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The coronavirus disease 2019 pandemic resulted in the cessation of elective surgery. The continued provision of complex head and neck cancer surgery was extremely variable, with some UK centres not performing any cancer surgery. During the pandemic, Guy's and St Thomas’ NHS Foundation Trust received high numbers of coronavirus disease 2019 admissions. This paper presents our experience of elective complex major head and neck cancer surgery throughout the pandemic.
A head and neck cancer surgery hub was set up that provided a co-ordinated managed care pathway for cancer patients during the pandemic; the Guy's Cancer Centre provided a separate, self-enclosed coronavirus-free environment within the hospital campus.
Sixty-nine head and neck cancer patients were operated on in two months, and 13 patients had a microvascular free tissue transfer. Nosocomial infection with coronavirus disease 2019 was detected in two cases (3 per cent), neither required critical care unit admission. Both patients made a complete recovery and were discharged home. There were no deaths.
Performing major head and neck surgery, including free flap surgery, is possible during the pandemic; however, significant changes to conventional practice are required to achieve desirable patient outcomes.
Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care.
The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions.
We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures.
We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.
Lewy body dementia, consisting of both dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD), is considerably under-recognised clinically compared with its frequency in autopsy series.
This study investigated the clinical diagnostic pathways of patients with Lewy body dementia to assess if difficulties in diagnosis may be contributing to these differences.
We reviewed the medical notes of 74 people with DLB and 72 with non-DLB dementia matched for age, gender and cognitive performance, together with 38 people with PDD and 35 with Parkinson's disease, matched for age and gender, from two geographically distinct UK regions.
The cases of individuals with DLB took longer to reach a final diagnosis (1.2 v. 0.6 years, P = 0.017), underwent more scans (1.7 v. 1.2, P = 0.002) and had more alternative prior diagnoses (0.8 v. 0.4, P = 0.002), than the cases of those with non-DLB dementia. Individuals diagnosed in one region of the UK had significantly more core features (2.1 v. 1.5, P = 0.007) than those in the other region, and were less likely to have dopamine transporter imaging (P < 0.001). For patients with PDD, more than 1.4 years prior to receiving a dementia diagnosis: 46% (12 of 26) had documented impaired activities of daily living because of cognitive impairment, 57% (16 of 28) had cognitive impairment in multiple domains, with 38% (6 of 16) having both, and 39% (9 of 23) already receiving anti-dementia drugs.
Our results show the pathway to diagnosis of DLB is longer and more complex than for non-DLB dementia. There were also marked differences between regions in the thresholds clinicians adopt for diagnosing DLB and also in the use of dopamine transporter imaging. For PDD, a diagnosis of dementia was delayed well beyond symptom onset and even treatment.
Cognitive Behaviour Therapy (CBT) is an effective psychological intervention for children and young people with anxiety disorders (James et al, 2013). This has led to interest in whether CBT programmes can be widely provided in schools to prevent or ameliorate anxiety symptoms in children.
Results from school based anxiety prevention trials are encouraging (Neil & Christensen 2009; Fisak, Richard, Mann 2011). Before the widespread use of school based preventive programmes can be advocated methodologically robust evaluations are required to demonstrate that they are effective when transported to everyday settings.
To undertake a pragmatic randomised controlled trial (RCT) of a universal school based CBT programme (Friends for Life) for children aged 9-10 years of age .
Three arm RCT comparing Friends for Life delivered by trained health or school leaders with usual school provision (Stallard et al,2012). Primary outcome the Revised Child Anxiety and Depression Scale (RCADS) at 12 month follow-up.
A total of 1362 children from 40 schools participated with 1257 (92%) being re-assessed at follow-up. There was a difference in adjusted mean child report RCADS scores for health-led versus school-led FRIENDS (−3.94, 95%CI −6.41 to −1.47) and health-led FRIENDS versus usual school provision (2.66, 95%CI −5.22 to −0.09). Health-led CBT resulted in greater reductions in symptoms of anxiety than the other two arms (Stallard et al 2014),
Our pragmatic trial demonstrates that universally delivered anxiety prevention programmes can be effective when transported into schools. However, effectiveness varies depending upon who delivers them.
In 2015, Guglielmi and Badia discussed optimal strategies in a particular type of service system with two strategic servers. In their setup, each server can be either active or inactive and an active server can be requested to transmit a sequence of packets. The servers have varying probabilities of successfully transmitting when they are active, and both servers receive a unit reward if the sequence of packets is transmitted successfully. Guglielmi and Badia provided an analysis of optimal strategies in four scenarios: where each server does not know the other’s successful transmission probability; one of the two servers is always inactive; each server knows the other’s successful transmission probability and they are willing to cooperate.
Unfortunately, the analysis by Guglielmi and Badia contained some errors. In this paper we correct these errors. We discuss three cases where both servers (I) communicate and cooperate; (II) neither communicate nor cooperate; (III) communicate but do not cooperate. In particular, we obtain the unique Nash equilibrium strategy in Case II through a Bayesian game formulation, and demonstrate that there is a region in the parameter space where there are multiple Nash equilibria in Case III. We also quantify the value of communication or cooperation by comparing the social welfare in the three cases, and propose possible regulations to make the Nash equilibrium strategy the socially optimal strategy for both Cases II and III.
The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural–geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.
We have observed the G23 field of the Galaxy AndMass Assembly (GAMA) survey using the Australian Square Kilometre Array Pathfinder (ASKAP) in its commissioning phase to validate the performance of the telescope and to characterise the detected galaxy populations. This observation covers ~48 deg2 with synthesised beam of 32.7 arcsec by 17.8 arcsec at 936MHz, and ~39 deg2 with synthesised beam of 15.8 arcsec by 12.0 arcsec at 1320MHz. At both frequencies, the root-mean-square (r.m.s.) noise is ~0.1 mJy/beam. We combine these radio observations with the GAMA galaxy data, which includes spectroscopy of galaxies that are i-band selected with a magnitude limit of 19.2. Wide-field Infrared Survey Explorer (WISE) infrared (IR) photometry is used to determine which galaxies host an active galactic nucleus (AGN). In properties including source counts, mass distributions, and IR versus radio luminosity relation, the ASKAP-detected radio sources behave as expected. Radio galaxies have higher stellar mass and luminosity in IR, optical, and UV than other galaxies. We apply optical and IR AGN diagnostics and find that they disagree for ~30% of the galaxies in our sample. We suggest possible causes for the disagreement. Some cases can be explained by optical extinction of the AGN, but for more than half of the cases we do not find a clear explanation. Radio sources aremore likely (~6%) to have an AGN than radio quiet galaxies (~1%), but the majority of AGN are not detected in radio at this sensitivity.
Little is known about the implications of accessing an outdoor range for broiler chicken welfare, particularly in relation to the distance ranged from the shed. Therefore, we monitored individual ranging behaviour of commercial free-range broiler chickens and identified relationships with welfare indicators. The individual ranging behaviour of 305 mixed-sex Ross 308 broiler chickens was tracked on a commercial farm from the second day of range access to slaughter age (from 16 to 42 days of age) by radio frequency identification (RFID) technology. The radio frequency identification antennas were placed at pop-holes and on the range at 2.7 and 11.2 m from the home shed to determine the total number of range visits and the distance ranged from the shed. Chickens were categorised into close-ranging (CR) or distant-ranging (DR) categories based on the frequency of visits less than or greater than 2.7 m from the home shed, respectively. Half of the tracked chickens (n=153) were weighed at 7 days of age, and from 14 days of age their body weight, foot pad dermatitis (FPD), hock burn (HB) and gait scores were assessed weekly. The remaining tracked chickens (n=152) were assessed for fear and stress responses before (12 days of age) and after range access was provided (45 days of age) by quantifying their plasma corticosterone response to capture and 12 min confinement in a transport crate followed by behavioural fear responses to a tonic immobility (TI) test. Distant-ranging chickens could be predicted based on lighter BW at 7 and 14 days of age (P=0.05), that is before range access was first provided. After range access was provided, DR chickens weighed less every week (P=0.001), had better gait scores (P=0.01) and reduced corticosterone response to handling and confinement (P<0.05) compared to CR chickens. Longer and more frequent range visits were correlated with the number of visits further from the shed (P<0.01); hence distant ranging was correlated with the amount of range access, and consequently the relationships between ranging frequency, duration and distance were strong. These relationships indicate that longer, more frequent and greater ranging from the home shed was associated with improved welfare. Further research is required to identify whether these relationships between ranging behaviour and welfare are causal.
Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
Excessive abdominal fat might be associated with more severe metabolic disorders in Holstein cows. Our hypothesis was that there are genetic differences between cows with low and high abdominal fat deposition and a normal cover of subcutaneous adipose tissue. The objective of this study was to assess the genetic basis for variation in visceral adiposity in US Holstein cows. The study included adult Holstein cows sampled from a slaughterhouse (Green Bay, WI, USA) during September 2016. Only animals with a body condition score between 2.75 and 3.25 were considered. The extent of omental fat at the level of the insertion of the lesser omentum over the pylorus area was assessed. A group of 100 Holstein cows with an omental fold <5 mm in thickness and minimum fat deposition throughout the entire omentum, and the second group of 100 cows with an omental fold ⩾20 mm in thickness and with a marked fat deposition observed throughout the entire omentum were sampled. A small piece of muscle from the neck was collected from each cow into a sterile container for DNA extraction. Samples were submitted to a commercial laboratory for interrogation of genome-wide genomic variation using the Illumina BovineHD Beadchip. Genome-Wide association analysis was performed to test potential associations between fat deposition and genomic variation. A univariate mixed linear model analysis was performed using genome-wide efficient mixed model association to identify single nucleotide polymorphisms (SNPs) significantly associated with variation in a visceral fat deposition. The chip heritability was 0.686 and the estimated additive genetic and residual variance components were 0.427 and 0.074, respectively. In total, 11 SNPs defining four quantitative trait locus (QTL) regions were found to be significantly associated with visceral fat deposition (P<0.00001). Among them, two of the QTL were detected with four and five significantly associated SNPs, respectively; whereas, the QTLs detected on BTA12 and BTA19 were each detected with only one significantly associated SNP. No enriched gene ontology terms were found within the gene networks harboring these genes when supplied to DAVID using either the Bos taurus or human gene ontology databases. We conclude that excessive omental fat in Holstein cows with similar body condition scores is not caused by a single Mendelian locus and that the trait appears to be at least moderately heritable; consequently, selection to reduce excessive omental fat is potentially possible, but would require the generation of predicted transmitting abilities from larger and random samples of Holstein cattle.
Wave loading on marine structures is the major external force to be considered in the design of such structures. The accurate prediction of the nonlinear high-order components of the wave loading has been an unresolved challenging problem. In this paper, the nonlinear harmonic components of hydrodynamic forces on a bottom-mounted vertical cylinder are investigated experimentally. A large number of experiments were conducted in the Danish Hydraulic Institute shallow water wave basin on the cylinder, both on a flat bed and a sloping bed, as part of a European collaborative research project. High-quality data sets for focused wave groups have been collected for a wide range of wave conditions. The high-order harmonic force components are separated by applying the ‘phase-inversion’ method to the measured force time histories for a crest focused wave group and the same wave group inverted. This separation method is found to work well even for locally violent nearly-breaking waves formed from bidirectional wave pairs. It is also found that the
th-harmonic force scales with the
th power of the envelope of both the linear undisturbed free-surface elevation and the linear force component in both time variation and amplitude. This allows estimation of the higher-order harmonic shapes and time histories from knowledge of the linear component alone. The experiments also show that the harmonic structure of the wave loading on the cylinder is virtually unaltered by the introduction of a sloping bed, depending only on the local wave properties at the cylinder. Furthermore, our new experimental results reveal that for certain wave cases the linear loading is actually less than 40 % of the total wave loading and the high-order harmonics contribute more than 60 % of the loading. The significance of this striking new result is that it reveals the importance of high-order nonlinear wave loading on offshore structures and means that such loading should be considered in their design.
An unexpected increase in gastroenteritis cases was reported by healthcare workers on the KwaZulu-Natal Coast, South Africa, January 2017 with >600 cases seen over a 3-week period. A case–control study was conducted to identify the source and risk factors associated with the outbreak so as to recommend control and prevention measures. Record review identified cases and controls and structured-telephonic interviews were conducted to obtain exposure history. Stool specimens were collected from 20 cases along with environmental samples and both screened for enteric pathogens. A total of 126 cases and 62 controls were included in the analysis. The odds of developing gastroenteritis were 6.0 times greater among holiday makers than residents (95% confidence interval (CI) 2.0–17.7). Swimming in the lagoon increased the odds of developing gastroenteritis by 3.3 times (95% CI 1.06–10.38). Lagoon water samples tested positive for norovirus (NoV) GI.6, GII.3 and GII.6, astrovirus and rotavirus. Eleven (55%) stool specimens were positive for NoV with eight genotyped as GI.1 (n = 2), GI.5 (n = 3), GI.6 (n = 2), and GI.7 (n = 1). A reported sewage contamination event impacting the lagoon was the likely source with person-to-person spread perpetuating the outbreak. Restriction to swimming in the lagoon was apparently ineffective at preventing the outbreak, possibly due to inadequate enforcement, communication and signage strategies.
Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) represent a disease continuum with common genetic causes and molecular pathology. We recently identified mutations in the T-cell restricted intracellular antigen-1 (TIA1) protein as a cause of ALS +/− FTD. TIA1 is an RNA-binding protein containing a low complexity domain (LCD) that promotes the assembly of membrane-less organelles, such as stress granules (SG). Whole exome sequencing of two family members with fALS/FTD revealed a novel missense mutation in the TIA1 LCD (P362L). Subsequent screening identified five more TIA1 mutations in six additional ALS patients, but none in controls. All mutation carriers presented with weakness, behavioral abnormalities or language impairments and had a final diagnosis of ALS +/− FTD. Autopsy on five TIA1 mutation carriers showed widespread neurodegeneration with TDP-43 pathology. Round eosinophilic inclusions in lower motor neurons were a consistent feature. Cellular assays revealed abnormal SG dynamics in the presence of TIA1 mutations. In summary, missense mutations in the LCD of TIA1 are a newly recognized cause of ALS/FTD with TDP-43 pathology and strengthen the role of RNA metabolism in the pathogenesis in this disease.
We performed a new series of measurements on samples that were part of early measurements on radiocarbon (14C) dating made in 1948–1949. Our results show generally good agreement to the data published in 1949–1951, despite vast changes in technology, with only two exceptions where there was a discrepancy in the original studies. Our new measurements give calibrated ages that overlap with the known ages. We dated several samples at four different laboratories, and so we were also able to make a small intercomparison at the same time. In addition, new measurements on samples from other Egyptian materials used by Libby and co-workers were made at UC Irvine. Samples of tree rings used in the original studies (from Broken Flute Cave and Centennial Stump) were obtained from the University of Arizona Laboratory of Tree-Ring Research archive and remeasured. New data were compared to the original studies and other records.
The Taipan galaxy survey (hereafter simply ‘Taipan’) is a multi-object spectroscopic survey starting in 2017 that will cover 2π steradians over the southern sky (δ ≲ 10°, |b| ≳ 10°), and obtain optical spectra for about two million galaxies out to z < 0.4. Taipan will use the newly refurbished 1.2-m UK Schmidt Telescope at Siding Spring Observatory with the new TAIPAN instrument, which includes an innovative ‘Starbugs’ positioning system capable of rapidly and simultaneously deploying up to 150 spectroscopic fibres (and up to 300 with a proposed upgrade) over the 6° diameter focal plane, and a purpose-built spectrograph operating in the range from 370 to 870 nm with resolving power R ≳ 2000. The main scientific goals of Taipan are (i) to measure the distance scale of the Universe (primarily governed by the local expansion rate, H0) to 1% precision, and the growth rate of structure to 5%; (ii) to make the most extensive map yet constructed of the total mass distribution and motions in the local Universe, using peculiar velocities based on improved Fundamental Plane distances, which will enable sensitive tests of gravitational physics; and (iii) to deliver a legacy sample of low-redshift galaxies as a unique laboratory for studying galaxy evolution as a function of dark matter halo and stellar mass and environment. The final survey, which will be completed within 5 yrs, will consist of a complete magnitude-limited sample (i ⩽ 17) of about 1.2 × 106 galaxies supplemented by an extension to higher redshifts and fainter magnitudes (i ⩽ 18.1) of a luminous red galaxy sample of about 0.8 × 106 galaxies. Observations and data processing will be carried out remotely and in a fully automated way, using a purpose-built automated ‘virtual observer’ software and an automated data reduction pipeline. The Taipan survey is deliberately designed to maximise its legacy value by complementing and enhancing current and planned surveys of the southern sky at wavelengths from the optical to the radio; it will become the primary redshift and optical spectroscopic reference catalogue for the local extragalactic Universe in the southern sky for the coming decade.
Precision agriculture (PA) may improve the sustainability of Chinese agriculture. Ten experts were interviewed and 34 farm workers surveyed regarding their understanding, attitudes and perceptions towards PA. PA technologies were considered inaccessible, unsuitable and unnecessary for smaller farms. High cost, lack of perceived benefits, and skills and capability required to adopt PA represented barriers to adoption. Financial incentives/subsidies, the need for tangible benefits and tailored solutions to be demonstrated to farmers, and agronomic and peer support were desired. Future research should further explore PA with Chinese stakeholders and end-users in China, to inform future socio-technological developments.
Background: Patients who require hospitalization for a mild or moderate traumatic brain injury (TBI) are often discharged home with uncertainty around their full recovery. This study examines the frequency and severity of common post-TBI symptoms, as assessed by the Rivermead Post-Concussion Symptoms Questionnaire (RPCQ). Methods: All adult TBI inpatients discharged home from the Neurosurgery service were interviewed by phone at two weeks by a rehab-based nurse practitioner. RPCQ components (cognitive, emotional, and somatic) were analyzed; findings and management recommendations were communicated to family practitioners and the treating neurosurgeon. Results: In 46 patients, cognitive symptoms were present in 52%, 91% had somatic, and 100% had emotional symptoms. Fatigue was the most common symptom (67%). Double vision was the least common symptom (4%). Recommendations for managing symptoms, return to work, and need for formal clinical assessment were provided for 37% of cases. Conclusions: All patients admitted to neurosurgery with mild or moderate TBI had symptoms at two weeks. The RPCQ is a low-cost structured evaluative tool which highlights needs and provides guidance for patients and care-givers; it also seems effective in identifying those who may require formal clinical assessment.