bluuebunny/crossref_metadata_2025 huggingface dataset:
Seizures with an atypical aetiology in an elderly patient: Eagle's syndrome—how does one treat it?
Authors: Malik Yasir , Dar Javeed Ahmed , Almadani Abubaker Abdul Rahman
Published: November 2015

Onset of epilepsy can occur at any age, but it is relatively rare in the elderly. Late onset epilepsy is usually secondary to stroke, tumour, trauma or neurodegenerative disorders. A 62-year-old Indian woman presented with frequent drop attacks sometimes leading to unconsciousness and, rarely, associated with seizure. Her epilepsy work up was unremarkable. As the disease progressed, she was diagnosed as having idiopathic epilepsy, syncope or pseudo-seizure, on different occasions, and was treated at length with no response. Finally, detailed history-taking revealed her as having glossopharyngeal neuralgia leading to syncope and seizures. She subsequently improved. In clinical practice, such rare entities should also be considered for proper management of patients’ ailments.
Elderly care between global and local services: the use of somatic care practices
Authors: Mazuz Keren
Published: November 2015

Israel's population is ageing alongside the worldwide ageing population. As the population ages and the number of older people who are ‘ageing in place’ increases, the system of elderly care will face new opportunities and challenges in responding to non-institutional services for elderly care. There is an increasing demand for foreign caregivers despite differences in language and cultural background. This case report describes the global care services provided in Israel by caregivers from the Philippines to emphasis the cultural and social components of elderly care. The following case analyses the use of somatic care practices as culturally intuitive sensitivity practices adjustable to the local culture, especially since the caregiver from the Philippines and her Israeli patient do not share a common language or cultural background.
Postpartum vertebral artery dissection
Authors: Finley Amanda , Rogers Brenton , Richards Theodore , Vogel Heather
Published: November 2015

We report a case of a right vertebral artery dissection in a 35-year-old woman, 3 weeks post partum, with manifestations of vertebrobasilar disease. She was 3 weeks out from the uneventful delivery of her fourth child, with presentation of acute neurological symptoms, predominantly intractable vertigo. Vertigo can have many non-specific generalised symptoms and clinical findings. Postpartum women have a lengthy list of possible aetiologies of vertigo not limited to our initially suspected preeclampsia, dural venous thrombosis and vertebral dissection.
Recurrent pericardial effusion and tamponade in a patient with Erdheim-Chester disease (ECD)
Authors: Mishra Ajay Kumar , Mani Sunithi , George Anu Anna , Sudarsanam Thambu David
Published: November 2015

Erdheim-Chester disease (ECD) is a rare xanthogranulomatous disorder characterised by the proliferation of lipid laden histiocytes along with infiltration of various organs of the body. Although commonly presenting with bone pains secondary to bony infiltration, cardiac involvement in the form of periaortic fibrosis and pericardial involvement may be seen in a subgroup of patients. We report a case of ECD presenting as recurrent pericardial effusion along with pericardial tamponade.
Walnut ingestion in adults at risk for diabetes: effects on body composition, diet quality, and cardiac risk measures
Authors: Njike Valentine Yanchou , Ayettey Rockiy , Petraro Paul , Treu Judith A , Katz David L
Published: November 2015

Background

Despite their energy density, walnuts can be included in the diet without adverse effects on weight or body composition. The effect of habitual walnut intake on total calorie intake is not well studied. Effects on overall diet quality have not been reported.

Methods

Randomized, controlled, modified Latin square parallel design study with 2 treatment arms. The 112 participants were randomly assigned to a diet with or without dietary counseling to adjust calorie intake. Within each treatment arm, participants were further randomized to 1 of the 2 possible sequence permutations to receive a walnut-included diet with 56 g (providing 366 kcal) of walnuts per day and a walnut-excluded diet. Participants were assessed for diet quality, body composition, and cardiac risk measures.

Results

When compared with a walnut-excluded diet, a walnut-included diet for 6 months, with or without dietary counseling to adjust caloric intake, significantly improved diet quality as measured by the Healthy Eating Index 2010 (9.14±17.71 vs 0.40±15.13; p=0.02 and 7.02±15.89 vs -5.92±21.84; p=0.001, respectively). Endothelial function, total and low-density lipoprotein (LDL) cholesterol improved significantly from baseline in the walnut-included diet. Body mass index, percent body fat, visceral fat, fasting glucose, glycated hemoglobin, and blood pressure did not change significantly.

Conclusions

The inclusion of walnuts in an ad libitum diet for 6 months, with or without dietary counseling to adjust calorie intake, significantly improved diet quality, endothelial function, total and LDL cholesterol, but had no effects on anthropometric measures, blood glucose level, and blood pressure.

Trial registration number:

NCT02330848
Prevalence of foot disease and risk factors in general inpatient populations: a systematic review and meta-analysis
Authors: Lazzarini Peter A , Hurn Sheree E , Fernando Malindu E , Jen Scott D , Kuys Suzanne S , Kamp Maarten C , Reed Lloyd F
Published: November 2015

Objective

To systematically review studies reporting the prevalence in general adult inpatient populations of foot disease disorders (foot wounds, foot infections, collective ‘foot disease’) and risk factors (peripheral arterial disease (PAD), peripheral neuropathy (PN), foot deformity).

Methods

A systematic review of studies published between 1980 and 2013 was undertaken using electronic databases (MEDLINE, EMBASE and CINAHL). Keywords and synonyms relating to prevalence, inpatients, foot disease disorders and risk factors were used. Studies reporting foot disease or risk factor prevalence data in general inpatient populations were included. Included study's reference lists and citations were searched and experts consulted to identify additional relevant studies. 2 authors, blinded to each other, assessed the methodological quality of included studies. Applicable data were extracted by 1 author and checked by a second author. Prevalence proportions and SEs were calculated for all included studies. Pooled prevalence estimates were calculated using random-effects models where 3 eligible studies were available.

Results

Of the 4972 studies initially identified, 78 studies reporting 84 different cohorts (total 60 231 517 participants) were included. Foot disease prevalence included: foot wounds 0.01–13.5% (70 cohorts), foot infections 0.05–6.4% (7 cohorts), collective foot disease 0.2–11.9% (12 cohorts). Risk factor prevalence included: PAD 0.01–36.0% (10 cohorts), PN 0.003–2.8% (6 cohorts), foot deformity was not reported. Pooled prevalence estimates were only able to be calculated for pressure ulcer-related foot wounds 4.6% (95% CI 3.7% to 5.4%)), diabetes-related foot wounds 2.4% (1.5% to 3.4%), diabetes-related foot infections 3.4% (0.2% to 6.5%), diabetes-related foot disease 4.7% (0.3% to 9.2%). Heterogeneity was high in all pooled estimates (I2=94.2–97.8%, p<0.001).

Conclusions

This review found high heterogeneity, yet suggests foot disease was present in 1 in every 20 inpatients and a major risk factor in 1 in 3 inpatients. These findings are likely an underestimate and more robust studies are required to provide more precise estimates.
Diffusion of anti-VEGF injections in the Portuguese National Health System
Authors: Marques Ana Patrícia , Macedo António Filipe , Perelman Julian , Aguiar Pedro , Rocha-Sousa Amândio , Santana Rui
Published: November 2015

Objectives

To analyse the temporal and geographical diffusion of antivascular endothelial growth factor (anti-VEGF) interventions, and its determinants in a National Health System (NHS).

Setting

NHS Portuguese hospitals.

Participants

All inpatient and day cases related to eye diseases at all Portuguese public hospitals for the period 2002–2012 were selected on the basis of four International Classification of Diseases 9th revision, Clinical Modification (ICD-9-CM) codes for procedures: 1474, 1475, 1479 and 149.

Primary and secondary outcome measures

We measured anti-VEGF treatment rates by year and county. The determinants of the geographical diffusion were investigated using generalised linear modelling.

Results

We analysed all hospital discharges from all NHS hospitals in Portugal (98 408 hospital discharges corresponding to 57 984 patients). National rates of hospitals episodes for the codes for procedures used were low before anti-VEGF approval in 2007 (less than 12% of hospital discharges). Between 2007 and 2012, the rates of hospital episodes related to the introduction of anti-VEGF injections increased by 27% per year. Patients from areas without ophthalmology departments received fewer treatments than those from areas with ophthalmology departments. The availability of an ophthalmology department in the county increased the rates of hospital episodes by 243%, and a 100-persons greater density per km2raised the rates by 11%.

Conclusions

Our study shows a large but unequal diffusion of anti-VEGF treatments despite the universal coverage and very low copayments. The technological innovation in ophthalmology may thus produce unexpected inequalities related to financial constraints unless the implementation of innovative techniques is planned and regulated.
Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales
Authors: Barnard Edward Benjamin Graham , Morrison Jonathan James , Madureira Ricardo Mondoni , Lendrum Robbie , Fragoso-Iñiguez Marisol , Edwards Antoinette , Lecky Fiona , Bouamra Omar , Lawrence Thomas , Jansen Jan Olaf
Published: November 2015

Introduction

Non-compressible torso haemorrhage (NCTH) carries a high mortality in trauma as many patients exsanguinate prior to definitive haemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct that has the potential to bridge patients to definitive haemostasis. However, the proportion of trauma patients in whom REBOA may be utilised is unknown.

Methods

We conducted a population based analysis of 2012–2013 Trauma Audit and Research Network (TARN) data. We identified the number of patients in whom REBOA may have been utilised, defined by an Abbreviated Injury Scale score ≥3 to abdominal solid organs, abdominal or pelvic vasculature, pelvic fracture with ring disruption or proximal traumatic lower limb amputation, together with a systolic blood pressure <90 mm Hg. Patients with non-compressible haemorrhage in the mediastinum, axilla, face or neck were excluded.

Results

During 2012–2013, 72 677 adult trauma patients admitted to hospitals in England and Wales were identified. 397 patients had an indication(s) and no contraindications for REBOA with evidence of haemorrhagic shock: 69% men, median age 43 years and median Injury Severity Score 32. Overall mortality was 32%. Major trauma centres (MTCs) received the highest concentration of potential REBOA patients, and would be anticipated to receive a patient in whom REBOA may be utilised every 95 days, increasing to every 46 days in the 10 MTCs with the highest attendance of this injury type.

Conclusions

This TARN database analysis has identified a small group of severely injured, resource intensive patients with a highly lethal injury that is theoretically amenable to REBOA. The highest density of these patients is seen at MTCs, and as such a planned evaluation of REBOA should be further considered in these hospitals.
LOWERING LEVELS OF BED OCCUPANCY IS ASSOCIATED WITH DECREASED INHOSPITAL MORTALITY AND IMPROVED PERFORMANCE ON THE 4 HOUR TARGET
Authors: Boden D
Published: November 2015

Objectives

The aim of this study is to determine if there is a relationship between medical bed occupancy, performance against the 4 hour standard and hospital mortality rates.

Background

The problem of crowding in EDs is recognised by professional bodies around the world as a patient safety issue and, in 2014, this was the principle campaign of the UK Royal College of Emergency Medicine. Past research has focused on the outcome of ED patients, but less is known about the effect of access block, capacity and performance for the wider group of patients in a hospital.

In June 2013, as a result of increasing workload pressures, Derby Hospitals NHS Foundation Trust introduced a 90% medicine bed occupancy target. A number of interventions were undertaken across the patient journey to facilitate this. These included daily Consultant ward rounds on medical wards, CCG-commissioning of additional community beds and planned utilisation of traditional surgical bed base for medical patients. This permitted a natural experiment to see the effect of this reduction in bed occupancy on 4HTP and mortality.

Methods

This before-and-after study was undertaken in a large UK District General Hospital over a 32 month period. A range of interventions were undertaken to reduce medical bed occupancy within the Trust. 4HTP and hospital mortality (HSMR, SHMI and Crude Mortality) were compared before, and after, intervention. Daily data on medical bed occupancy and 4HTP was collected from hospital records. Segmented regression analysis of interrupted time-series method was used to estimate the changes in levels and trends in average medical bed occupancy, monthly 95% 4HTP and monthly mortality measures (HSMR, SHMI and crude mortality) that followed the intervention.

Results

Mean medical bed occupancy decreased significantly from 93.7% to 90.2% (p=0.02). The trend change in 4HTP, when comparing pre- and post-intervention, revealed a significant improvement in performance (p=0.019). The intervention resulted in a mean reduction in all markers of mortality (range 4.5%–4.8%). SHMI (p=0.02) and Crude Mortality (p=0.018) showed significant trend changes after intervention.

Conclusion

Whole system transformation can create lower average medical bed occupancy, reduce mortality and improve performance against the four hour target.
RAISING THE BAR FOR EXCLUSION OF ACUTE VENOUS THROMBOEMBOLISM IN THE EMERGENCY DEPARTMENT
Authors: Horner D , Wells S , Bonnici K , Reeves N , Parris RJ
Published: November 2015

Objectives & Background

Current assessment protocols for suspected acute venous thromboembolism (VTE) have low specificity. As a result, many patients without disease receive high dose anticoagulation or undergo hospital admission for short periods pending definitive investigation. Elderly patients are particularly at risk. It has been suggested that increasing the threshold for a positive d-dimer test in patients over 50 years old may lead to significantly increased specificity of the test, without decreasing sensitivity. We sought to identify the clinical and cost impact of a variable ‘age adjusted' threshold in the Manchester area, to externally validate these findings.

Table 1

Test characteristics for use of an 'age adjusted d-dimer' assessment, during initial workup to exclude venous thromboembolic disease

Disease PositiveDisease Negative Test Positive66253Positive Predictive Value 21%Test Negative2176Negative Predictive Value 98% Sensitivity 97%Specificity 41% 

Negative Likelihood Ratio – 0.07.

Methods

A multicentre 6 month retrospective cohort study. Patients undergoing invasive investigation for exclusion of VTE were identified in several centres undertaking ambulatory management. All patients were identified as disease positive or negative via gold standard imaging. Serum d-dimer measurements collected on initial assessment were recorded. Age adjusted cut offs were calculated retrospectively by formula in line with recent evidence (age*10).

Diagnostic test characteristics were calculated along with proportional reductions in imaging, therapeutic exposure and baseline estimates of cost.

Results

During the study period, 497 patients over 50 years of age were identified who were referred for definitive investigation to exclude VTE. Mean age was 74. Incidence of VTE was 16.3%. Use of an age adjusted cut point for d-dimer measurement would have resulted in withheld imaging/treatment in 138 patients (35.8%). Of these patients, 2 were false negative results – an 85 year old with a 5 week history of back pain eventually treated as a pulmonary embolus after high probability v/q scan, and an isolated distal deep vein thrombosis in a 72 year old. Test characteristics are displayed in Table 1. The strategy would have saved 128 doppler scans, 10 V/Q scans and 2 CTPA scans, in addition to 652 days of LMWH administration over the 6 month period, at a cost estimate of £11,620.56.

Conclusion

Retrospective application of an age adjusted d-dimer cut point for exclusion of VTE in ths cohort significantly increased specificity with limited impact on sensitivity. Caveats include those patients with longstanding symptoms and those with isolated distal deep vein thrombosis. UK centres should consider further local validation and trial adoption.
THE EFFECT OF FASCIA ILIACA COMPARTMENT BLOCK FOR HIP FRACTURES ON LENGTH OF HOSPITAL STAY AND DISCHARGE DESTINATION
Authors: Bray H , Collins N
Published: November 2015

Objectives & Background

Fascia iliaca compartment block (FICB) provides excellent pain relief for neck of femur fractures (NOFF). It can be given safely using an ultrasound guided technique in the Emergency Department (ED). At Salford Royal NHS Foundation Trust (SRFT) FICB was introduced to the analgesic pathway for hip fracture management in 2012, in combination with paracetamol and then opioids third line. The aim of this audit is to further investigate the effectiveness of FICB and determine whether the use of FICB can reduce hospital stay, discharge destination and in-hospital complication rates.

Methods

Data was collected retrospectively for all patients attending SRFT ED with a NOFF from 1 August 2011– 31 January 2012 and 1 August 2014–31 January 2015. 136 of 198 patients were included in the study. Patients were omitted if they were later found not to have NOFF, if they were treated non-surgically, or if any scanned notes from the ED or theatre were not available. Any patient receiving an alternative nerve block was also omitted from the study. Patient demographics and whether or not they received a FICB in the ED and in theatre were recorded. The length of stay in hospital, discharge destination, any in-hospital complications and 7 and 30 day mortality were also recorded for each patient.

Results

The results showed that significantly more patients were unable to go immediately home after their acute hospital admission when they did not have a FICB in the ED or theatre, compared to when they did (Pearsons Chi square test, p=0.028). The biggest impact on patient destination was determined by receiving FICB in theatre (Pearsons Chi square test, p=0.006). Giving FICB during hospital stay had no significant influence on length of stay (Mann Whitney U test, p=0.507) or in-hospital complication rates (Pearson Chi square test, p=0.117).

Conclusion

Giving patients a FICB increases their chances of returning home at discharge. Without it patients are more likely to be discharged to intermediate care or residential and nursing homes. FICB had no effect on length of stay or in-hospital complications. We recommend that all patients be offered a FICB in the ED.
WHAT PROPORTION OF PATIENTS ARE ATTENDING THE ED AVOIDABLY? AN ANALYSIS OF THE ROYAL COLLEGE OF EMERGENCY MEDICINE'S SENTINEL SITE SURVEY
Authors: Morris T , Mason S , O'Keeffe C , Moulton C
Published: November 2015

Objectives & Background

Crowding and exit block have been identified as major issues in emergency medicine, affecting patient safety, effectiveness of care and staff well being. Avoidable attendances (AAs – typically defined as non-urgent, self-referred patients who could be managed effectively and efficiently by other services) have been identified as a factor in the overall problem of crowding. The lack of a universal definition of an AA means these have been estimated to constitute between 10% and 90% of ED attendances.

This study used data from the Royal College of Emergency Medicine's (RCEM) Sentinel Site Survey (SSS) to estimate the proportion of AAs in 12 Emergency Departments (EDs) across the country on a standard day.

Methods

12 EDs across England completed the SSS on 20.03.14, reflecting a standard day in the ED. All patients attending were recorded on the survey with details of investigations/treatments they received. The criteria used to define an appropriate attendance were developed using the questions from the survey, and the proportion of patients thought to be attending avoidably in each department was calculated.

Results

Data analysis showed that a mean value of 22.4% (95% CI=20.9%–23.9%) of attendances could be deemed avoidable. Proportions of reported AAs ranged from 11.5% to 49.6%.

With arrival by ambulance, the issue of prescriptions, or both these variables included in the criteria defining an appropriate attendance, this figure fell to 19.4%, 17.6% and 15.1% respectively.

Younger age was shown to be a significant predictor of avoidable attendance, with 40.5% of under 16's attending avoidable, compared to 20.9% of adults aged 16–64 and 6.3% of over 65's.

Conclusion

The proportion of potentially avoidable ED attendances shown by this study was lower than the percentages of patients reported to not need treatments in the ED by the Urgent and Emergency Care Review. This suggests that the ED is still the most appropriate healthcare setting for many patients due to the its comprehensive investigations, treatments and capability for urgent referrals. Younger patients were more likely to attend avoidably.

The proportion of AAs is dependent on the defining criteria, highlighting the need for a standardised, universal definition of an appropriate/avoidable ED attendance. This is essential to understanding how AAs contribute to the overall issue of crowding.
ADMITTED AND IGNORED? WHAT HAPPENS WHEN ED PATIENTS ARRIVE ON WARDS?
Authors: Turner C , Hargreaves A , Nailor A
Published: November 2015

Objectives & Background

There is compelling evidence that way we treat fellow staff can reflect the way we treat patients. The greeting of staff/patients on wards is not something that is generally looked at and Emergency Medicine is in a unique position to measure this.

When patients are moved to wards there is an expectation that their welcome will be professional and courteous. After the lead author received a clinical adverse event regarding the lack of welcome an HCA received on transferring a patient, he started a prospective collection of mixed data around the type of reception that patients and staff had when they arrived on the wards.

Methods

Over 3 months in 2015 staff who were transferring patients were asked to fill in a standardised questionnaire regarding how they were received on the wards. The data was anonymised to person but not ward.

The data collection tool was designed for ease of use by portering/HCA staff (as they do the majority of our transfers). Data collection involved both visual analogue scales (for warmth of reception), a Likert scale and boxes for free text (good and bad points).

A data set of 150 reports was decided upon a priori as a pragmatic compromise, getting sufficient examples to have robust conclusions but also stopping and using the findings before the good will of the transfer staff was exhausted. Reporting was not mandated but the reasons for doing this were explained to the portering and HCA staff who usually were very willing to take part.

There were no exclusion criteria.

Results

150 completed questionnaires were received, with a 65/35 split between those classified as good (warm) and those regarded as being poor (cold).

Areas where there was a consistently positive or negative welcome were identified.

Comments have been coded and classified and tabulated. Narratives have been used to describe the perceived experiences.

Conclusion

There are areas of our hospital where patients consistently receive a warm and caring welcome. Unfortunately there are also areas where the culture permits a negative and cold welcome.

Used sensitively, this information can help inform organisational/cultural change at a ward level to the benefit of both patients and staff.

The information that we have gleaned is now being used to inform change and praise at a ward level within the trust. We have started a “Meet, Greet and Treat” programe with staff, aiming to improve the experience for all.
OBSERVATIONAL STUDY TO QUANTIFY THE CORRELATION OF DEPARTMENTAL EXIT BLOCK TO 4 HOUR STANDARD COMPLIANCE BREECHES
Authors: Moss P , Treanor D , Chan C
Published: November 2015

Objectives & Background

The Royal College of Emergency Medicine (RCEM) recent campaign, focusing on Emergency Department (ED) performance against the 4 hour standard, has highlighted exit block as a fundamental inhibitor of compliance with the standard. This leads to overcrowding, inefficiency processing patients, poor departmental flow and subsequent increased clinical risk. The study took place in the ED at St George's Hospital, London which is a major trauma centre seeing around 400 patients per day with the aim of quantifying the effect of exit block on the 4 hour standard.

Methods

Data was extracted from our patient tracking system (Cerner iCLIP) on a daily basis for a period of 9 months commencing September 2014. Exit block was defined as patients occupying cubicles whilst awaiting a bed allocation for 6 hours or more. We only included adult patients in this study. The data for a given day was extracted the following morning. The cumulative duration of stay of all the included patients was divided by 24 to calculate the number of cubicles “lost” to exit block in that 24 hour period.

A scatter plot was then constructed of cubicles “lost” vs number of breeches of the 4 hour standard that day A correlation co-efficient was then derived. We also produce a similar graph for the same time frame correlating attendance number per day with number of breeches.

Results

The data produced a correlation of 0.886 between cubicle loss and number of breeches per day. The correlation between attendance numbers and breeches was 0.208.

Conclusion

From this data we have been able to quantify the effect of exit block on departmental performance. The correlation is 0.883. This supports the previous published work on the subject of exit block and the Royal College of Emergency Medicine's “STEP” campaign; specifically the “E” for exit block as something that needs urgent attention to improve 4 hour standard compliance. This data could be used to derive a performance prediction model based not only exit block as we have defined it but other variables., at play in the ED such as ambulance arrivals, age profile of patients, absolute number of patients etc.

Figure 1Figure 2
OUT OF HOSPITAL CARDIAC ARRESTS AND EMERGENCY CORONARY ANGIOGRAPHY
Authors: Slessor D , Ashton A
Published: November 2015

Objectives & Background

The rate of survival to discharge from an out-of-hospital cardiac arrest (OOHCA) is ∼10%. In patients with OOHCA improved survival rates have been reported in patients who have a ST-elevation myocardial infarction (STEMI) who undergo percutaneous coronary intervention (PCI). The evidence for patients without STEMI is unclear.

The aim of this paper was to review our current management of patients following an OOHCA with ventricular fibrillation (VF); to determine how sensitive and specific our current practice is at ruling in and out stentable lesions, and to determine whether staff have a consistent approach.

Methods

Patients were identified retrospectively, over a 6-month period, through the ICNARC database using diagnostic codes. All notes were reviewed to determine if the patient had an angiogram performed, whether this was an emergency procedure and if a PCI was performed. Sensitivity and specificity was determined for our current practice at ruling in and out stentable lesions. Survival was determined at six months.

Cardiologists and Emergency Physicians were shown the ECG of each patient, blinded to the patient identification. They were given a short clinical history and asked to decide if the patient should have undergone an immediate angiography.

Results

27 patients were included. 12 patients had an immediate angiogram of whom eight had a PCI. A further four patients had a delayed angiogram, of whom three had PCI performed. The sensitivity and specificity of our current practice for ruling in and out stentable lesions was 73% and 75% respectively. Emergency physicians and Cardiologists were 91% and 78% sensitive respectively, and 54% and 78% specific. There was a wide variation in practice within each group of specialists.

Conclusion

Less than 50% of patients who had an OOHCA from VF underwent immediate coronary angiography. In those patients that did not undergo immediate coronary angiography, a delayed angiography was performed in 27%, of whom 75% had a PCI. Current practice resulted in a sensitivity and specificity that was too low to rule in or out stentable lesions.

Emergency Physicians would arrange for more patients to have immediate angiography following cardiac arrest compared with Cardiologists. This would result in more patients with stentable lesions having PCI performed immediately, but would result in more cases of immediate angiography being performed in patients who do not have stentable lesions.
CAPS—A UKOSS STUDY OF CARDIAC ARREST IN PREGNANCY AND THE USE OF PERI-MORTEM CAESAREAN SECTION. IMPLICATIONS FOR THE EMERGENCY DEPARTMENT
Authors: Beckett VA , Sharpe P , Knight M
Published: November 2015

Objectives & Background

There is limited data regarding the nature and number of cardiac arrests in pregnancy (CAP). The Resuscitation Council and simulation courses such as MOET and ATLS, recommend that, in order to improve maternal outcome, perimortem caesarean section (PMCS) should be considered at 4 minutes post-arrest and completed at 5 minutes. There is no prospective data on the efficacy of this intervention or on how many women who arrest in pregnancy are managed in this way. Data from Holland suggests that, whilst more PMCS is being performed, there is significant delay in performing PMCS and low rates of maternal survival. We set out to determine the incidence of cardiac arrest in pregnancy as well as the use of PMCS. We also wanted to explore the outcomes, whether the cardiac arrest happened on the delivery suite, elsewhere in hospital or in the community.

Methods

We have carried out the first prospective study of cardiac arrest in pregnancy & perimortem caesarean section, using the well established UK Obstetric Surveillance System (UKOSS). Over a 3 year period, all cases of CAP in the UK were collected.

Results

Between 2011 & 2014, 70 cases of CAP were reported. The UK incidence of CAP was 1:34 000 maternities. 16 women collapsed in the community, of which 87% (n=14) died. Of 47 women where the method of relieving aorto-caval compression was recorded, 21 had pelvic tilt & only 4 cases had the recommended manual uterine displacement. 7 women were avoidably moved to theatre for their PMCS. 47 women had a PMCS performed, 11 of which were performed in the Emergency Department (ED). In 43 of the cases, the decision to perform the PMCS was made by an Obstetrician, with 46 of the cases performed by an Obstetrician. Cardiac output was restored in 53 women. 60% (n=42) ultimately survived their arrest. In all women who survived, the median time from collapse to PMCS was significantly shorter than in those that died (p<0.001). There was no difference in time from collapse to ALS (p=0.098).

Conclusion

We report a UK incidence of 1:34 000, with evidence of a readiness to perform PMCS. This intervention was usually carried out within the recommended time post arrest, with good maternal outcomes. Several cases were encountered in the ED. We recommend that the management of CAP should be embedded within resucitation training for ED staff to minimise delay in PMCS.
LAVAS: LACTATE—ARTERIAL AND VENOUS AGREEMENT IN SEPSIS
Authors: Datta D , Grahamslaw J , Gray AJ , Walker C , Graham C
Published: November 2015

Objectives & Background

Sepsis is a common condition with around 30% hospital mortality. Measurement of lactate levels is an important part of the sepsis bundle. Although peripheral venous lactate (PV-LACT) is widely measured, most research has used arterial lactate (A-LACT). The interchangeability between the measurements is debatable, with no research supporting the widespread use of PV-LACT instead of A-LACT. If we can demonstrate that PV-LACT has good agreement it would significantly reduce patient discomfort and the potential risks of arterial sampling for a large group of acutely unwell patients, whilst potentially reducing costs to the healthcare system.

Table 1

Analysis of PV-LACT cut-offs to predict A-LACT≥2

PV-LACT cutpointNumber with arterial lactate ≥2 above PV-LACT cutpoint [n=49]SensitivityNumber with arterial lactate <2 below PV-LACT cutpoint [n=255]Specificity1.05491850.3331.554911710.6712.054912210.8672.55380.7762460.9653260.5312540.9963.5160.3272551

PV-LACT=peripheral venous lactate A-LACT=arterial lactate.

The aim of this study is to determine if peripheral venous lactate measurement gives the same results as arterial lactate measurement in septic patients attending the Emergency Department (ED).

Methods

We performed a prospective observational cohort study of 304 consecutive consented patients presenting with sepsis to a single UK NHS ED (110,000 adult attendances annually) between October 2013 and March 2014. Arterial and peripheral venous samples were taken within 20 minutes of each other, and measured in mmol/L. Bland-Altman analysis was used to compare the level of agreement between PV-LACT and A-LACT. Receiver operating characteristic (ROC) curves were created to delineate optimal cut-off points to predict arterial lactate ≥2 mmol/L.

Results

Bland-Altman analysis noted a mean difference (PV-LACT-A-LACT) of 0.4 mmol/L, with 95% limits of agreement from −0.4 to 1.2 (figure 1). The majority of PV-LACT samples were higher than A-LACT samples, with a trend to a greater difference as lactate concentration increased. Only 7 A-LACT samples had a concentration ≥4 mmol/L. ROC analysis showed that we have a 100% ability to predict (i) A-LACT of <2 with a PV-LACT cut-off of 2.05, and (ii) A-LACT of ≥2 with a PV-LACT cut-off of 3.5 (table 1).

Conclusion

This study shows good clinical agreement between PV-LACT and A-LACT. PV-LACT measurements <2 mmol/L predict A-LACT <2 mmol/L with 100% accuracy. We recommend the routine use of peripheral venous lactate in the management of septic patients presenting to the ED. This will allow faster screening of this important group of patients in EDs (as well as other healthcare settings) where arterial lactate analysis or appropriately trained staff are not available. We can also improve patient care by reducing patient risk and discomfort.

Figure 1

Bland–Altman plot of agreement between peripheral venous (PV-LACT) and arterial (A-LACT) lactate.
TROPONIN USE IN EMERGENCY DEPARTMENT SYNCOPE
Authors: Reed M.J. , O'Neill A
Published: November 2015

Objectives & Background

There is evidence to suggest that contemporary troponin assays predict serious outcome in syncope, however recent data from newer high sensitive assays show less predictive accuracy. It is still unclear where troponin fits into Emergency Department (ED) syncope decision-making, and also where current practice lies.

The aims of this study were:

(1) to assess current use of troponin by clinicians in ED syncope patients, and

(2) to assess whether a high sensitive troponin assay is better able to predict outcome in ED patients presenting with syncope than a contemporary assay.

Table 1

Area under the Receiver Operating Characteristic curves for contemporary and sensitive troponin and serious outcome at one month and one year

Area under Receiver Operating Characteristic curve (95% CI)Contemporary Troponin assay and 1 month serious outcome0.587 (0.254-0.919)Contemporary Troponin assay and 1 year serious outcome0.631 (0.438-0.823)Sensitive troponin assay and 1 month serious outcome0.766 (0.539-0.993)Sensitive troponin assay and 1 year serious outcome0.741 (0.581-0.902)

Methods

Single centre retrospective ED cohort study. Eligible patients were identified by way of an electronic patient record keyword search, then individually searched.

Patient's contemporary troponin (Abbott Architect troponin I; Abbott Laboratories, Abbott Park, Illinois) and high sensitive troponin assays (Abbott Architect STAT high sensitivity troponin I) were recorded. Both were being measured in our ED during this period, only the contemporary being released to clinicians.

Serious outcome at one month and one year was recorded.

Results

Between 1st November 2012 and 31st January 2013, there were 27,878 presentations to the ED. 27,128 patients were non syncopal, and 497 had an exclusion criteria. 253 patients were enrolled in study. Mean age was 59.0 (SD 24.7). 19 (8%) patients were reported to have chest pain and 36 (14%) patients had ECG changes suggestive of ACS, 5 had both. 100 (40%) patients were admitted to hospital. 15 (6%) patients had a serious outcome at one month and 43 (17%) patients at one year. At one year, 26 (10%) patients had died.

Troponin was measured in 43 patients (17%). 29 (67%) had chest pain and/or ECG changes. Troponin was more likely to be measured in a patient with chest pain (p <0.001; Chi-squared 15.86, df=1) or ECG changes (p <0.001; Chi-squared 54.31, df=1).

5 of 43 patients had a raised initial contemporary troponin (≥0.05 ng/ml). 7 of 43 patients had a raised initial sensitive troponin (men ≥34 ng/L, women ≥16 ng/L). ROC analysis is detailed in the table.

Conclusion

ED clinicians are more likely to order troponin in syncope patients that present with chest pain or ECG changes, symptoms characteristic of ACS in line with current NICE guidelines.

A high sensitivity troponin is able to predict serious outcomes at one month and one year much better that the contemporary troponin assay.
IT'S NOT ALL ABOUT NUMBERS: IS THE SUPPLY OF LEARNING ENCOUNTERS SUFFICIENT TO GENERATE COMPETENCE IN TRAUMA TEAM LEADERSHIP DURING HIGHER SPECIALITY TRAINING?
Authors: Graham B , Nutbeam T , Smith J
Published: November 2015

Objectives & Background

Higher Speciality Trainees (HSTs) are expected to gain competence required for autonomous practice as a consultant. Whether EM HSTs have adequate exposure to achieve competence in the trauma team leader (TTL) role is unclear.

Our primary aim was to investigate whether the supply of learning encounters is sufficient to generate competence in the TTL role during HST. Secondary aims were to explore HSTs' participation in trauma calls, roles undertaken, confidence and competence within the TTL role, supervision, opinions on training and the number of TTL encounters required to attain competence.

Methods

HSTs in the West Midlands completed a survey exploring the study objectives including confidence in the TTL role. Consultants completed a separate survey assessing HST competence in the TTL role, reasons for lack of competence, and the desired number of supervised encounters required for HSTs to attain competence.

To estimate the supply of TTL encounters available, the number of trauma calls was derived from regional and TARN data. This number was proportionally reduced to represent a 48 hour week, divided by the number of HSTs. To assess demand, the supply estimate was compared to the mean number of supervised TTL encounters specified by consultants.

Results

27/27 eligible HSTs responded. HSTs reported attending 67% of activations during working hours, frequently in the TTL (67%) or Primary Survey roles (29%) but rarely in the airway role (3.2%). 39% of TTL encounters were supervised. 70% reported being confident in the TTL role.

35/37 eligible consultants responded. 42% felt that their HSTs were competent in the TTL role. Common deficiencies were lack of exposure and leadership ability.

100% of HSTs and 88.5% of consultants reported that a dedicated trauma placement would be desirable (median duration=6 months).

Analysis estimates that the number of actual supervised TTL encounters during HST (n=33) is in keeping with the number desired by consultants (n=36) (figure 1).

Conclusion

The quantity of TTL encounters during HST broadly matches the demand for exposure specified by consultants. Despite this, there is a disparity between trainee confidence and consultant assessment of competence. Exploration of reasons underlying this difference and the desire for dedicated training may identify areas where HSTs development can be enhanced.

Figure 1

Flow diagram demonstrating methodology to estimate supply of supervised TTL encounters and average number of supervised TTL encounters desired by consultants.
INADVERTENT INTRA-ARTERIAL CANNULATION IN THE EMERGENCY DEPARTMENT: FEASIBILITY OUTCOMES FROM A PILOT STUDY
Authors: Edwards RG , Kehoe A , Graham B , Smith J
Published: November 2015

Objectives & Background

Inadvertent intra-arterial cannulation (IIAC) occurs in some Emergency Department (ED) patients. Interpretation of point of care blood gas analysis (BGA) by a senior emergency physician (EP) may be used to screen for this. We conducted a prospective observational pilot study to investigate the rate of IIAC in the ED setting and to explore feasibility questions to inform a future larger study.

Objectives:

▸ To assess the performance of medical students and foundation year one doctors in ultrasound (US) assessment of cannula location.

▸ To determine the time taken to complete US assessment of one cannula.

▸ To assess EP confidence in BGA interpretation.

▸ To explore whether or not venous BGA values varied by site of cannula.

Methods

Five medical students and FY1 doctors received a two-hour training session from an EP in US assessment of peripheral cannula location. Competence was confirmed by five observed US assessments. Data collectors performed US assessment of cannulas inserted in a convenience sample of ED patients over a two week period (83 patients). Their confidence and time taken to complete US assessment were recorded. Routine BGA obtained during cannula insertion were shown to an EP whose confidence in interpretation was recorded. Data collectors completed a survey to record their experience of various aspects of the study.

Results

100% of data collectors found using ultrasound to determine the location of a cannula to be 'very easy' or 'quite easy'. Adequate US views were obtained in 94% of examinations. Mean duration of US assessment was 11 minutes 25 seconds. 87% of cannulae had a routine BGA taken and EPs were 'quite confident' or 'very confident' in their interpretation in 97% of BGAs. There was no difference in blood gas values between different insertion sites.

Conclusion

Junior doctors and medical students can be trained in US assessment of cannula placement. BGA is frequently performed during cannula insertion. EPs interpret BGA confidently. Insertion site does not complicate interpretation. It is feasible to use this methodology for larger studies.

Figure 1Figure 2
END-TIDAL CO2 DETECTION DURING CADAVERIC VENTILATION
Authors: Coats T , Biggs M , Robinson C , Rutty G , Adnan A , Morgan B
Published: November 2015

Objectives & Background

“Life like” end-tidal CO2 production has been reported in frozen cadaver during intubation training. There is currently no human model of CPR, however the new technique of post-mortem CT (PMCT) uses CPR to circulate injected contrast for an enhanced CT scan to aid the diagnosis of the cause of death. This might give the potential to compare different methods of CPR. This procedure also allowed us to examine ETCO2 production, to see if the previous single observation could be reproduced.

Methods

The patient was an elderly female without known abnormality of the airway, who had been in a temperature-controlled environment at 4 degrees centigrade for 32 hours after death with no other preservation. She was intubated and approximately 60 minutes later ventilation was commenced. End-tidal CO2 was measured from the start of ventilation using continuous waveform capnography (Propaq CS Monitor, Model 246, Software version 3.7X, Welch Allyn). After eight minutes of ventilation a right ante-cubital venous injection of contrast was given and two minutes of chest compressions performed using a Lucas device. Ventilation was then stopped on an inspiratory hold and a whole body CT was undertaken. The project had Research Ethics Committee approval and was supported by a Resuscitation Council (UK) grant. Consent was obtained from relatives.

Results

The initial ETCO2 levels were high (6kPa), then decreased rapidly confirming previous findings. A novel observation was that the level of CO2 rose again (albeit at low levels) when CPR was started, presumably due to effective circulation. The post-mortem CT confirmed circulation had been achieved, as contrast was seen in the pulmonary vessels, and also confirmed that the endotracheal tube placement. A further novel finding was that end-tidal CO2 was again higher after the pause in ventilation required for the CT scan, presumably due to diffusion of CO2 down a concentration gradient created by the ventilation-induced fall in alveolar partial pressure.

Conclusion

This initial case suggests that end-tidal CO2 in cadavers might have a role; (a) in a protocol for post-mortem CT (as it may indicate effective ventilation and circulation of contrast), or (b) in the comparison of the effectiveness of different methods of CPR.

Figure 1
THE ESCAPE OF EMERGENCY MEDICINE TRAINEES FROM IRELAND
Authors: Pflipsen J , Kennedy U
Published: November 2015

Objectives & Background

Emergency Medicine (EM) is facing a worsening recruitment and retention crisis in Ireland. We sought to document the numbers of doctors applying to, resigning from, and completing Core Specialist Training in EM (CSTEM), as well as applying to and resigning from Advanced Specialist Training in EM (ASTEM).

Methods

Records of CSTEM and ASTEM data were interrogated by hand search following approval from the Irish Committee for Emergency Medicine Training (ICEMT) for the time periods from 2011 to 2015 for CSTEM and 2007 to 2015 for ASTEM.

Results

Following a peak in 2013, the numbers of CSTEM applicants decreased by 28% by 2015 (75 to 54). The percentage of CSTEM trainees who resigned during their 3-year Training Programme increased from 4% in 2011 to 15% in 2014. Only 1–2 CSTEM trainees out of up to 26 who started first year applied to ASTEM on completion of CSTEM each year. Following an increase between 2007 and 2009, the number of doctors applying to ASTEM decreased by 66% between 2009 and 2015 (29 to 10 trainees). The number of doctors accepted to ASTEM decreased by 70% from its peak of 10 in 2012 to 3 in 2015. A total of 7 trainees who completed CSTEM since it was established have been accepted for ASTEM. There has been no attrition from ASTEM in recent years.

Conclusion

ICEMT data demonstrates a dramatic decrease in the number of doctors applying to both CSTEM and ASTEM in Ireland, coupled with an increase in the number of trainees resigning from CSTEM. Significant improvement in terms and working conditions must be implemented if we are to recruit and retain trainees, and make EM a more attractive and sustainable specialty in Ireland.