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Jeffrey C Cegan,1 Benjamin D Trump,1 Susan M Cibulsky,2 Zachary A Collier,3 Christopher L Cummings,4 Scott L Greer,5 Holly Jarman,5 Kasia Klasa,1,5 Gary Kleinman,2 Melissa A Surette,6 Emily Wells,1 Igor Linkov1 1US Army Engineer Research and Development Center, US Army Corps of Engineers, Vicksburg, MS, USA; 2US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Boston, MA, USA; 3Radford University, Davis College of Business and Economics, Department of Management, Radford, VA, USA; 4North Carolina State University, Genetic Engineering and Society Center, Raleigh, NC, USA; 5University of Michigan, School of Public Health, Department of Health Management and Policy, Ann Arbor, MI, USA; 6Federal Emergency Management Agency, Region I, Boston, MA, USACorrespondence: Jeffrey C Cegan; Igor LinkovUS Army Engineer Research and Development Center, US Army Corps of Engineers, 696 Virginia Road, Concord, MA, 01742, USATel +1-978-318-8881; +1-617-233-9869Email Jeffrey.C.Cegan@usace.army.mil; Igor.Linkov@usace.army.milAbstract: Many efforts to predict the impact of COVID-19 on hospitalization, intensive care unit (ICU) utilization, and mortality rely on age and comorbidities. These predictions are foundational to learning, policymaking, and planning for the pandemic, and therefore understanding the relationship between age, comorbidities, and health outcomes is critical to assessing and managing public health risks. From a US government database of 1.4 million patient records collected in May 2020, we extracted the relationships between age and number of comorbidities at the individual level to predict the likelihood of hospitalization, admission to intensive care, and death. We then applied the relationships to each US state and a selection of different countries in order to see whether they predicted observed outcome rates. We found that age and comorbidity data within these geographical regions do not explain much of the international or within-country variation in hospitalization, ICU admission, or death. Identifying alternative explanations for the limited predictive power of comorbidities and age at the population level should be considered for future research.Keywords: comorbidity, health outcomes, COVID-19, mortality rates

Siân A McLean,1,2 Hannah K Jarman,2 Rachel F Rodgers3,41Institute for Health and Sport, Victoria University, Melbourne, Victoria, Australia; 2School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia; 3Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, Chru Montpellier, Montpellier, France; 4Department of Applied Psychology, Northeastern University, Boston, MA, USAAbstract: Social media use has grown rapidly in recent years, with one of the most popular activities for young people being the taking, sharing, and browsing of digital self-photos, known as selfies. However, research has only recently begun to investigate selfies, and little is known about selfie practices in adolescents, or the associations between these practices and well-being and body confidence. This paper aimed to address this gap and conduct a narrative review of selfie practices and the relationships with well-being and body confidence in adolescents. No studies were found reporting on selfie practices and these relationships among children. However, taking selfies appears to be common practice among adolescents, although posting selfies online is less frequent. The studies reviewed indicate that certain aspects of selfie behaviors may be more problematic than others. Specifically, viewing selfies online appears to have a negative impact on adolescents’ well-being and body confidence, at least in the short term in experimental contexts. Moreover, seeking and placing importance on feedback from others may also be a harmful aspect of selfie practices. Finally, consistent with research examining social media, social comparison has been identified in this emerging body of research as a potential mechanism which links selfie engagement to well-being and body confidence. To further advance understanding of the correlates and effects of selfie practices, research with children and with boys, and research focused on a wider range of indicators of well-being, is needed. Most importantly, prospective research is required to examine the directionality of links between selfie practices and well-being and body confidence.Keywords: selfies, social media, adolescents, well-being, body image, social comparison

Background: Pre-injury frailty is associated with adverse in-hospital outcomes in older trauma patients, but the association with longer term survival and recovery is unclear. We aimed to investigate post discharge survival and health-related quality of life (HRQoL) in older frail patients at six months after Major Trauma Centre (MTC) admission., Methods: This was a multi-centre study of patients aged ≥ 65 years admitted to five MTCs. Data were collected via questionnaire at hospital discharge and six months later. The primary outcome was patient-reported HRQoL at follow up using Euroqol EQ5D-5 L visual analogue scale (VAS). Secondary outcomes included health status according to EQ5D dimensions and care requirements at follow up. Multivariable linear regression analysis was conducted to evaluate the association between predictor variables and EQ-5D-5 L VAS at follow up., Results: Fifty-four patients died in the follow up period, of which two-third (64%) had been categorised as frail pre-injury, compared to 21 (16%) of the 133 survivors. There was no difference in self-reported HRQoL between frail and not-frail patients at discharge (Mean EQ-VAS: Frail 55.8 vs. Not-frail 64.1, p = 0.137) however at follow-up HRQoL had improved for the not-frail group but deteriorated for frail patients (Mean EQ-VAS: Frail: 50.0 vs. Not-frail: 65.8, p = 0.009). There was a two-fold increase in poor quality of life at six months (VAS ≤ 50) for frail patients (Frail: 65% vs. Not-frail: 30% p < 0.009). Frailty (β-13.741 [95% CI -25.377, 2.105], p = 0.02), increased age (β -1.064 [95% CI [-1.705, -0.423] p = 0.00) and non-home discharge (β -12.017 [95% CI [118.403, 207.203], p = 0.04) were associated with worse HRQoL at follow up. Requirements for professional carers increased five-fold in frail patients at follow-up (Frail: 25% vs. Not-frail: 4%, p = 0.01)., Conclusions: Frailty is associated with increased mortality post trauma discharge and frail older trauma survivors had worse HRQoL and increased care needs at six months post-discharge. Pre-injury frailty is a predictor of poor longer-term HRQoL after trauma and recognition should enable early specialist pathways and discharge planning., (© 2024. The Author(s).)

Background: Patient demand, internationally, on emergency departments and urgent care treatment centres has grown. Shortages of staff, particularly of emergency medicine doctors, have compounded problems. Some countries are pursuing solutions of including non-medical practitioners e.g., nurse practitioners and physician associates/assistants in their emergency department workforces. This study investigated at the macro and meso level of the health system in England: what the rationale was and the factors influencing the current and future employment, or otherwise, of non-medical practitioners in emergency departments and urgent treatment centres., Methods: Mixed qualitative methods in the interpretative tradition were employed. We undertook, in 2021-2022, a documentary analysis of national, regional and subregional policy (2017-2021), followed by semi-structured interviews of a purposive sample (n = 18) of stakeholders from national, regional and subregional levels. The data were thematically analysed and then synthesised., Results: There was general national policy support for increasing the presence of non-medical practitioners as part of the solution to shortages of emergency medicine doctors. However, evidence of policy support dissipated at regional and subregional levels. There were no published numbers for non-medical practitioners in emergency departments, but stakeholders suggested they were relatively small in number, unevenly distributed and faced uncertain growth. While the experience of the COVID-19 pandemic and its aftermath were said to have made senior decision makers more receptive to workforce innovation, many factors contributed to the uncertain growth. These factors included: limited evidence on the relative advantage of including non-medical practitioners; variation in the models of service being pursued to address patient demand on emergency departments and the place of non-medical practitioners within them; the lack of a national workforce plan with clear directives; and the variation in training for non-medical practitioner roles, combined with the lack of regulation of that level of practice., Conclusions: We identified many features of a system ready to introduce non-medical practitioners in emergency departments and urgent treatment centres but there were uncertainties and the potential for conflict with other professional groups. One area of uncertainty was evidence of relative advantage in including non-medical practitioners in staffing. This requires urgent attention to inform decision making for short- and long-term workforce planning. Further investigation is required to consider whether these findings are generalisable to other specialties, and to similar health systems in other countries., (© 2023. The Author(s).)

Background: Low-dose analgesic methoxyflurane (Penthrox ® ) was approved in Europe for emergency relief of moderate to severe pain in conscious adults with trauma in 2015. A comparative post-authorisation safety study (PASS) was conducted to assess the risk of hepatotoxicity and nephrotoxicity with methoxyflurane during routine clinical practice., Methods: This was a comparative hybrid prospective-retrospective cohort study. The comparative cohorts consisted of adults who were given methoxyflurane (methoxyflurane cohort) or another analgesic (concurrent cohort) routinely used for moderate to severe trauma and associated pain in the emergency setting (ambulance and Emergency Department) in the UK between December 2016 and November 2018. Hepatic and renal events were captured in the ensuing 12 weeks. A blinded clinical adjudication committee assessed events. A historical comparator cohort (non-concurrent cohort) was identified from patients with fractures in the English Hospital Episode Statistics (HES) accident and emergency database from November 2013 and November 2015 (before commercial launch of methoxyflurane). Hepatic and renal events were captured in the ensuing 12 weeks via linkage with the Clinical Practice Research Datalink (CPRD) and HES hospital admissions databases., Results: Overall, 1,236, 1,101 and 45,112 patients were analysed in the methoxyflurane, concurrent and non-concurrent comparator cohorts respectively. There was no significant difference in hepatic events between the methoxyflurane and concurrent cohorts (1.9% vs. 3.0%, P = 0.079) or between the methoxyflurane and non-concurrent cohorts (1.9% vs. 2.5%, P = 0.192). Renal events were significantly less common in the methoxyflurane cohort than in the concurrent cohort (2.3% vs. 5.6%, P < 0.001). For methoxyflurane versus non-concurrent cohort the lower occurrence of renal events (2.3% vs. 3.2%, P = 0.070) was not statistically significant. Multivariable adjustment did not change these associations., Conclusions: Methoxyflurane administration was not associated with an increased risk of hepatotoxicity or nephrotoxicity compared with other routinely administered analgesics and was associated with a reduced risk of nephrotoxicity compared with other routinely administered analgesics., Trial Registration: Study registered in the EU PAS Register (ENCEPP/SDPP/13040)., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Low-level exposure to carbon monoxide (CO) is a significant health concern but is difficult to diagnose. This main study aim was to establish the prevalence of low-level CO poisoning in Emergency Department (ED) patients., Methods: A prospective cross-sectional study of patients with symptoms of CO exposure was conducted in four UK EDs between December 2018 and March 2020. Data on symptoms, a CO screening tool and carboxyhaemoglobin were collected. An investigation of participants' homes was undertaken to identify sources of CO exposure., Results: Based on an ED assessment of 4175 participants, the prevalence of suspected CO exposure was 0.62% (95% CI; 0.41-0.91%). CO testing in homes confirmed 1 case of CO presence and 21 probable cases. Normal levels of carboxyhaemoglobin were found in 19 cases of probable exposure and in the confirmed case., Conclusion: This study provides evidence that ED patients with symptoms suggestive of CO poisoning but no history of CO exposure are at risk from CO poisoning. The findings suggest components of the CO screening tool may be an indicator of CO exposure over and above elevated COHb. Clinicians should have a high index of suspicion for CO exposure so that this important diagnosis is not missed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Faculty of Public Health.)

Objective: To systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma., Setting: Electronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched., Included Articles: Peer-reviewed articles of any study design, published in English, 1999-2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone., Methods: Screening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken., Outcome Measures: Any outcomes reported for patients, staff or care system., Results: 17 603 references were identified and 518 read in full; 22 were included-frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury., Conclusions: This systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma. INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS PROSPERO: CRD42016032895., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known., Objective: The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK., Methods: A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each., Results: Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age., Conclusions: This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes., (© 2022. The Author(s).)

Introduction: The most common place for unintentional, non-fire-related carbon monoxide (CO) exposure to occur is in the home, but this is preventable if CO producing sources are properly maintained and CO alarms/detectors are in use. It is estimated that less than half of all homes have a CO alarm, but there is variation across countries, housing types and different demographic and socioeconomic groups. The purpose of this study is to provide up-to-date data on the use of CO alarms by surveying attendees to emergency departments using an online anonymous questionnaire., Methods and Analysis: A multicentre prospective, cross-sectional survey of 4000 patients or carers in three emergency departments will be used. A questionnaire comprising of a maximum of 14 items will be administered following completion of an informed consent process. Data collected include participant demographics, household information and CO alarm use. Statistical analyses will comprise descriptive techniques to present respondents' use of CO alarms and examine associations between alarm use and participant characteristics. The proportion of homes with CO alarms installed will be calculated for all subjects and for selected subgroups., Ethics and Dissemination: The study obtained ethical approval from the Westminster Research Ethics Committee (REC number 1/PR/1657). Informed consent will be obtained prior to the participant undergoing any activities that are specifically for the purposes of the study. Findings will be published in scientific journals, presented to national and international conferences and disseminated to CO safety groups., Trial Registration Number: ISRCTN registry 12562718., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Internationally, an increasing proportion of emergency department visits are mental health related. Concurrently, psychiatric wards are often occupied above capacity. Healthcare providers have introduced short-stay, hospital-based crisis units offering a therapeutic space for stabilisation, assessment and appropriate referral. Research lags behind roll-out, and a review of the evidence is urgently needed to inform policy and further introduction of similar units., Aims: This systematic review aims to evaluate the effectiveness of short-stay, hospital-based mental health crisis units., Method: We searched EMBASE, Medline, CINAHL and PsycINFO up to March 2021. All designs incorporating a control or comparison group were eligible for inclusion, and all effect estimates with a comparison group were extracted and combined meta-analytically where appropriate. We assessed study risk of bias with Risk of Bias in Non-Randomized Studies - of Interventions and Risk of Bias in Randomized Trials., Results: Data from twelve studies across six countries (Australia, Belgium, Canada, The Netherlands, UK and USA) and 67 505 participants were included. Data indicated that units delivered benefits on many outcomes. Units could reduce psychiatric holds (42% after intervention compared with 49.8% before intervention; difference = 7.8%; P < 0.0001) and increase out-patient follow-up care (χ 2 = 37.42, d.f. = 1; P < 0.001). Meta-analysis indicated a significant reduction in length of emergency department stay (by 164.24 min; 95% CI -261.24 to -67.23 min; P < 0.001) and number of in-patient admissions (odds ratio 0.55, 95% CI 0.43-0.68; P < 0.001)., Conclusions: Short-stay mental health crisis units are effective for reducing emergency department wait times and in-patient admissions. Further research should investigate the impact of units on patient experience, and clinical and social outcomes.

Rural areas face well known and distinctive health care challenges that can limit their resilience in the face of health emergencies such as the COVID-19 pandemic. These include problems of sparsity and consequent limited health care provisioning; poverty, inequalities, and distinctive economic structures that limit access to health care; and underlying population health risks and inequalities that can increase vulnerability. Nonetheless, not all rural areas face the same problems, and non-rural areas can have challenges. To be useful in influencing policy, a tool to identify more and less resilient areas is necessary. This Commentary reviews key forms of risk and constructs a county-level index of resilience for the United States which helps to identify countries with limited resilience. Further, it argues that health care resilience should be conceptualized in terms of broader regions than counties since health care facilities' referral regions are larger than individual counties; resilience needs to be understood at that level. The index, read at the level of counties and referral regions, can contribute to identification of immediate problems as well as targets for longer term investment and policy response., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022, Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: There is an extensive body of research demonstrating that trade and globalisation can have wide-ranging implications for health. Robust governance is key to ensuring that health, social justice and sustainability are key considerations within trade policy, and that health risks from trade are effectively mitigated and benefits are maximised. The UK's departure from the EU provides a rare opportunity to examine a context where trade governance arrangements are being created anew, and to explore the consequences of governance choices and structures for health and social justice. Despite its importance to public health, there has been no systematic analysis of the implications of UK trade policy governance. We therefore conducted an analysis of the governance of the UK's trade policy from a public health and social justice perspective., Results: Several arrangements required for good governance appear to have been implemented - information provision, public consultation, accountability to Parliament, and strengthening of civil service capacity. However, our detailed analyses of these pillars of governance identified significant weaknesses in each of these areas., Conclusion: The establishment of a new trade policy agenda calls for robust systems of governance. However, our analysis demonstrates that, despite decades of mounting evidence on the health and equity impacts of trade and the importance of strong systems of governance, the UK government has largely ignored this evidence and failed to galvanise the opportunity to include public health and equity considerations and strengthen democratic involvement in trade policy. This underscores the point that the evidence alone will not guarantee that health and justice are prioritised. Rather, we need strong systems of governance everywhere that can help seize the health benefits of international trade and minimise its detrimental impacts. A failure to strengthen governance risks poor policy design and implementation, with unintended and inequitable distribution of harms, and 'on-paper' commitments to health, social justice, and democracy unfulfilled in practice. Although the detailed findings relate to the situation in the UK, the issues raised are, we believe, of wider relevance for those with an interest of governing for health in the area of international trade.

Background: The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older trauma patients in the ED in patients admitted to major trauma centres., Methods: Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary outcome was identification of frailty in the ED using three different assessment tools., Results: We included 372 patients whose median age was 80, 53.8% of whom were female. The most common mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate using PRISMA7 and slight using TSFI., Conclusions: This prospective study has demonstrated that screening for frailty in older major trauma patients within the Emergency Department is feasible and accurate using CFS., Trial Registration: ISRCTN, ISRCTN10671514 . Registered 22 October 2019.

Background: Intravenous tranexamic acid (TXA) reduces bleeding deaths after injury and childbirth. It is most effective when given early. In many countries, pre-hospital care is provided by people who cannot give i.v. injections. We examined the pharmacokinetics of intramuscular TXA in bleeding trauma patients., Methods: We conducted an open-label pharmacokinetic study in two UK hospitals. Thirty bleeding trauma patients received a loading dose of TXA 1 g i.v., as per guidelines. The second TXA dose was given as two 5 ml (0·5 g each) i.m. injections. We collected blood at intervals and monitored injection sites. We measured TXA concentrations using liquid chromatography coupled to mass spectrometry. We assessed the concentration time course using non-linear mixed-effect models with age, sex, ethnicity, body weight, type of injury, signs of shock, and glomerular filtration rate as possible covariates., Results: Intramuscular TXA was well tolerated with only mild injection site reactions. A two-compartment open model with first-order absorption and elimination best described the data. For a 70-kg patient, aged 44 yr without signs of shock, the population estimates were 1.94 h -1 for i.m. absorption constant, 0.77 for i.m. bioavailability, 7.1 L h -1 for elimination clearance, 11.7 L h -1 for inter-compartmental clearance, 16.1 L volume of central compartment, and 9.4 L volume of the peripheral compartment. The time to reach therapeutic concentrations (5 or 10 mg L -1 ) after a single intramuscular TXA 1 g injection are 4 or 11 min, with the time above these concentrations being 10 or 5.6 h, respectively., Conclusions: In bleeding trauma patients, intramuscular TXA is well tolerated and rapidly absorbed., Clinical Trial Registration: 2019-000898-23 (EudraCT); NCT03875937 (ClinicalTrials.gov)., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Brexit has direct and indirect negative health consequences, whether from economic damage or from the political paralysis and distraction from public health that it has created. Brexit is a public health problem in its own right, as other literature has shown-but, we argue, it is also a symptom of deeper problems in the governance of the United Kingdom. In particular, the combination of executive dominance, partisanship and opacity that give rise to the constitutional casualism of the Brexit decisions has already affected public health policy and will continue to do so unless addressed., (© The Author(s) 2020. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The burden of frailty on older people is easily recognisable by increasing mortality and morbidity, longer hospital stays and adverse discharge locations. In the UK, frailty screening has recently become part of the best practice commissioning tariff within National Health Service England, yet there is no evidence or consensus as to who should carry out this assessment or within which time frame. As major trauma is an increasing burden for older people, there is a need to focus clinician's attention on early identification of frailty in the emergency department (ED) in patients with major trauma as a way to underpin frailty specific major trauma pathways, to optimise recovery and improve patient experience. Throughout the patient with major trauma pathway, nurses are perhaps best placed to conduct timely clinical assessments working with the patient, family and multidisciplinary team to influence ongoing care. This study aims to determine the feasibility of nurse-led assessment of frailty in patients aged 65 years or more admitted to major trauma centres (MTCs)., Methods and Analysis: This is a prospective observational study conducted across five UK MTCs, enrolling 370 participants over 9 months. The primary aim is to determine the feasibility of nurse-led frailty assessment in MTC EDs in patients aged 65 years or more following traumatic injury. The prevalence of frailty and the best assessment tool for use in the ED will be determined. Other outcome measures include quality of life and frailty assessment 6 months after injury, mortality and discharge outcomes., Ethics and Dissemination: The study was given ethical approval by the Social Care Research Ethics Committee (REC no 19/IEC08/0006). Findings will be published in scientific journals and presented to national and international conferences., Trial Registration Number: ISRCTN10671514., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To explore factors influencing confidence and willingness among laypersons in the UK to act in a head injury situation, in order to inform first aid education offered by the British Red Cross., Design: Qualitative focus group study., Setting: South East England., Participants: Forty-four laypersons (37 women, 7 men) were purposively recruited from the general public using snowball sampling, into one focus group each for six population groups: parents of young children (n=8), informal carers of older adults (n=7), school staff (n=7), sports coaches (n=2), young adults (n=9) and 'other' adults (n=11). The median (range) age group across the sample was 25-34 years (18-24, 84-95). Participants were from Asian (n=6), Black (n=6), Mixed (n=2) and White (n=30) ethnic backgrounds., Results: The majority of participants described being confident and willing to act in a head injury scenario if that meant calling for assistance, but did not feel sufficiently confident or knowledgeable to assist or make decisions in a more involved way. Individuals' confidence and willingness presented as fluid and dependent on an interplay of situational and contextual considerations, which strongly impacted decision-making: prior knowledge and experience, characteristics of the injured person, un/observed head injury, and location and environment. These considerations may be framed as enablers or barriers to helping behaviour, impacting decision-making to the same extent as-or even more so than-the clinical signs and symptoms of head injury. An individual conceptual model is proposed to illustrate inter-relationships between these factors., Conclusions: Our findings show that confidence and willingness to act in a head injury scenario are dependent on several contextual and situational factors. It is important to address such factors, in addition to knowledge of clinical signs and symptoms, in first aid education and training to improve confidence and willingness to act., Competing Interests: Competing interests: MH reports grants from British Red Cross during the conduct of the study. BK reports grants from Elastoplast during the conduct of the study. EO reports grants from Elastoplast during the conduct of the study and outside the submitted work. EO reports the British Red Cross commissioned this study in the context of developing a lay responder pathway to head injuries. The British Red Cross is a first aid education provider and standard setter., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

US political debates often refer to the experience of "single-payer" systems such as those of Canada and the United Kingdom. We argue that single payer is not a very useful category in comparative health policy analysis but that the experiences of countries such as Canada, the United Kingdom, Spain, Sweden, and Australia provide useful lessons. In creating universal tax-financed systems, they teach the importance of strong, unified governments at critical junctures-most notably democratization. The United States seems politically hospitable to creating such a system.The process of creation, however, highlights the malleability of interests in the health care system, the opportunities for creative coalition building, and the problems caused by linking health care finance and reform. In maintaining these systems, keeping the middle class supportive is crucial to avoiding universal health care that is essentially a program for the poor.For a technical term from the 1970s, "single-payer health care" has proved to have remarkable political power and persistence. We argue it is not a very useful term but the lessons from such systems can be valuable for those contemplating movement toward universal health coverage in the United States.

Objectives: We sought to evaluate diagnostic accuracy of a high-sensitivity cardiac troponin I (hs-cTnI) assay for acute coronary syndromes (ACS) in the emergency department (ED). The assay has high precision at low concentrations and can detect cTnI in 96.8% of healthy individuals., Methods: In successive prospective multicenter studies ("testing" and "validation"), we included ED patients with suspected ACS. We drew blood for hs-cTnI [Singulex Clarity ® cTnI; 99th percentile, 8.67 ng/L; limit of detection (LoD), 0.08 ng/L] on arrival. Patients also underwent hs-cTnT (Roche Elecsys) testing over ≥3 h. The primary outcome was an adjudicated diagnosis of ACS, defined as acute myocardial infarction (AMI; prevalent or incident), death, or revascularization within 30 days., Results: The testing and validation studies included 665 and 2470 patients, respectively, of which 94 (14.1%) and 565 (22.9%) had ACS. At a 1.5-ng/L cutoff, hs-cTnI had good sensitivity for AMI in both studies (98.7% and 98.1%, respectively) and would have "ruled out" 40.1% and 48.9% patients. However, sensitivity was lower for ACS (95.7% and 90.6%, respectively). At a 0.8-ng/L cutoff, sensitivity for ACS was higher (97.5% and 97.9%, ruling out 28.6% patients in each cohort). The hs-cTnT assay had similar performance at the LoD (24.6% ruled out; 97.2% sensitivity for ACS)., Conclusions: The hs-cTnI assay could immediately rule out AMI in 40% of patients and ACS in >25%, with similar accuracy to hs-cTnT at the LoD. Because of its high precision at low concentrations, this hs-cTnI assay has favorable characteristics for this clinical application., (© 2019 American Association for Clinical Chemistry.)

Policy Points Tobacco industry denormalization is a key strategy for tobacco control that has been formalized in the WHO Framework Convention on Tobacco Control. International trade and investment laws are a potential threat to tobacco industry denormalization because they do not automatically incorporate denormalization and, in theory, treat tobacco firms like other commercial interests. Countries that seek to defend tobacco control policies against international trade and investment challenges need to have good governance in two senses: good governance as understood by tribunals and good-enough governance to manage the processes and requirements that enable policies to survive international challenges., Context: Tobacco industry denormalization (TID), portraying tobacco product manufacturers as a deadly industry, is a major strategy for public health advocates. Using this strategy, activists around the world have successfully pushed for governments to enact tobacco control regulations, including the unprecedented international Framework Convention on Tobacco Control (FCTC). TID has been a distinctive legal and political strategy that has affected the place of tobacco in law and has both inspired and constrained those who would imitate the strategy in other areas of regulation, such as diet or alcohol. It is therefore a case study in the creation of a distinctive legal approach and of threats to that approach from the changing role of world trade and investment law, which creates a new set of venues that tobacco industry advocates can use to redefine tobacco as a normal good and to seek out "fair and equitable treatment" for their industry., Methods: I review legal and policy documents pertaining to two major challenges to tobacco control policies in Australia and Uruguay aimed at controlling industry branding., Findings: International trade and investment law challenges TID and raises fundamental questions about the role of the state in protecting public health. Recent trade disputes involving Uruguay and Australia illustrate this dynamic. Despite losing high-court challenges against packaging regulations in both countries, tobacco firms were still able to challenge states in a different way, through international trade and investment agreements. This article identifies the industry's strategies and the responses of those seeking to avoid renormalizing tobacco as a part of world trade. In particular, states must demonstrate that their tobacco control policies satisfy standards set by tribunals, which include standards of good governance, and they must prepare their policies in a way that reduces legal risk and requires good governance., Conclusions: Although TID has strengthened the hand of tobacco control advocates, TID strategies alone are not sufficient to defend public regulations against extraterritorial legal challenges in an arena that resists the basic TID technique of singling out a particular industry. Public health advocates might also note the FCTC's aid in helping governments defend themselves against these challenges and consider similar international instruments for other areas., (© 2019 Milbank Memorial Fund.)

Tobacco control policies rely heavily on law and are steeped in litigation. Examining the creation of tobacco control laws in the European Union, this article lays out the potential costs and benefits of legalism for public health practitioners and advocates. Legalism is a form of governance that relies heavily on the authority of law to settle political disputes, with consequences for the ways in which governments make, and advocates push for, public health policies. To the extent that legalism creates procedural problems and distortions in the content of public health policy, then the content of law and its making is a public health problem. On the other hand, litigation can also be a public health tool, and an enforceable, justiciable right to health is a powerful political and legal weapon in its own right.

Objective: To compare flucloxacillin with clindamycin to flucloxacillin alone for the treatment of limb cellulitis., Design: Parallel, double-blinded, randomised controlled trial., Setting: Emergency department attendances and general practice referrals within 20 hospitals in England., Interventions: Flucloxacillin, at a minimum of 500 mg 4 times per day for 5 days, with clindamycin 300 mg 4 times per day for 2 days given orally versus flucloxacillin given alone., Main Outcome Measures: The primary outcome was improvement at day 5. This was defined as being afebrile with either a reduction in affected skin surface temperature or a reduction in the circumference of the affected area. Secondary outcomes included resolution of systemic features, resolution of inflammatory markers, recovery of renal function, reduction in the affected area, decrease in pain, return to work or normal activities and the absence of increased side effects., Results: 410 patients were included in the trial. No significant difference was seen in improvement at day 5 for flucloxacillin with clindamycin (136/156, 87%) versus flucloxacillin alone (140/172, 81%)-OR 1.55 (95% CI 0.81 to 3.01), p=0.174. There was a significant difference in the number of patients with diarrhoea at day 5 in the flucloxacillin with clindamycin allocation (34/160, 22%) versus flucloxacillin alone (16/176, 9%)-OR 2.7 (95% CI 1.41 to 5.07), p=0.002. There was no clinically significant difference in any secondary outcome measures. There was no significant difference in the number of patients stating that they had returned to normal activities at the day 30 interview in the flucloxacillin with clindamycin allocation (99/121, 82%) versus flucloxacillin alone (104/129, 81%)-adjusted OR 0.90 (95% CI 0.44 to 1.84)., Conclusions: The addition of a short course of clindamycin to flucloxacillin early on in limb cellulitis does not improve outcome. The addition of clindamycin doubles the likelihood of diarrhoea within the first few days., Trial Registration Number: NCT01876628, Results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

In 2011, the Australian Government passed landmark legislation requiring tobacco manufacturers to adopt 'plain packaging', a government-mandated design standardized across all brands of tobacco products. In response, plain packaging policy in Australia has faced multiple, simultaneous challenges from a global, well-resourced industry able to use all available fora to seek redress. Generalizing from the Australian experience, we analyze four types of challenges to plain packaging from the tobacco industry. We characterize three ways in which industry questions public health policies through international trade and investment law, on: (i) the intent or purpose of the policy; (ii) the economic consequences of it; and (iii) the regulatory authority behind it. We make recommendations and suggest that public health policymakers can know with some precision what attacks will be launched on tobacco control policies, and prepare their strategies and legislation accordingly.