Jonathan P Shepherd CBE FRCS FFPH FRCPsych FMedSci FLSW is a Welsh surgeon, criminologist and professor at Cardiff University's Crime and Security Research Institute which he co-founded in 2015. He also founded the University's Violence Research Group. [1] [2] He has initiated UK public service reforms and other measures to strengthen the evidence foundations on which these services are based. These include new professional bodies for policing, probation and teaching; the UK What Works Centres and What Works Council; new university police research centres in England and Wales; and a new police research funding scheme. [3]
Shepherd's research career began as a research fellow in the Nuffield Department of Surgery at Oxford University (1978–79) where, leading to his Oxford MSc, he studied wound healing after cryosurgery under the supervision of Rodney Dawber. He discovered that the reasons low temperature injury resulted in little or no scarring was the preservation of the fibrous architecture of the dermis and resistance to low temperatures of fibroblasts. [4]
During a UK government Overseas Development Administration (Now DfID) secondment as a surgeon to the Ahmadu Bello University, Kaduna, Nigeria, he studied links between Epstein Barr Virus (EBV) and the jaw tumour prevalent in sub Saharan Africa, ameloblastoma. This research was inspired by the work of Denis Burkett who had found a causal link between this virus and lymphoma. Shepherd found no links with ameloblastoma apart from in immunocompromised patients. [5] After returning to his substantive surgical training post in Leeds in 1981 he donated the remaining serum samples from his research in Nigeria to Harald zur Hausen for his ongoing research on Human Papilloma Virus – work which would win zur Hausen the Nobel Prize for Physiology or Medicine.
Shepherd's surgical experiences in West Yorkshire (1980–3) brought about an interest in behavioural science and epidemiology. He observed that the miners' strikes in the Yorkshire Coalfield led to more people being injured in violence, and that a few pubs seemed to be the locations of hugely disproportionate numbers of violent incidents.
Following his appointment as senior lecturer and consultant oral and maxillofacial surgeon at Bristol University and the United Bristol Hospitals he completed his PhD, Assault; Characteristics of Injuries and Injured, awarded in 1988, supervised by Phyllida Parsloe and Crispian Scully. In these studies of consecutive patients injured in violence who attended the emergency department of the Bristol Royal Infirmary, Shepherd discovered that three-quarters of these incidents were not known to the police; [6] that these patients went through a bereavement process; [7] that their depression and anxiety levels remained much higher than in patients with similar injures but sustained in accidents rather than violence; [8] and that a previously unrecognised weapon type, glasses, had been used to inflict injury in 10% of cases. [9] These and other findings are the foundations of all Shepherd's research, policy development and impact on violence which followed.
After appointment as professor of oral and maxillofacial surgery and head of the department of oral surgery, medicine and pathology at the University of Wales College of Medicine (part of Cardiff University since 2004), Shepherd created the Violence Research Group and the Clinical Decisions Research Group.
Shepherd established the Clinical Decisions Research Group expressly to investigate decisions about wisdom teeth, the surgical removal of which, in the early 1990s, was one of only four surgical operations common to both top ten lists of UK in-patient and day case procedures. Working with Mark Brickley, he discovered that decisions to operate were being made almost at random; [10] that complication rates were far higher if these teeth were removed under general anaesthesia compared with local anaesthesia; [11] and that prophylactic removal resulted in worse outcomes for patients and less cost benefit than removal only after these teeth had become diseased. [12] [13] These findings were instrumental in the mid-1990s in the substantial switch away from prophylactic surgery and removal under general anaesthesia on an in-patient basis, and also prompted the first guidelines and technology appraisal published by the then National Institute for Clinical Excellence (NICE) in 2000.
Prompted by his PhD and subsequent confirmation that police ascertain, at most, only 50% of violence which results in emergency treatment, and by public fears of violence, Shepherd, with Vaseekaran Sivarajasingam, founded the National Violence Surveillance Network (NVSN) of 120 hospital emergency departments across England and Wales. Since 2000, NVSN has published annual reports on violence. These demonstrate falling violence trends almost identical to those derived from the Office of National Statistics' Crime Survey of England and Wales, and attest to the unreliability of police records as a measure of violence. This new, hospital perspective, is of violence affecting all age groups and both genders and has done much to clarify violence trends and risks. [14]
Working with Jonathan Bisson, Shepherd, studied post-traumatic stress and concluded that there was evidence of traumatic stress disorder in around 30% of people injured in violence and that a diagnosis of PTSD could be predicted on the basis of patients' acute stress reactions identified by junior surgeons in the emergency department when patients first attend. [15] They then carried out a randomised trial of cognitive behavioural therapy and discovered that this could prevent the onset of PTSD symptoms. [16] These findings prompted Shepherd and Bisson to start a victim support clinic in the emergency department, as Shepherd had done in the Bristol Royal Infirmary. But evaluation showed little uptake, and a PTSD service was set up with third sector Victim Support services referring patients through primary care instead. [17] Based on their findings, Shepherd and Bisson designed a framework for the management of the mental health impact of violence, published by the Royal College of Psychiatrists. [18]
Having discovered that many people are injured in violence where glasses are used as weapons and that glass fragmentation rather than whole glasses were the problem, Shepherd set about finding out which glass types were most frequently involved, and how they stood up to laboratory impact testing. A national survey showed that straight sided pint glasses (noniks) were used in three-quarters of these incidents [19] and, subsequently, that one particular pint glass product was much more impact resistant than all the rest. [20] Prompted by this finding Shepherd led a randomised trial of tempered pint glasses in pubs in the West Midlands and South Wales and concluded that tougher glasses were associated with a 60% lower injury risk compared with less impact resistant glasses. [21] In turn this prompted Shepherd to lead the Face of Wales campaign, supported by the Welsh Development Agency, for a switch to tempered glassware in the UK pub trade – a campaign which resulted in this change in the late 1990s, a change which Home Office statisticians estimated was associated with a reduction in glass assaults of around 47,000/year. [22]
Shepherd's discovery that the police were unaware of 50–75% of violence which results in hospital treatment – a finding since replicated in every Western country where this overlap has been studied – prompted him to hypothesise that emergency departments are sources of unique information which could be used to prevent violence more effectively than is possible using police intelligence alone. To test this idea, in 1996 he convened the Cardiff Violence Prevention Group (now Board). This group was a prototype Community Safety Partnership and was replicated by law across Britain in 1998. First, methods of collection in emergency departments of data on precise violence location, weapon, time and day and assailants were compared; electronic data capture by receptionists (termed registrars in the United States) proved most effective and sustainable. [23] Second, the use of these hospital data was trialled in the context of violence in pubs and nightclubs – and found to result in significantly greater prevention. [24] Third, a controlled experiment in 14 similar cities was carried out with collaborators at the Centres for Disease Control and Prevention (CDC) in the U.S; violence levels in the intervention city fell 42% more than in control cities. [25] Shepherd has attributed this decline in part to better targeted policing and an increased use of street CCTV. Fourth, an economic analysis concluded that cost benefit ratios were highly favourable; in Cardiff alone in 2007, savings were £6.9M compared with estimated costs in similar cities. [26] This evidence is central to the UK government's impact assessment of new public health measures which led to the decision to mandate multiagency violence prevention; this new law was announced in the December 2019 Queen's Speech to the UK parliament. [27]
By 2007, violent incidents in Cardiff had declined by 40%. [28] In 2009, the Cardiff Violence Prevention Group received the Queen's Anniversary Prize. [29]
This "Cardiff Model" was first implemented elsewhere in the UK in the late 1990s, starting in south east England, Merseyside and in Glasgow. In 2008, it was included in the UK government's alcohol strategy and in 2010 it was included in the new coalition government's programme. [30] By 2014 more than 60% of emergency departments were collecting and sharing Cardiff Model data and in 2016 this became mandatory in England. In 2017, the data were included in the new Emergency Care Data Set. [31] The Model has been endorsed by the World Health Organization, [32] adopted by the Centers for Disease Control and Prevention (CDC) for implementation in the United States, [33] and implemented in cities in the United States, Australia, South Africa and the Netherlands. [34] [35]
Shepherd summarised the public health effectiveness of policing and criminal justice systems in an article in the Lancet. [36]
After discovering a distinctive pattern of illness and injury among people injured in violence, Shepherd coined the term DATES Syndrome (Drug Abuse, Assault, Trauma and Elective Surgery). [37] He then led a series of studies with the Cambridge criminologist David Farrington of links between offending and health, using data from the longitudinal Cambridge Study of Delinquent Development (CSDD). Discoveries from this research include relatively good health among young offenders until their mid-20s; strong links between childhood impulsivity, adolescent offending and injury; and that early death and disability by age 48 which they discovered, is linked with conviction between ages 10–18 and antisocial behaviour at age 8–10. [38]
Shepherd's finding that consumption of more than eight units of alcohol in a drinking session substantially increased the risk of injury in violence prompted him and his colleagues to investigate links between alcohol prices and violence, and the effectiveness of brief motivational advice to reduce risky consumption. Of all the drivers of injury in violence they studied, low alcohol price was found to be the most powerful. [39] In six randomised trials, Shepherd and his colleagues found that this advice was effective for at least a year when it was given to alcohol abusers on probation, in trauma clinics and in primary care, but not effective when it was given to offenders in magistrates' courts or to patients in emergency departments – when offenders' and patients' thoughts were dominated by their conviction or injuries or clouded by their intoxication. [40]
To incorporate this effective advice into national health services, Shepherd, collaborating with Welsh Government, led two knowledge transfer projects. With Craig and Sarah Jones, he developed brief advice training courses, local collaborations across Wales, a training team, and social media support under the new "Brief Advice works, Have a Word!" brand. [41] By 2017, 18,000 practitioners had been trained, the Have a Word package sold to Public Health England, and the scheme implemented in the armed forces by the Ministry of Defence. [42]
Shepherd's study of controlled trials across public services showed that there had been an exponential increase of these rigorous evaluations in healthcare, but not in other sectors such as education and policing. [43] Shepherd concluded that this disparity reflected a lack of organisations which publish evidence-based guidelines, such as the National Institute for Health and Care Excellence, in these other sectors and that these organisations should be replicated in other public services and a mechanism created for sectors to learn from each other about evidence. [43]
He campaigned for these changes through Sir Adrian Smith at the UK Department for Business and Skills and Sir Michael Bichard, director of the Institute for Government. As a result, the Institute for Government ran a conference where these proposals found favour. This was the genesis of the new "What Works Centres" (NICE equivalents across six service sectors) and the "What Works Council" supported by the Cabinet Office and the Economic and Social Research Council. [44]
Next, supported by the Cabinet Office What Works team, Shepherd investigated what he first defined as the "evidence ecosystem", in which evidence first has to be generated, then synthesised, and then adopted and used in practice and policy. This needs to be a dynamic process Shepherd concluded – evidence demand is needed as well as supply. [45] The report's recommendations for a research funding scheme for policing, for a social policy trials unit and for a professional body for teachers were adopted in the form of the new Police Knowledge Fund, the Government Trials advisory Panel and the Chartered College of Teaching. [45]
Shepherd also proposed a national College of Policing – a medical Royal College equivalent. [46] This concept was adopted by the Home Office and the new college launched in 2013. Shepherd also proposed and worked for a similar standard setting institution for probation. [47] The Probation Institute was launched by the president of the Supreme Court, Lord Neuberger, at an event hosted by Shepherd at the Royal College of Surgeons in 2014. [48]
Shepherd was nominated by the Royal College of Surgeons to explain to teachers' leaders the value and functions of a medical Royal College and how these might be applied to form a standard setting professional body for teachers and teaching. After serving on the Commission which produced a blueprint for a new College of Teaching [49] and Shepherd's appointment as a founder College trustee, the new Chartered College was founded in 2016. [50]
To improve effectiveness and cost benefit of public services on the basis of reliable evidence, Shepherd also convened two evidence summits, at the Royal College of Surgeons in 2012, and at the Institution of Civil Engineers in 2013. [51] [52]
Shepherd wrote The Declaration on Evidence which was agreed by the UK medical Royal Colleges, the College of Policing and the Chartered College of Teaching - institutions with a major influence on the professional lives of over a million practitioners. This declaration was signed by the leaders of these bodies at the Royal Society in November 2017 at an event hosted by Shepherd and the Alliance for Useful Evidence and chaired by the former Cabinet Secretary Lord O'Donnell. [53] [54]
Realising the need for incentives for public health academics to translate their research into practice, Shepherd initiated and sourced funding for a new professorship which he titled the Bazalgette Chair for Research Translation in honour of Sir Joseph Bazalgette who famously engineered the sewers which helped eradicate cholera in 19th Century London and in other cities. The, now annual, Bazalgette professorship was first awarded by the Faculty of Public Health in 2019. [55] Prompted by the rapid, perplexing expansion across sectors of evidence production, synthesis and translation into guidance, and the economic impact of the COVID-19 pandemic, Shepherd wrote the 2020 report Evidence and Guidance for Better Public Services. [56] Summarised in the science journal Nature [57] and in Civil Service World, [58] report recommendations include standardisation and proportionate regulation of the evidence ecosystem.
Working with Michael Harrison, Shepherd mapped head and face injuries sustained by cyclists, [59] and discovered that cycle helmet designs conferred little face protection. [60] Their published recommendation that helmet design should change to incorporate this protection was taken up a Formula One engineer, Matthew Jeffreys, who designed and patented the Face Saver helmet and worked with the Formula One driver, David Coulthard, to manufacture and market this new product.
Coulthard exhibited the prototype at the 2002 UK Motor Show. This new design was instrumental in bringing about a new generation of helmet designs, especially in mountain and other sports cycling disciplines.
Shepherd was elected a fellow of the Academy of Medical Sciences in 2002. [61] Shepherd is a member of the Home Office Science Advisory Council. [62] In 2007, he was appointed a Commander of the Most Excellent Order of the British Empire for his services to justice and healthcare. [63] He was one of two recipients of the 2008 Stockholm Prize in Criminology. [61] His Violence Research Group won Cardiff University a 2009 Queen's Anniversary Prize. [29] He is a recipient of the American Society of Criminology's Sellin-Glueck Award; [64] the Royal College of Surgeons' Colyer Gold Medal, [65] and the British Association of Oral and Maxillofacial Surgeons' Down Surgery Prize. [66] He was the Royal College of Surgeons' Bradlaw Orator in 2014. He is an honorary fellow of the Royal College of Psychiatrists, the Royal College of Emergency Medicine, the Royal College of Surgeons of England, and the Faculty of Public Health of the UK Royal Colleges of Physicians. [61] In 2011, Shepherd was elected a Fellow of the Learned Society of Wales. [67]
Dentistry, also known as dental medicine and oral medicine, is the branch of medicine focused on the teeth, gums, and mouth. It consists of the study, diagnosis, prevention, management, and treatment of diseases, disorders, and conditions of the mouth, most commonly focused on dentition as well as the oral mucosa. Dentistry may also encompass other aspects of the craniofacial complex including the temporomandibular joint. The practitioner is called a dentist.
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Contemporary medicine applies biomedical sciences, biomedical research, genetics, and medical technology to diagnose, treat, and prevent injury and disease, typically through pharmaceuticals or surgery, but also through therapies as diverse as psychotherapy, external splints and traction, medical devices, biologics, and ionizing radiation, amongst others.
Surgery is a medical specialty that uses manual and/or instrumental techniques to physically reach into a subject's body in order to investigate or treat pathological conditions such as a disease or injury, to alter bodily functions, to improve appearance, or to remove/replace unwanted tissues or foreign bodies. The subject receiving the surgery is typically a person, but can also be a non-human animal.
Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians specialize in providing care for unscheduled and undifferentiated patients of all ages. As first-line providers, in coordination with emergency medical services, they are primarily responsible for initiating resuscitation and stabilization and performing the initial investigations and interventions necessary to diagnose and treat illnesses or injuries in the acute phase. Emergency medical physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.
An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center.
A trauma center, or trauma centre, is a hospital equipped and staffed to provide care for patients suffering from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds. A trauma center may also refer to an emergency department without the presence of specialized services to care for victims of major trauma.
Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.
Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment.
Perioperative mortality has been defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the hospital. Globally, 4.2 million people are estimated to die within 30 days of surgery each year. An important consideration in the decision to perform any surgical procedure is to weigh the benefits against the risks. Anesthesiologists and surgeons employ various methods in assessing whether a patient is in optimal condition from a medical standpoint prior to undertaking surgery, and various statistical tools are available. ASA score is the most well known of these.
In urology, a Foley catheter is a brand name for one of many brands of urinary catheters (UC). Foleys and their namesakes are indwelling UC, often referred to as an IDCs or the alternative type being an in/out catheters. The foley UC was named after Frederic Foley, who produced the original design in 1929. The UC is a flexible tube if it is indwelling and stays put, or rigid if it is in/out, that a clinician, or the client themselves, often in the case of in/out UC, passes it through the urethra and into the bladder to drain urine.
Suicide prevention is a collection of efforts to reduce the risk of suicide. Suicide is often preventable, and the efforts to prevent it may occur at the individual, relationship, community, and society level. Suicide is a serious public health problem that can have long-lasting effects on individuals, families, and communities. Preventing suicide requires strategies at all levels of society. This includes prevention and protective strategies for individuals, families, and communities. Suicide can be prevented by learning the warning signs, promoting prevention and resilience, and committing to social change.
Tranexamic acid (TXA) is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for hereditary angioedema. It is taken either orally or by injection into a vein.
Lincoln Hospital is a full service medical center and teaching hospital affiliated with Weill Cornell Medical College, in the Mott Haven neighborhood of the Bronx, New York City, New York. The medical center is municipally owned by NYC Health + Hospitals.
Geriatric trauma refers to a traumatic injury that occurs to an elderly person. People around the world are living longer than ever. In developed and underdeveloped countries, the pace of population aging is increasing. By 2050, the world's population aged 60 years and older is expected to total 2 billion, up from 900 million in 2015. While this trend presents opportunities for productivity and additional experiences, it also comes with its own set of challenges for health systems. More so than ever, elderly populations are presenting to the Emergency Department following traumatic injury. In addition, given advances in the management of chronic illnesses, more elderly adults are living active lifestyles and are at risk of traumatic injury. In the United States, this population accounts for 14% of all traumatic injuries, of which a majority are just mainly from falls.
A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.
Ned Abraham was an Associate Professor of surgery at the Faculty of Medicine, University of New South Wales and is a general & colorectal surgeon, a clinical academic and a retired Australian Army Reserve Officer. He has spoken at multiple national and international meetings in four continents and his published articles in general, colorectal and academic surgery have been cited in the medical literature close to two thousand times. He continues to practice surgery in Coffs Harbour, NSW, Australia.
Joseph V. Sakran is an American trauma surgeon, public health researcher, gun violence prevention advocate and activist. His career in medicine and trauma surgery was sparked after nearly being killed at the age of 17 when he was shot in the throat. He is currently an associate professor of surgery at the Johns Hopkins University, director of Emergency General Surgery at Johns Hopkins Hospital, and vice chair of Clinical Operations. He also serves as the Associate Chief for the Division of Acute Care Surgery.
Olive Chifefe Kobusingye is a Ugandan consultant trauma surgeon, emergency surgeon, accident injury epidemiologist and academic, who serves as a Senior Research Fellow at both Makerere University School of Public Health and the Institute for Social and Health Sciences of the University of South Africa. She heads the Trauma, Injury, & Disability (TRIAD) Project at Makerere University School of Public Health, where she coordinates the TRIAD graduate courses.
A medial epicondyle fracture is an avulsion injury to the medial epicondyle of the humerus; the prominence of bone on the inside of the elbow. Medial epicondyle fractures account for 10% elbow fractures in children. 25% of injuries are associated with a dislocation of the elbow.