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Skin and soft tissue defects of the lower extremity present a unique challenge for the reconstructive surgeon. Successful repair of the lower extremity relies not only on strong anatomical knowledge and surgical expertise, but also on careful consideration of the numerous preoperative factors and indications that may alter the patient's response to operative management. While many of these injuries result from burns, avulsive trauma, diabetes, or vascular insufficiencies, a significant portion can be associated with resection of neoplastic pathologies. This review outlines the uses, indications, and considerations for biologic wound agents in reconstructing skin and soft tissue defects of the lower extremity following Mohs micrographic surgery.

Background: Women experience diverse symptoms of mental ill-health in pregnancy, yet measures usually only assess depression or anxiety. Measures may, therefore, miss out on identifying women experiencing distress.\ud \ud Objective: We aimed to examine the validity and reliability of the CORE-10: a short measure with broad coverage of symptoms of distress and associated functioning, in pregnant women.\ud \ud Methods: 366 women 26-38 weeks pregnant completed online measures of distress (CORE-10), depression (Whooley questions), anxiety (Generalised Anxiety Disorder-2), and a single item measuring worry about psychological health. We examined convergent and factorial validity and concordance rates of the measures.\ud \ud Results: Levels of distress were high, with anxiety the most reported symptom. The CORE-10 showed good convergent validity. A two-factor structure representing 'symptoms' and 'ways of coping' best fit this sample. Internal reliability of the symptoms' factor was good.\ud \ud Discussion: The self-selected online sample may not be representative of pregnant women in the third trimester and a diagnostic interview was not used. Based on this validation study, the CORE-10 potentially offers an assessment of a broad range of symptoms of postnatal distress within the confines of a measure brief enough to be usable in clinical settings. Further validation is needed.

Downy brome (Bromus tectorum L., syn. cheatgrass) is a winter annual grass that invades North American cropping, forage, and rangeland systems. Control is often difficult to achieve, because B. tectorum has a large seedbank, which results in continuous propagule pressure. Pyrenophora semeniperda (Brittlebank and Adam) Shoemaker, a soilborne fungal pathogen, has been investigated as a biological control for B. tectorum, because it can kill seeds that remain in the seedbank, thereby reducing propagule pressure. Temperature influences P. semeniperda and has not been investigated in the context of seeds collected from different B. tectorum locations, that may vary in susceptibility to infection. We compared the effects of temperature (13, 17, 21, 25 C) and B. tectorum seed locations (range, crop, subalpine) with different mean seed weights on infection rates of P. semeniperda using a temperature-gradient table. Infection differed by seed location (P < 0.001) and temperature (P < 0.001), with lighter-weight seeds (i.e., range and subalpine) more susceptible to P. semeniperda infection. Infection increased as temperature increased and was higher at 21 C (66.7 ± 6.7%) and 25 C (73.3 ± 6.0%). Germination was affected by seed location (P < 0.001) and temperature (P = 0.019). Germination was highest for the crop seed location (45.4 ± 4.2%) and overall decreased at higher temperatures (21 and 25 C). Our results suggest that B. tectorum seeds from a crop location are less affected by P. semeniperda than those from range and subalpine locations. Moreover, this demonstrates a temperature-dependent effect on all populations.

Research suggests that some fathers and birth partners can experience post-traumatic stress disorder (PTSD) after witnessing a traumatic birth. Birth-related PTSD may impact on many aspects of fathers’ and birth partners’ life, including relationship breakdown, self-blame and reducing plans for future children. Despite the potential impact on birth partners’ lives there is currently no measure of birth-related PTSD validated for use with birth partners. The current study therefore adapted the City Birth Trauma Scale for use with birth partners. The City Birth Trauma Scale (Partner version) is a 29-item questionnaire developed to measure birth-related PTSD according to DSM-5 criteria: stressor criteria (A), symptoms of re-experiencing (B), avoidance (C), negative cognitions and mood (D), and hyperarousal (E), as well as duration of symptoms (F), significant distress or impairment (G), and exclusion criteria or other causes (H). A sample of 301 fathers/birth partners was recruited online and completed measures of birth-related PTSD, bonding, and demographic details. Results showed the City Birth Trauma Scale (Partner version) had good reliability (α = 0.94) and psychometric and construct validity. The fathers/birth partners version has the same two-factor structure as the original scale: (1) general symptoms and (2) birth-related symptoms, which accounted for 51% of the variance. PTSD symptoms were associated with preterm birth and maternal and infant complications. Overall, the City Birth Trauma Scale (Partner version) provides a promising measure of PTSD following childbirth that can be used in research and clinical practice.

BackgroundMental health service users in acute inpatient wards, whether informal or detained, should be involved in planning and reviewing their care. Care planning processes should be personalised and focused on recovery, with goals that are specific to the individual and designed to maximise their achievements and social integration.Objective(s)We aimed to ascertain the views and experiences of service users, carers and staff to enable us to identify factors that facilitated or acted as barriers to collaborative, recovery-focused care and to make suggestions for future research.DesignA cross-national comparative mixed-methods study involving 19 mental health wards in six NHS sites in England and Wales included a metanarrative synthesis of policies and literature; a survey of service users (n = 301) and staff (n = 290); embedded case studies involving interviews with staff, service users and carers (n = 76); and a review of care plans (n = 51) and meetings (n = 12).ResultsNo global differences were found across the sites in the scores of the four questionnaires completed by service users. For staff, there was significant difference between sites in mean scores on recovery-orientation and therapeutic relationships. For service users, when recovery-orientated focus was high, the quality of care was viewed highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Across all sites, staff’s scores were significantly higher than service users’ scores on the scale to assess therapeutic relationships. Staff across the sites spoke of the importance of collaborative care planning. However, the staff, service user and carer interviews revealed gaps between shared aspirations and realities. Staff accounts of routine collaboration contrasted with service user accounts and care plan reviews. Definitions and understandings of recovery varied, as did views of the role of hospital care in promoting recovery. ‘Personalisation’ was not a familiar term, although there was recognition that care was often provided in an individualised way. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent.ConclusionsOur results suggest that there is positive practice taking place within acute inpatient wards, with evidence of widespread commitment to safe, respectful, compassionate care. Although ideas of recovery were evident, there was some uncertainty about and discrepancy in the relevance of recovery ideals to inpatient care and the ability of people in acute distress to engage in recovery-focused approaches. Despite the fact that staff spoke of efforts to involve them, the majority of service users and carers did not feel that they had been genuinely involved, although they were aware of efforts to keep them safe.Future workFuture research should investigate approaches that increase contact time with service users and promote personalised, recovery-focused working; introduce shared decision-making in risk assessment and management; and improve service user experiences of care planning and review and the use of recovery-focused tools during inpatient care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Pregnancy, birth and adjusting to a new baby is a potentially stressful time that can negatively affect the health of women. There is some evidence that expressive writing can have positive effects on psychological and physical health, particularly during stressful periods. The current study aimed to evaluate whether expressive writing would improve women’s postpartum health. A randomized controlled trial was conducted with three conditions: expressive writing (n = 188), a control writing task (n = 213), or normal care (n = 163). Measures of psychological health, physical health and quality of life were measured at baseline (6–12 weeks postpartum), 1 and 6 months later. Ratings of stress were taken before and after the expressive writing task. Intent-to-treat analyses showed no significant differences between women in the expressive writing, control writing and normal care groups on measures of physical health, anxiety, depression, mood or quality of life at 1 and 6 months. Uptake and adherence to the writing tasks was low. However, women in the expressive writing group rated their stress as significantly reduced after completing the task. Cost analysis suggest women who did expressive writing had the lowest costs in terms of healthcare service use and lowest cost per unit of improvement in quality of life. Results suggest expressive writing is not effective as a universal intervention for all women 6–12 weeks postpartum. Future research should examine expressive writing as a targeted intervention for women in high-risk groups, such as those with mild or moderate depression, and further examine cost-effectiveness.Clinical trial registration number ISRCTN58399513 www.isrctn.com

Background: Pregnancy, birth and adjusting to a new baby is a potentially stressful time that can negatively affect\ud women’s mental and physical health. Expressive writing, where people write about a stressful event for at least\ud 15 min on three consecutive days, has been associated with improved health in some groups but it is not clear\ud whether it is feasible and acceptable for use with postpartum women. This study therefore examined the feasibility and acceptability of expressive writing for postpartum women as part of a randomised controlled trial (RCT).\ud Methods: The Health After Birth Trial (HABiT) was an RCT evaluating expressive writing for postpartum women\ud which included measures of feasibility and acceptability. At 6 to 12 weeks after birth 854 women were randomised\ud to expressive writing, a control writing task or normal care, and outcome measures of health were measured at\ud baseline, one month later and six months later. Feasibility was measured by recruitment, attrition, and adherence to\ud the intervention. Quantitative and qualitative measures of acceptability of the materials and the task were\ud completed six months after the intervention.\ud Results: Recruitment was low (10.7% of those invited to participate) and the recruited sample was from a restricted\ud sociodemographic range. Attrition was high, increased as the study progressed (35.8% at baseline, 57.5% at one\ud month, and 68.1% at six months) and was higher in the writing groups than in the normal care group. Women\ud complied with instructions to write expressively or not, but adherence to the instruction to write for 15 min per\ud day for three days was low (Expressive writing: 29.3%; Control writing: 23.5%). Acceptability measures showed that\ud women who wrote expressively rated the materials/task both more positively and more negatively than those in\ud the control writing group, and qualitative comments revealed that women enjoyed the writing and/or found it\ud helpful even when it was upsetting.\ud Conclusions: The feasibility of offering expressive writing as a universal self-help intervention to all postpartum\ud women 6 to 12 weeks after birth in the HABiT trial was low, but the expressive writing intervention was acceptable\ud to the majority of women who completed it.\ud Trial registration: ISRCTN58399513, 10/09/2013.\ud Keywords: Feasibility, Acceptability, Expressive writing, Postpartum, Postnatal, Maternal

The stability of hydrate-in-oil dispersions is a critical parameter in assessing the risk of flowline blockage due to particle aggregation or wall deposition. Many studies of hydrate particle transportability have used deionized water to form the dispersion; however, the resulting lack of ions means that the crude oil’s natural surfactants will be less active, which does not represent production conditions. This study presents a new investigation of both hydrate-in-oil dispersion stability and water-in-oil emulsion stability, measured with a differential scanning calorimeter (DSC) and low-field nuclear magnetic resonance (NMR) apparatus, respectively. The results show that hydrate-in-oil dispersion stability increases directly with sodium chloride (NaCl) mass fraction in the aqueous phase; above 5 wt % NaCl, the dispersion was observed to be stable over ten hydrate formation–dissociation trials. This was comparable with the dispersion stability observed previously when an ionic surfactant was dosed at 2 w...

Post-traumatic stress disorder (PTSD) affects 4% of women after birth yet there are very few questionnaire measures of postpartum PTSD that have been validated in this population. In addition, none of the available questionnaires assess postpartum PTSD in accordance with criteria specified in the latest edition of the Diagnostic and Statistical Manual [DSM-5, (1)]. The City Birth Trauma Scale is a 29-item questionnaire developed to measure birth-related PTSD according to DSM-5 criteria of: stressor criteria (A), symptoms of re-experiencing (B), avoidance (C), negative cognitions and mood (D), and hyperarousal (E), as well as duration of symptoms (F), significant distress or impairment (E), and exclusion criteria or other causes (H). Two additional items from DSM-IV were also included on the basis of evidence suggesting they might be important in this population. The first was criterion A2 that women responded to events during birth with intense fear, helplessness or horror. The second was symptoms of emotional numbing. Items were first reviewed by researchers (n = 9) and postpartum women (n = 8) and revised accordingly. The questionnaire was then completed by 950 women recruited online. Results showed the City Birth Trauma Scale had excellent reliability (Cronbach's α = 0.92) and is easy to understand (Flesch reading score 64.17). Exploratory factor analysis found two factors which together accounted for 56% of the variance: (i) Birth-related symptoms (40.8% variance) and (ii) General symptoms (15.5% variance). PTSD symptoms were highly associated with distress, impaired functioning, and women reporting they wanted treatment (r = 0.50–0.61). Removing DSM-IV A2 criteria only increased births classified as traumatic by 2%. Adding the item on emotional numbing did not change the psychometric properties of the scale. These items were therefore removed. The City Birth Trauma Scale has good psychometric properties and the two symptom clusters identified are consistent with previous research on symptoms of postpartum PTSD. This scale therefore provides a promising measure of PTSD following childbirth that can be used in research and clinical practice. Future research should examine the scale's predictive validity using clinical interviews.

BackgroundWomen may not seek help for perinatal psychological distress, despite regular contact with primary care services. Barriers include ignorance of symptoms, inability to disclose distress, others’ attitudes, and cultural expectations. Much of the evidence has been obtained from North American populations and may not, therefore, extrapolate to the UK.AimTo understand the factors affecting women’s decision to seek help for perinatal distress.Design and settingMeta-synthesis of the available published qualitative evidence on UK women’s experiences of seeking help for perinatal distress.MethodSystematic searches were conducted in accordance with PRISMA guidelines. Databases searched were PubMed, Scopus, PsycINFO, PsycARTICLES, CINAHL, and Academic Search Complete. Searches of grey literature and references were also conducted. Studies were eligible for inclusion if they reported qualitative data on UK women’s experiences of perinatal distress and contact with healthcare professionals. The synthesis was conducted using meta-ethnography.ResultsIn all, 24 studies were eligible for inclusion. Metasynthesis identified three main themes: identifying a problem, the influence of healthcare professionals, and stigma. These themes build on current understanding of help seeking by identifying the need for women to be able to frame their experience, for healthcare professionals to educate women about their roles, the need for continuity of care, and the way that being seen as a ‘bad mother’ causes women to self-silence.ConclusionPerinatal care provision needs to allow for continuity of care and for staff training that facilitates awareness of factors that influence women’s help seeking. Further research is required, particularly in relation to effective means of identifying perinatal psychological distress.

Background In the UK, concerns about safety and fragmented community mental health care led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require service users to have a care coordinator, written care plan and regular reviews of their care. Processes are required to be collaborative, recovery-focused and personalised but have rarely been researched. We aimed to obtain the views and experiences of stakeholders involved in community mental health care and identify factors that facilitate or act as barriers to personalised, collaborative, recovery-focused care. Methods We conducted a cross-national comparative study employing a concurrent transformative mixed-methods approach with embedded case studies across six service provider sites in England and Wales. The study included a survey of views on recovery, empowerment and therapeutic relationships in service users (n = 448) and recovery in care coordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117) and a review of care plans (n = 33). Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and framework method. Results Significant differences were found across sites for scores on therapeutic relationships. Variation within sites and participant groups was reported in experiences of care planning and understandings of recovery and personalisation. Care plans were described as administratively burdensome and were rarely consulted. Carers reported varying levels of involvement. Risk assessments were central to clinical concerns but were rarely discussed with service users. Service users valued therapeutic relationships with care coordinators and others, and saw these as central to recovery. Conclusions Administrative elements of care coordination reduce opportunities for recovery-focused and personalised work. There were few common understandings of recovery which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work. Research to investigate innovative approaches to maximise staff contact time with service users and carers, shared decision-making in risk assessments, and training designed to enable personalised, recovery-focused care coordination is indicated. Electronic supplementary material The online version of this article (doi:10.1186/s12888-016-0858-x) contains supplementary material, which is available to authorized users.