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Colonoscopy skills improvement training improves patient comfort during colonoscopy

INTRODUCTION

We aimed to assess the effect of Colonoscopy Skills Improvement (CSI) training on patient comfort and sedation-related complications during colonoscopy.

METHODS

This retrospective cohort study was performed on 19 endoscopists practicing in a Canadian tertiary care center who completed CSI training between October 2014 and May 2016. Data from 50 procedures immediately prior to, immediately after, and eight months following CSI training were included for each endoscopist. The primary outcome variable was intraprocedural comfort, and secondary outcomes included intraprocedural hypotension and hypoxia. Data were extracted from an electronic medical record and analyzed using SPSS version 20.0. Univariate analysis and stepwise multivariable logistic regression were performed to determine if there was an association between patient comfort and CSI training. Predictors of these outcomes including patient age, gender, sedation use and dosing, procedure completion, quality of bowel preparation, endoscopist experience, and specialty were included in the analysis.

RESULTS

2533 colonoscopies were included in the study. The mean dose of sedatives was reduced immediately following CSI training and at 8 months for both Fentanyl (75.4 mcg v. 67.8 mcg v. 65.9 mcg, p < 0.001) and Midazolam (2.57 mg v. 2.27 mg v. 2.19 mg, p < 0.001). The percentage of patients deemed to have a comfortable exam improved following endoscopist participation in CSI training and remained improved at 8 months (55.1% v. 70.2% v. 69.8%, p < 0.001). No significant change in rates of intraprocedural hypoxia or hypotension were noted following CSI training.

CONCLUSION

CSI training is associated with improved patient comfort and reduced sedation requirements during colonoscopy.

COVID-19 infection in patients with intestinal failure: UK experience

BACKGROUND

The direct effect of the coronavirus disease 2019 (COVID-19) pandemic on patients with intestinal failure (IF) has not been described.

METHODS

We conducted a nationwide study of UK IF centers to evaluate the infection rates, presentations, and outcomes in patients with types 2 and 3 IF.

RESULTS

A total of 45 patients with IF contracted COVID-19 between March and August 2020; this included 26 of 2191 (1.2%) home parenteral nutrition (HPN)-dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community-acquired COVID-19 (66.7%) than the proportion in the entire HPN cohort (26.1%; P < .01). Two HPN-dependent and 1 hospitalized patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected).

CONCLUSION

This is the first study to describe the outcomes of COVID-19 in a large cohort of patients requiring long-term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficial.

Changes in patterns of adolescent substance use from 1988 to 2011 in Sweden: a latent class analysis

Background

Prevalence rates of adolescent substance use have shifted over time, although potential changes in nuanced patterns of substance use remain unexplored. We examined patterns of adolescent substance use in Sweden and changes in these patterns between 1988 and 2011. Furthermore, we investigated whether gender and internalizing problems were associated with substance use and whether these associations changed over time.

Methods

The sample included all 15-16-year-old students in Värmland County, Sweden (N = 20,057). Survey data were collected eight times between 1988 and 2011 and analyzed as four cohorts (1988/1991, 1995/1998, 2002/2005, 2008/2011). We measured alcohol, tobacco and inhalant use and internalizing problems.

Results

A latent class analysis showed that a three-class model fit the data best (i.e. non/low use, experimental use, and polysubstance use classes). Class- and item-response probabilities changed over time: fewer adolescents exhibited riskier substance use patterns in the later cohorts. Boys were more likely than girls to be in the polysubstance use class compared to the non/low use class across all cohorts (all ps &lt; .001). Gender differences in experimental use differed across the cohorts. Adolescents who reported more internalizing problems were more likely to be included in the experimental and polysubstance use classes compared to the non/low use class (all ps &lt; .001) and this effect did not change over the study period.

Conclusions

We extended the research on trends in rates of substance use by mapping how patterns of substance use changed over time as well as how the effects of gender and internalizing problems shifted. While fewer adolescents exhibited riskier patterns of substance use in the later cohorts, these patterns were associated with experiencing more internalizing problems across the study period. Prevention efforts could be more effective by targeting patterns of substance use rather than prevalence rates.

Key messages

We tested whether patterns of adolescent substance use changed from 1988 to 2011 in Sweden. Fewer adolescents showed riskier substance use patterns in the late 2000s than in the earlier study years. Gender differences shifted over time for experimental use but not polysubstance use. Internalizing problems were consistently associated with riskier substance use patterns across the study period.

Severe Uncontrolled Pain in Buttock in a Patient on Naltrexone: A Diagnostic Challenge

A 26-year-old woman with a history of intravenous drug use was admitted to hospital with worsening pain in the right buttock radiating to the lateral part of the thigh and to the calf with no suspicion of cauda equina compression. Eventually, a diagnosis of sacroiliitis was made and appropriate antibiotics were administered. Provision of analgesia for this patient was difficult. On admission her medications included naltrexone, venlafaxine and tramadol. Initially naltrexone was continued and analgesia provided by epidural local anaesthetic and clonidine, intravenous ketamine and oral agents. After several days, naltrexone was ceased and opioids were used in addition to the other analgesics. The epidural analgesia was only partially effective, perhaps because of inadequate blockade of the L4-S1 nerve roots, which carry sensation from the sacroiliac joint.

Naltrexone is a long-acting opioid antagonist. If opioid analgesia is planned, it is necessary to cease naltrexone for 24 to 72 hours. In an emergency, if non-opioid techniques prove ineffective, short-acting opioids can be titrated to effect in a monitored environment.

Effects of developmental lead exposure on the hippocampal methylome: Influences of sex and timing and level of exposure

Developmental lead (Pb) exposure results in persistent cognitive/behavioral impairments as well as an elevated risk for developing a variety of diseases in later life. Environmental exposures during development can result in a variety of epigenetic changes, including alterations in DNA methylation, that can influence gene expression patterns and affect the function and development of the nervous system. The present promoter-based methylation microarray profiling study explored the extent to which developmental Pb exposure may modify the methylome of a brain region, hippocampus, known to be sensitive to the effects of Pb exposure. Male and female Long Evans rats were exposed to 0 ppm, 150 ppm, 375 ppm, or 750 ppm Pb through perinatal exposures (gestation through lactation), early postnatal exposures (birth through weaning), or long-term postnatal exposures (birth through postnatal day 55). Results showed a significant contribution of sex to the hippocampal methylome and effects of Pb exposure level, with non-linear dose response effects on methylation. Surprisingly, the developmental period of exposure contributed only a small amount of variance to the overall data and gene ontology (GO) analysis revealed the largest number of overrepresented GO terms in the groups with the lowest level of exposure. The highest number of significant differentially methylated regions was found in females exposed to Pb at the lowest exposure level. Our data reinforce the significant effect that low level Pb exposure may have on gene-specific DNA methylation patterns in brain and that this occurs in a sex-dependent manner.

OCO-2 advances photosynthesis observation from space via solar-induced chlorophyll fluorescence

Quantifying gross primary production (GPP) remains a major challenge in global carbon cycle research. Spaceborne monitoring of solar-induced chlorophyll fluorescence (SIF), an integrative photosynthetic signal of molecular origin, can assist in terrestrial GPP monitoring. However, the extent to which SIF tracks spatiotemporal variations in GPP remains unresolved. Orbiting Carbon Observatory-2 (OCO-2)'s SIF data acquisition and fine spatial resolution permit direct validation against ground and airborne observations. Empirical orthogonal function analysis shows consistent spatiotemporal correspondence between OCO-2 SIF and GPP globally. A linear SIF-GPP relationship is also obtained at eddy-flux sites covering diverse biomes, setting the stage for future investigations of the robustness of such a relationship across more biomes. Our findings support the central importance of high-quality satellite SIF for studying terrestrial carbon cycle dynamics.

Molecular basis of dendritic atrophy and activity in stress susceptibility

Molecular and cellular adaptations in nucleus accumbens (NAc) medium spiny neurons (MSNs) underlie stress-induced depression-like behavior, but the molecular substrates mediating cellular plasticity and activity in MSN subtypes in stress susceptibility are poorly understood. We find the transcription factor early growth response 3 (EGR3) is increased in D1 receptor containing MSNs of mice susceptible to social defeat stress. Genetic reduction of Egr3 levels in D1-MSNs prevented depression-like outcomes in stress susceptible mice by preventing D1-MSN dendritic atrophy, reduced frequency of excitatory input and altered in vivo activity. Overall, we identify NAc neuronal-subtype molecular control of dendritic morphology and related functional adaptations, which underlie susceptibility to stress.

A genetically encoded cyclobutene probe for labelling of live cells

We have identified an aminoacyl-tRNA synthetase/tRNA pair for the efficient and site-specific incorporation of a cyclobutene-containing amino acid into proteins in response to an amber nonsense codon. Fast and fluorescent labeling of purified proteins and intact proteins in live cells was demonstrated using the inverse electron demand Diels-Alder reaction with a tetrazine.

A Novel Mutation in Human PAX9 Causes Molar Oligodontia

Experimental and animal studies, as well as genetic mutations in man, have indicated that the development of dentition is under the control of several genes. So far, mutations in MSX1 and PAX9 have been associated with dominantly inherited forms of human tooth agenesis that mainly involve posterior teeth. We identified a large kindred with several individuals affected with molar oligodontia that was transmitted as an isolated autosomal-dominant trait. Two-point linkage analysis using DNA from the family and polymorphic marker D14S288 in chromosome 14q12 produced a maximum lod score of 2.29 at Θ = 0.1. Direct sequencing of exons 2 to 4 of PAX9revealed a cytosine insertion mutation at nucleotide 793, leading to a premature termination of translation at aa 315. Our results support the conclusion that molar oligodontia is due to allelic heterogeneity in PAX9, and these data further corroborate the role of PAX9 as an important regulator of molar development.

Diversity and linkage disequilibrium in farmed Tasmanian Atlantic salmon

Farmed Atlantic salmon (Salmo salar) is a globally important production species, including in Australia where breeding and selection has been in progress since the 1960s. The recent development of SNP genotyping platforms means genome-wide association and genomic prediction can now be implemented to speed genetic gain. As a precursor, this study collected genotypes at 218 132 SNPs in 777 fish from a Tasmanian breeding population to assess levels of genetic diversity, the strength of linkage disequilibrium (LD) and imputation accuracy. Genetic diversity in Tasmanian Atlantic salmon was lower than observed within European populations when compared using four diversity metrics. The distribution of allele frequencies also showed a clear difference, with the Tasmanian animals carrying an excess of low minor allele frequency variants. The strength of observed LD was high at short distances (<25 kb) and remained above background for marker pairs separated by large chromosomal distances (hundreds of kb), in sharp contrast to the European Atlantic salmon tested. Genotypes were used to evaluate the accuracy of imputation from low density (0.5 to 5 K) up to increased density SNP sets (78 K). This revealed high imputation accuracies (0.89-0.97), suggesting that the use of low density SNP sets will be a successful approach for genomic prediction in this population. The long-range LD, comparatively low genetic diversity and high imputation accuracy in Tasmanian salmon is consistent with known aspects of their population history, which involved a small founding population and an absence of subsequent introgression. The findings of this study represent an important first step towards the design of methods to apply genomics in this economically important population.

The incidence of congenital syphilis in the United Kingdom: February 2010 to January 2015

OBJECTIVE

To estimate the incidence of congenital syphilis in the UK.

DESIGN

Prospective study.

SETTING AND POPULATION

United Kingdom.

METHODS

Children born between February 2010 and January 2015 with a suspected diagnosis of congenital syphilis were reported through an active surveillance system.

MAIN OUTCOME MEASURES

Number of congenital syphilis cases and incidence.

RESULTS

For all years, reported incidence was below the WHO threshold for elimination (<0.5/1000 live births). Seventeen cases (12 male, five female) were identified. About 50% of infants (8/17) were born preterm (<37 weeks' gestation): median birthweight 2000 g (865-3170 g). Clinical presentation varied from asymptomatic to acute disease, including severe anaemia, hepatosplenomegaly, rhinitis, thrombocytopaenia, skeletal damage, and neurosyphilis. One infant was deaf and blind. Median maternal age was 20 years (17-31) at delivery. Where maternal stage of infection was recorded, 6/10 had primary, 3/10 secondary and 1/10 early latent syphilis. Most mothers were white (13/16). Country of birth was recorded for 12 mothers: UK (n = 6), Eastern Europe (n = 3), Middle East (n = 1), and South East Asia (n = 2). The social circumstances of mothers varied and included drug use and sex work. Some experienced difficulty accessing health care.

CONCLUSION

The incidence of congenital syphilis is controlled and monitored by healthcare services and related surveillance systems, and is now below the WHO elimination threshold. However, reducing the public health impact of this preventable disease in the UK is highly dependent on the successful implementation of WHO elimination standards across Europe.

TWEETABLE ABSTRACT

Congenital syphilis incidence in the UK is at a very low level and well below the WHO elimination threshold.

Self-sampling for community respiratory illness: a new tool for national virological surveillance

This report aims to evaluate the usefulness of self-sampling as an approach for future national surveillance of emerging respiratory infections by comparing virological data from two parallel surveillance schemes in England. Nasal swabs were obtained via self-administered sampling from consenting adults (≥ 16 years-old) with influenza symptoms who had contacted the National Pandemic Flu Service (NPFS) health line during the 2009 influenza pandemic. Equivalent samples submitted by sentinel general practitioners participating in the national influenza surveillance scheme run jointly by the Royal College of General Practitioners (RCGP) and Health Protection Agency were also obtained. When comparable samples were analysed there was no significant difference in results obtained from self-sampling and clinician-led sampling schemes. These results demonstrate that self-sampling can be applied in a responsive and flexible manner, to supplement sentinel clinician-based sampling, to achieve a wide spread and geographically representative way of assessing community transmission of a known organism.

Position paper: improving governance for effective veterinary services in developing countries--a priority for donor funding

Livestock contributes significantly to the world economy. However, animal diseases and food safety are still major constraints on livestock-sector productivity, economic growth, the reduction of poverty and food security. Efficient and effective governance of Veterinary Services throughout the world is a fundamental requirement for addressing the global animal health and related public health threats. Recent work by the World Organisation for Animal Health (OIE) through the application of the Tool for the Evaluation of Performance of Veterinary Services (PVS Tool) and related Gap Analysis (both of which form part of the PVS Pathway) has indicated that a significant proportion of the national Veterinary Services worldwide do not meet the essential requirements for good governance. This shortcoming poses a significant risk for many developing countries and their trading partners when considered in the context of the growing trade in animal-source foods, and the burgeoning global livestock population. Well-managed, transparent and credible Veterinary Services, in both the public and private sector, are essential for mitigating animal disease risks and ensuring sustainable incomes for vulnerable producers. They are also vital for limiting the public health risks posed by zoonotic diseases. This paper is intended to highlight the impact of governance on the delivery of veterinary services in a development context and the benefits generated by improving veterinary governance. It recognises 'global public good' elements embedded in the good governance of Veterinary Services, and it could also provide an operational development investment roadmap that builds on the OIE PVS Pathway, and innovative financing options based on government commitments supported by donor programmes.

Employee perception of a mandated helmet policy at Vail Resorts

OBJECTIVE

The purpose of this study was to measure support for a mandated helmet policy among resort employees along with the impact of such a policy on job satisfaction, and additionally, to measure the prevalence of barriers to helmet use among this population.

METHODS

In all, 728 Vail Resort employees were surveyed regarding their opinions on the helmet policy and on general helmet use.

RESULTS

The majority of the 728 employees surveyed (66.5%; 95% CI: 63% to 70%) agreed with the helmet policy. Only 18% (95% CI: 16% to 21%) reported a negative effect on job satisfaction. Older employees (>25 years old) were more likely to disagree with the policy (odds ratio [OR] 3.1; 95% CI: 2.2 to 4.3) and report a negative effect on job satisfaction (OR 4.8; 95% CI: 3.0 to 7.6). Skiers were much more likely than snowboarders to report a negative effect on job satisfaction (OR 9.8; 95% CI: 5.2 to 18.1). Among resort employees, ski patrollers were more likely to disagree with the mandate (OR 9.8; 95% CI: 6.8 to 13.9) and report a negative effect on job satisfaction (OR 13.2; 95% CI: 8.3 to 21.). Forty-three percent of participants (95% CI: 39% to 46%) agreed with the statement that wearing a helmet encourages reckless behavior whereas 51.0% (95% CI: 47% to 54%) believed that wearing a helmet limits sensory perception.

CONCLUSIONS

A mandatory helmet use policy was supported by most resort employees. However, ski patrollers and older, more experienced employees were more likely to report a negative effect on job satisfaction. Barriers to helmet use continue to persist in the ski industry and represent a target for further educational efforts.

Gastrocnemius flap reconstruction of soft-tissue defects following infected total knee replacement

A soft-tissue defect over an infected total knee replacement (TKR) presents a difficult technical problem that can be treated with a gastrocnemius flap, which is rotated over the defect during the first-stage of a revision procedure. This facilitates wound healing and the safe introduction of a prosthesis at the second stage. We describe the outcome at a mean follow-up of 4.5 years (1 to 10) in 24 patients with an infected TKR who underwent this procedure. A total of 22 (92%) eventually obtained a satisfactory result. The mean Knee Society score improved from 53 pre-operatively to 103 at the latest follow-up (p < 0.001). The mean Western Ontario and McMaster Universities osteoarthritis index and Short-Form 12 score also improved significantly (p < 0.001).

This form of treatment can be used reliably and safely to treat many of these complex cases where control of infection, retention of the components and acceptable functional recovery are the primary goals.

Cite this article: Bone Joint J 2013;95-B:1217–21.

Shaping veterinary health policies in a global and evolving context

National animal health policies have at their foundation the overarching need to address society's concerns about animal disease control, the welfare of animals and the safety and security of the animal production food supply. However, in today's global, complex and interdependent context, national animal health policies also impact a broader range of policy outcomes, ranging from public health protection through ecosystem health and biodiversity to the economic well-being and performance of many countries. As a result, there are several fundamentally important elements that must be considered in the elaboration of effective and relevant animal health policies. Policies must be (i) proportionate to the risk to be managed, (ii) transparent (to ensure easy understanding and implementation), and (iii) responsive to constantly evolving and changing hazards and risk pathways. In addition, it is critical that there are sufficient resources and capacity to implement the policies as well as incentives for compliance on the part of affected parties.