South Cumbria Research Articles

Relocate the base of the Arundian? A re-evaluation from south Cumbrian sections and implications for British and Irish Lower Carboniferous successions

The largely ice-free world of the ‘Chadian’–Arundian (early Visean) is investigated in two successions in south Cumbria to better understand the relationships between transgression, hiatus and the position of the basal Arundian. A detailed foraminiferal biostratigraphy is used to age-constrain the transition from the late ‘Chadian’ to early Arundian. This demonstrates a good synchronous relationship between the sequence stratigraphy of the two successions and the first occurrence of key species (mostly primitive archaediscids, rapidly followed by more evolved forms of the same family), suggesting that there is no significant hiatus and that the record of faunal changes is closely comparable in the key successions. A synthesis of other ‘Chadian’–Arundian boundary successions in Britain and Ireland indicates some key problems with the current Arundian boundary stratotype in practical usage. We propose a stratigraphically higher position for the Arundian boundary in the stratotype, which is more easily correlated to the Bobrikian and Moliniacian substages of eastern Europe and Belgium, respectively, and tied to the first occurrences of foraminifera species, allowing more robust age assessments, free from the confounding factors of inferred lithological or sequence stratigraphic changes.

Specialist referrals and diagnostic delays in motor neurone disease: Mapping patients’ journey through hoops and hurdles in healthcare

Motor neuron disease (MND) is an uncommon but invariably fatal condition, with a median survival of 24–48 months from symptom onset. Although there is no cure at the moment, early diagnosis is crucial to enable timely access to multidisciplinary care, and enrolment in clinical trials utilising investigational therapies. Unfortunately, diagnostic delays remain common, and the average delay between symptom onset and diagnosis is 12 months. Large numbers of specialist referrals have been suggested as a key contributor to diagnostic delays.We conducted a retrospective review of the medical records of patients diagnosed with MND in Lancashire and South Cumbria, to investigate whether large numbers of specialty referrals are a common occurrence in MND.Our review identified that 35% of patients with MND were seen by two or more specialties before being referred to neurology. This rose to 49% when patients with bulbar onset disease were considered. 9% of cases saw three or more specialists. There was a statistically significant correlation between the number of specialist referrals and delays in neurology referral. We hope our findings will increase awareness of the importance of early neurology referral in the diagnosis of MND and promote the use of the MND Red Flag tool as a means of identifying patients in need of prompt neurological evaluation.

Monitoring of Antipsychotics in CAMHS Intellectual Disability Service in Lancashire and South Cumbria NHS Foundation Trust

Monitoring of Antipsychotics in CAMHS Intellectual Disability Service in Lancashire and South Cumbria NHS Foundation Trust

P012 Health inequalities in the diagnosis and treatment of rheumatoid arthritis

Abstract Background/Aims Patients with chronic diseases, such as rheumatoid arthritis (RA), from socially deprived backgrounds are known to have more severe disease, comorbidity and higher mortality rates. This study used National Early Inflammatory Arthritis Audit (NEIAA) data submitted by Lancashire and South Cumbria Foundation Trust to ascertain if social deprivation influences time to diagnosis and treatment escalation onto a high-cost drug (HCD). Methods Patients diagnosed with an inflammatory arthritis were recruited to NEIAA over a five-year period (May 2018 to March 2023). Information on demographics, patient postcodes, duration of symptoms prior to referral, GP referral time and rheumatology waiting time were analysed. Index of Multiple Deprivation (IMD) was derived from patient postcodes and patients divided into three groups based on IMD deciles. Patients with deciles 1-3 were grouped as most deprived, deciles 4-6 as middle and deciles 7-10 as least deprived. A case note review of a subgroup of patients who had been on treatment for 2-5 years was undertaken to investigate whether IMD decile was associated with treatment escalation onto a HCD. Data were analysed using descriptive and inferential statistics on Stata. Results were adjusted for confounders including age and gender. Results A total of 265 patients with RA were included, mean age 60 years, 63% female and 10% from ethnic minority groups. There were 31%, 25% and 44% in the most, middle and least deprived groups respectively. There was a higher proportion of patients from minority ethnic backgrounds in the most deprived group (most 21% vs least 3%). Symptom duration at time of presentation to the GP was greater than 3 months in 57% vs 48% of patients in the most and least deprived groups, respectively. Median was used to compare the GP referral times and rheumatology waiting times as there were outliers in the dataset. The most deprived group had longer GP referral times (most 16 days vs least 7 days); however, median rheumatology waiting time was similar across the three groups (most, middle and least deprived 27, 24 and 25 days respectively). There was no difference in escalation onto a HCD across the three groups. Conclusion Patients from the most deprived areas presented later and took longer to be referred. However, time to being seen in the rheumatology clinic and escalation onto a HCD was not found to be associated with social deprivation. Exploring this further on a national level will help understand if social deprivation is influencing care elsewhere. This work supports the need to focus more resource on raising public awareness in more deprived areas. Disclosure S. Jeyaratnam: None. S. Fish: None. S. Horton: None. A. Madan: None. C. Rao: None. E. MacPhie: None.

P011 Time to diagnosis for different types of inflammatory arthritis

Abstract Background/Aims Timely diagnosis of inflammatory arthritis (IA) is crucial for optimising patient outcomes. However, it is appreciated that some types of inflammatory arthritis may be more challenging to diagnose as they present very differently. The National Early Inflammatory Arthritis Audit (NEIAA) provides the opportunity for rheumatology services to benchmark the care they provide. This project used NEIAA to investigate if there is a difference in time to diagnosis for rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA). Methods Lancashire and South Cumbria Foundation Trust (LSCFT) recruited patients diagnosed with an IA to NEIAA over a five-year period (May 2018 to March 2023). Information on demographics, duration of symptoms prior to referral, GP referral time and rheumatology waiting time were analysed. Results A total of 393 patients with either RA, PsA or AxSpA were included in the analysis. There was a higher proportion of patients from minority ethnic backgrounds in the AxSpA group. The ratio of female to male was >1 in RA and PSA but approximately 1:1 in AxSpA. The mean ages of patients in the RA, PsA and AxSpA groups were 60, 49 and 40 years, respectively. Table 1: Difference in time to diagnosis for the different types of IA, highlights the median time to diagnosis. Median was used due to outliers in data. Patients with AxSpA had the longest average duration of symptoms prior to presenting to the GP, with nearly 80% having symptoms for over a year. GP referral time was significantly shorter in the AxSpA group. Time to first rheumatology appointment was similar across the three groups. Conclusion There is a difference in time to diagnosis for the different types of IA. Further work is needed to understand why patients with AxSpA are presenting so late to their GP before being referred. We recognise the importance of exploring whether patients with AxSpA have been referred to other specialities or healthcare professionals. Investment in clinical triage and education sessions for primary care may help explain these results. More focus is needed on raising public awareness locally. Disclosure S. Jeyaratnam: None. S. Fish: None. S. Horton: None. A. Madan: None. C. Rao: None. E. MacPhie: None.

Solutions Trial: Solution Focused Brief Therapy (SFBT) in 10–17-year-olds presenting at police custody: a randomised controlled trial

BackgroundWithin England, children and young people (CYP) who come into police custody are referred to Liaison and Diversion (L&D) teams. L&D teams have responsibility for liaising with healthcare and other support services while working to divert CYP away from the criminal justice system but have traditionally not provided targeted psychological interventions to CYP. Considering evidence that Solution Focused Brief Therapy (SFBT) leads to a reduction in internalising and externalising behaviour problems in CYP, the aim of this randomised controlled trial (RCT) was to determine whether there is a difference between services as usual (SAU) plus SFBT offered by trained therapists working within a L&D team, and SAU alone, in reducing offending behaviours in 10–17-year-olds presenting at police custody.MethodsDesign: two-arm individually RCT with internal pilot and process evaluation.Participants: N = approximately 448 CYP aged 10–17 years presenting at one of three police custody suites in the area served by Lancashire and South Cumbria NHS Foundation Trust (LSCFT) who are referred to the L&D team. Participants will be recruited and allocated to intervention:control on a 1:1 basis. Interviews will be performed with 30–40 CYP in the intervention arm, 15 CYP in the control arm, up to 20 parents/guardians across both arms, up to 15 practitioners, and up to 10 site staff responsible for screening CYP for the trial.Intervention and control: Those allocated to the intervention will be offered SAU plus SFBT, and control participants will receive SAU only.Primary outcome: CYP frequency of offending behaviours assessed through the Self-Report Delinquency Measure (SRDM) at 12 months post-randomisation.Secondary outcomes: criminal offence data (national police database); emotional and behavioural difficulties (self-report and parent/guardian reported); gang affiliation (self-report).Process evaluation: evaluation of acceptability and experiences of the CYP, parents/guardians, site staff and practitioners; fidelity of SFBT delivery.DiscussionThis two-arm individually RCT will evaluate the effectiveness of SFBT in reducing offending behaviours in CYP presenting at police custody suites within the area served by LSCFT. Our process evaluation will assess the fidelity of delivery of SFBT, the factors affecting implementation, the acceptability of SFBT in CYP aged 10–17 years and recruitment and reach. We will also examine systems and structures for future delivery, therefore assessing overall scalability.Trial registrationClinicalTrials.gov ISRCTN14195235. Registered on June 16, 2023.

Comparing patient and community representation in the NHS in South Cumbria, 1974-82

The separation of Westmorland and Furness from Cumbria created the newest Healthwatch in England, launched on 18th October 2023. Squeezed between regulators, local authority scrutiny, and democratic organisational accountability, Healthwatch occupies an awkward position as both patient and consumer champion in the National Health Service (NHS). This awkwardness is amplified by Cumbria’s geography, which has distinct historical communities with differing service priorities to the north and south. Within the south, these are divided between west and east. This paper uses the creation of separate South West and South East Community Health Councils (CHCs) from 1974 until their unification in 1982 as South Cumbria to explore patient and community representation in the NHS.

P09 Lancashire and South Cumbria Critical Care Network Vancomycin Project

Abstract Background This project was a collaborative piece of work across a critical care network that included specialist advice from colleagues including aseptic/technically trained pharmacists and microbiology to optimize care for critical care patients in Lancashire and South Cumbria. We used several members of our workforce including pharmacists, nursing staff, microbiologists, rotational doctors and consultants to work towards a harmonized guideline. Methods During our initial meeting, we identified that different centres were using different glycopeptides and administering them differently: East Lancashire Hospitals (ELHT)—continuous vancomycin infusion; Blackpool Cardiac and Blackpool General—continuous vancomycin infusion, with no formal guideline in place but adopted from ELHT; Lancashire Teaching Hospitals—intermittent vancomycin infusions; and University Hospitals Morecambe Bay—teicoplanin is glycopeptide of choice. Our consultant microbiologist discussed the use of glycopeptides and what infections they are used for in critical care. The pharmacokinetics of vancomycin and the benefit of using a continuous infusion was also discussed. We decided to undertake a clinical audit of our vancomycin guidelines at ELHT to ensure that we had an evidence base to implement our guideline and provide assurance to the working group. We agreed to reconvene the working group after this audit was completed and after the concerns of colleagues had been addressed. Results and conclusions We presented the results of our audit and highlighted the opportunities harmonizing this guideline would provide. We discussed various scenarios such as stepping up from a ward protocol to a continuous infusion and the different methods of calculating creatinine clearance and if this would influence the first 24 h of the infusion. One comment was concerning the administration of vancomycin and the number of times nurses will be changing bags for patients requiring higher doses, i.e. the majority of patients would usually be on 3 g/day or more depending on concentrations. This would mean changing the bag more than twice a day; as much as there is a therapeutic benefit to continuous vancomycin infusions, considering the max. concentration for peripheral and central lines allows for larger volumes, it would be beneficial (except in fluid restricted cases) to have a slightly larger volume to reduce the number of bag changes and plastic consumption. We considered this comment and discussed it with our aseptic services lead pharmacist. We attended a meeting of the ICS Aseptics Working Party across Lancashire and South Cumbria. WE discussed the proposed guideline and requested that aseptic units across Lancashire and South Cumbria developed worksheets to manufacture 5 g in 600 mL or 10 g in 1.2 L for central use to stop breaking the line when changing a bag and reducing plastic consumption. We also met with critical care practice educators across the network to discuss how we can promote this guideline and ensure nursing staff and prescribers are aware of how to prescribe and administer continuous vancomycin infusions. One of our units noted that they have had a few incidents with incorrect concentrations of vancomycin being made up for patients. We developed an e-learning package to educate our workforce.

High-resolution definition and correlation of the Asbian–Brigantian boundary in northern England and the Scottish borders, using foraminiferal diversity and richness

Foraminiferal diversity and taxa richness from beds transitional between the Asbian and Brigantian substages (Middle Mississippian) show patterns of secular change which allow detailed inter-regional correlations to be established. Foraminifera from the Askrigg Block, Stainmore Trough, Alston Block, South Cumbria Shelf and Solway Basin show similar secular changes (foraminiferal trends, FTs), allowing correlation to be made with the basal Brigantian Stratotype at Janny Wood. Despite the absence of consistent microfossil first occurrence markers for the recognition of the base of the Brigantian, this horizon can be confidently recognized by means of foraminiferal trends. The FTs allow the precise location of the base of the correlated Brigantian in sections where this boundary was questioned or controversial in previous studies, as well as to amend the position of the foraminiferal zones and subzones during the late Asbian and basal Brigantian. This type of analysis when used in combination with foraminiferal zonations, emergent surfaces and lithological cyclicity, together, provide a robust means for high-resolution correlation. This methodology, provides the least uncertainty in sections that have been most densely sampled, whereas for less intensely sampled sections there is more correlation uncertainty.

Risk reduction intervention for raised blood pressure (REVERSE): protocol for a mixed-methods feasibility study

IntroductionAround 40% of adults have pre-hypertension (blood pressure between 120–139/80–89), meaning they are at increased risk of developing hypertension and other cardiovascular disease-related conditions. There are limited studies on the...

Problems of practising public health in Westmorland: John A. Guy as County Medical Officer, 1946-70

The Covid-19 pandemic constituted an unprecedented public health crisis for the National Health Service (NHS) since its inception in 1948. The crisis exposed the fragmented nature of health services, the centralisation of decision-making, and the weakened position of the Director of Public Health (DPH) to provide essential local leadership. This position reflects years of uncertainty along with a pyrrhic ‘return’ to local government for public health in 2013. Using the career of Westmorland County Medical Officer (CMO) John A. Guy, this paper offers a historical examination of the problems of practicing public health in local government until its absorption into reformed NHS structures in 1974. The case study reflects upon the shape of current community health services in Lancashire and South Cumbria, the ambiguous place of local public health in a nationalised service, and the ability of individual leadership to overcome structural constraints.

A reassessment of Arundian–Holkerian (Viséan) carbonates in South Cumbria, UK

Despite the importance of south Cumbrian sections for the Arundian–Holkerian (mid Viséan) boundary, beyond the stratotype proposed at Barker Scar in 1976, little else is known regionally about this boundary and its relationship to adjacent formations. We re-evaluate the Dalton Formation, making its upper and lower boundaries regionally more consistent and precisely-defined, in good quality outcrops with associated biostratigraphy. The Dalton Formation is formally divided into the Blackstone Member and overlying Raven's Member. Rich foraminiferal assemblages of the Cf4δ subzone are recognized in the Blackstone Member and the lower to mid Raven's Member in nine sections. The Cf4γ–Cf4δ boundary is recognized in the underlying Red Hill Limestone Formation in 3 sections. The upper part of the Raven's Member shows the first appearance of taxa assigned to the Cf5α and Cf5β subzones of the Holkerian in three of the sections. Bentonitic shales in the mid and upper-most part of the Raven's Member were evaluated for zircon and apatite geochronology, although only 4 out of 504 analyses yielded Carboniferous ages, indicating an almost entirely detrital source. This detritus was northerly or northeasterly-derived and predominantly from the Southern Uplands Terrane with subsidiary input from the Lewisian Complex or eastern Greenland sources. Petrographic analysis identified 13 microfacies indicating that the Dalton Formation represents the inner to outer part of a southward inclined shelf, in which east–west changes in microfacies were generated by synsedimentary faulting inherited from northwest–southeast aligned basement structures.

Medical education, workforce inequalities, and hierarchical regionalism: the University of Lancaster and the unrealised medical school, 1964-68

Part of the justification for the Lancashire and South Cumbria New Hospitals Programme (NHP) is that a modern estateis necessary to attract high quality medical students as an international centre of excellence. Workforce proposals produced by Healthier Lancashire and South Cumbria (LSC) align this with plans for improved recruitment and retention of doctors. These also relate to efforts at reducing reliance on locums and improving patient access to modern specialist services. This interrelationship between the demands of medical education, workforce inequalities, and the organisation of services has a long history which precedes the current NHP proposals. Indeed, it has been a structural feature of the region’s National Health Service (NHS) since 1948. Using the attempt by the newly founded University of Lancaster to obtain a medical school from 1964 to 1968, this paper demonstrates the compounding relationship between medical education, workforce inequalities and hierarchical regionalism as a process of ‘sedimented governance’ which shapes the limits of future horizons for current health services leaders and the NHP.

Foraminifers in the Holkerian Stratotype, regional substage in Britain: key taxa for the Viséan subdivision

Foraminiferal revision of the Holkerian Stratotype of Britain at Barker Scar, Holker Hall, south Cumbria, UK, allows the subdivision of the section into the Cf4δ, Cf5α and Cf5β subzones (the latter being further subdivided into lower Cf5β1 and upper Cf5β2 intervals). The base of Cf5α subzone at the base of bed C and base of Cf5β subzone from the middle part of bed C, occur at 14 m and 10.5 m, respectively, below the traditional basal boundary of the Holkerian at bed K. The lower boundaries of these foraminiferal subzones occur within the main interval affected by dolomitization in the section, which poses problems in defining precisely the bases for these subzones. Nevertheless, in spite of the dolomitization, a more or less continuous foraminiferal record allows a solid correlation of the base of the Cf5β with the preserved succession in the Livian Substage (defined in Belgium, but also used in France), and it is assumed that the base of this substage should correspond to the base of the Cf5α subzone. The base of the Cf5α subzone can be correlated with the base of the Russian Tulian Substage, since it contains many taxa in common with the Holkerian. However, further investigation is needed to establish other levels of correlation (e. g., base of the Cf5β subzone) higher up in the Holkerian substage. All of these problems suggest that the Holkerian, as it is currently recognised, and the Barker Scar stratotype section, in particular, should be reconsidered, and a new para-stratotype section, ideally devoid of dolomitization, should be located and investigated, in order to corroborate the occurrence of the Cf5α and Cf5β foraminiferal subzones compared to those recognised in the Barker Scar Stratotype. These modifications would allow identification of an apparent synchronous faunal event forming the basis of a future subdivision of the Visean.

Fibromyalgia Self-Management Programme – 12-Month new service evaluation

Purpose: A need was identified within the service for effective long-term management of patients with pre-existing or newly diagnosed fibromyalgia. These patients make up 25% of all referrals into the Pain Team. Fibromyalgia is a complex, long-term, multi-factorial health condition that has high healthcare and societal burden. Previously these patients have received inconsistent management which has been frustrating for patients and clinicians alike. The goal was to be able to create a clear, consistent and effective patient pathway within the Moving Well Service at Lancashire and South Cumbria NHS Foundation Trust and with external referrers. To educate and empower the patient and to improve the quality of their life whilst living with a long-term pain condition.

COVID-19 lockdown and recovery: a dental public health perspective from Lancashire and South Cumbria.

The COVID-19 pandemic has created novel barriers in providing and accessing all forms of healthcare, including dentistry. The national dental response during the first peak of the pandemic resulted in rapid changes in the provision of service, to safeguard providers and users of dental care.Such rapidly leveraged changes resulted in several issues in service delivery, requiring careful input from managers and commissioners within NHS England and Improvement, trainees and consultants in dental public health within Public Health England, and frontline dental teams working across the health and social care system. The local response from Lancashire and South Cumbria is outlined within this article.Teamwork, communication and reflexive, iterative learning from these groups ensured the delivery of an Urgent Dental Care service during the first lockdown of the pandemic.The impact of COVID-19 has enabled considerable learning which will inform future pandemic planning, alongside providing the opportunity to deliver meaningful change within NHS dentistry as the service continues to recover.

Lancashire and South Cumbria New Hospitals Programme: once in a generation or generation gap?

The Lancashire and South Cumbria New Hospitals Programme (NHP) contends that the region has a ‘once in a generation opportunity’ to transform hospitals for 1.8 million local people by 2030. The NHP is the central pillar of a regional strategy developed by Lancashire and South Cumbria Health and Care Partnership (HCP), one of 42 Integrated Care Systems (ICS) constituted by the Conservative Government’s National Health Service (NHS) reform outlined in Integration and Innovation as the building block of services. The strategy envisions organising services as a ‘network’ comprising existing hospital sites and services as spokes which centre around a new world-leading hospital hub. However, rather than being ‘once in a generation’, this model mirrors exactly the intentions of the original architects of the NHS. The NHP is, in fact, a generation gap. The 2030 vision is the realisation of the model which planners conceived in 1948. This paper shows how the original 1948 model emerged and how, ultimately, it was rejected. The rejection was not due to clinical or service failings in the model, but to the rivalries and jealousies of hospitals, services, and universities. This history has several lessons for current health services leaders and the NHP.

An audit on admission clerkings across Lancashire and South Cumbria NHS Foundation Trust (LSCFT)

AimsFollowing a Care Quality Commission (CQC) outcome showing that capacity assessments were not routinely completed on admission of patients we decided to complete an audit on current practice. We planned to review admission clerkings at Chorley Mental Health Inpatient Unit to assess quality, with the overall aim of putting measures in place to improve standards. We planned to make the results reflective of all psychiatry wards within Lancashire and South Cumbria NHS Foundation Trust (LSCFT) with the addition of a qualitative survey.BackgroundWe are aware the standard of clerkings can vary and affect patient care. CQC outcome showed that that capacity assessment was not routinely documented and consultants have stated that clinical impressions are rarely documented in junior doctor clerkings. This audit allowed us to objectively assess these observations. We believed the results may show common themes throughout psychiatric practice more generally.MethodThe gold standard was a 20 item list of expected components of a clerking, based on trust guidelines. A snapshot of current inpatients (n = 30) on 31/10/19 was taken. An Excel sheet was used for information gathering. Data were analysed and graphs created. A qualitative questionnaire on current practice was sent to trainees (n = 8) on different sites for an overview of practice across LSCFT. Therefore, a mixed-methods model was employed.ResultItems with the highest completion included clerking within 6 hours, face-to-face review with consultant completed within a week and current medication documentation. The items with the lowest completion included clinical impression documentation, bloods completed within 24 hours and documentation of capacity assessment and smoking/substances history. Common factors between clerkings with fewer completed items included poor patient engagement and patient transfer from another ward.Qualitative survey (n = 8) showed that junior doctors across the health board are not using uniform methods for capacity documentation or an official checklist for clerking.ConclusionWe concluded that the low rate of capacity assessment completion was an important finding due to legal implications, and that there should be a uniform place for documentation of this. Physical health consequences of other missing components were explored. We will introduce standardisation of capacity assessment documentation and use of a clerking checklist, before re-auditing. The results were presented at local teaching and recommendations sent to Site Tutors for inclusion in local inductions.

Bypassing the nearest emergency department for a more distant neurosurgical centre in traumatic brain injury patients

Background and objective Major trauma triage within regional trauma networks (RTN) select patients with suspected TBI for bypass to specialist neuroscience centres (SNC), expediting neurosurgical care but may delay resuscitation. This comparative effectiveness study assessed the impact of this strategy on the risk adjusted hospital survival rates of patients confirmed to have intracranial injury on brain computed tomography (CT) scan. Method A retrospective cohort study was conducted using Trauma Audit and Research Network trauma registry data. Adult patients with a TBI on CT scan were included if they presented between June 2015 to February 2016 to SNCs or non-specialist acute hospitals (NSAH) in the North of England (South Cumbria, Lancashire and the North East Region). Patients were identified as having bypassed a nearer NSAH emergency department (ED) to a SNC using google maps. Their standardised excess survival rate was compared to TBI patients who received primary treatment at a NSAH. A multivariate logistic regression model predicting 30-day survival after TBI (Ps14n) 1 was used to adjust for variation in casemix between cohorts. Study design and results 355 patients met the study inclusion criteria, with 89/355 (25%) of TBI patients bypassing a nearer NSAH to a SNC, and 266/355 (75%) receiving primary treatment at an NSAH. The median severity of intracranial injury was equivalent (median Head Abbreviated Injury Scale 4 (IQR 4–5) in each group. There was no statistically significant difference in the standardised excess survival rate between the two cohorts; +6.15% for bypass (95% CI −1.24% to +13.55%) versus −1.12% for non-bypass (95% CI −4.51% to +2.25%). Conclusion and future research No statistically significant survival benefit was identified for TBI patients who bypassed the nearest ED to attend a SNC compared to those receiving treatment at the nearest NSAH, however a clinically significant 7% excess survival rate merits a larger study.

Meaningful practices: The contemporary relevance of traditional making for sustainable material futures

Abstract This article explores the relationship between design for sustainability and traditional making practices. It presents results from key informant interviews and observational research into traditional hand making of functional goods in Santa Fe in the United States, Jingdezhen, China, various locations in New South Wales, Australia and Cumbria, United Kingdom. We find that such goods fall into three main categories, primarily utilitarian, symbolic and aesthetic. These practices are discussed in terms of their contemporary relevance, potential futures and relationship to current understandings of sustainability. More specifically, they are considered against the four elements of the Quadruple Bottom Line of Design for Sustainability (), a rigorous interpretation extended from the philosophy of , which comprises: practical meaning including environmental impacts; social meaning; personal meaning; and economic means. The originality of this research lies in the development of new arguments and insights with regard to the complex issues of design for sustainability and traditional making practices. Significantly, we find that many of these practices are intellectually consistent with broad, contemporary understandings of design for sustainability. However, we also find that it is often not easy to reconcile these practices with modern consumer culture. Our research shows that pursuing these practices part-time for their own sake, rather than for primarily commercial reasons can often facilitate the pursuit of excellence and the continuation of cultural traditions.