bluuebunny/crossref_metadata_2025 huggingface dataset:
ULTRASONOGRAPHY OF THE INTERNAL JUGULAR VEIN TO ASSESS INTRAVASCULAR STATUS IN THE ED
Authors: Anwer S , Majeed A , Naveed A , Rehman S
Published: November 2016

Objectives

To assess the intravascular volume status using bedside ultrasonography of the internal jugular vein in the ED & to compare the results of two different methods, one qualitative and the other quantitative.

Background

Estimation of intravascular volume status is an important parameter both for initial assessment and to evaluate the response to treatment in critically ill undifferentiated patients especially in an ED setting.

Point of care ultrasound has been gaining popularity in the practice of EM. Ultrasound of the inferior vena cava (IVC) is used in estimating the Intra vascular volume, and is part of the RCEM's level 2 ultrasound training. IVC can be difficult to visualise in some patients. Internal Jugular Vein (IJV) is more easily accessible. Ultrasonography of the IJV has been described in the literature both as a qualitative and a quantitative tool to predict intravascular volume status.

Methods

A prospective feasibility study at the ED of a tertiary hospital. We used a convenience sample. In phase-1 we scanned 15 healthy volunteers and in phase-2 we scanned 21 acutely unwell adult patients from Oct to Nov 2015. The appearance of the IJV was noted in first 45 degrees and than in supine position as described by Lipton, 2008. Than the aspect ratio (height/width) of the IJV was measured in supine position as described by Kelleret al,2009. We used a high frequency linear probe at a depth of 3.5–4 cm. The EP performing the ultrasound was blinded to the clinical information. The findings of the ultrasound were kept blinded from the attending EP. Results of the ultrasound were retrospectively compared with the final clinical judgment of the attending EP using clinical data to assess the fluid status of the patient as recommended by NICE Guidelines on intrvenous fluid therapy, 2013.

Results

The results showed that for assessing the intravascular volume status bedside ultrasonography of the IJV byaspect ratio technique has a Sensitivity of 83.33%.

▸ Specificity of 73.33

▸ PPV of 55.56

▸ NPV of 91.67

▸ LR+of 3.12

▸ LR– of 0.23

▸ Whereas by appearance technique

▸ sensitivity of 85.71%

▸ Specificity of 88.71

▸ PPV of 75.0

▸ NPV of 92.31

▸ LR+of 6

▸ LR– of 0.17

Conclusion

The results of this feasibility study demonstrated that point-of-care ultrasonography of the IJV in the ED can aid in the assessment of intravascular volume status. Both techniques showed moderate sensitivities and specificities which were comparable.

Figure 1Figure 2Figure 3Figure 4
HOW TO DEVELOP AN EMERGENCY DEPARTMENTIN-SITUSIMULATION PROGRAM
Authors: Trippick S , Buckley A
Published: November 2016

Objectives & Background

The Department of Health recommends innovative, evidence-based, high quality simulation for learning.1

The focus in recent years has shifted toin-situsimulation (ISS) which is physically integrated into the clinical environment.

The development of ISS remains in its infancy with national variation in quality.2Limited evidence-based standards along with powerful cultural and logistic challenges often impede implementation of this practice.3

We will describe the process in developing an ISS program in the ED and discuss the challenges. It is hoped this will be useful for other departments wishing to develop simulation.

Methods

A multi disciplinary faculty was established. Faculty training needs were identified and local training supported. Quarterly faculty meetings were founded.

A training needs assessment survey with a safety and teamwork questionnaire was emailed to all ED staff. A program of fortnightly sessions was designed in line with this, alternating adults and paediatrics. Scenario development was based on the RCEM curriculum, problematic events in the ED and observed learning needs.

Simulations varied in level of fidelity, timing and location within the ED. Scenarios progressed to involve cross-specialty.

Simulations commenced with a pre-briefing and lasted around 20 minutes followed by a 20 minute debrief. Debriefs were structured around a standard format incorporating clinical and non technical elements. Following each session participants completed an evaluation questionnaire (figure 1). During the scenario faculty noted observed latent safety threats on a template adapted from the NPSA contributory factors framework (figure 2). Identified latent threats were reviewed and escalated, including incident reporting.

Results

The ISS program over the first year delivered 22 sessions to 86 participants with a good spread of participation across the team (figure 3).

Participant feedback demonstrated the positive impact of ISS on team working, communication, technical skills and overall practice (figure 4).

The identified latent threats covered a variety of contributory factors (figure 5).

The main obstacle encountered relates to cancelling sessions due to service delivery needs.

Conclusion

Through developing an ISS program in the ED our key learnings include:

▸

involving relevant stakeholders

▸

regular multi-professional faculty meetings

▸

minimising effects on service delivery

▸

tailoring simulations for the local team

▸

recording outcomes

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5
KEEPING THE DREAM ALIVE. A RAPID REMOTE PEER CPD TOOL FOR SENIOR EMERGENCY PHYSICIANS
Authors: Rowlinson J
Published: November 2016

Objectives & Background

During times of ED pressures training & CPD opportunities are often sacrificed, with conversations & emails focused on operational issues. Senior EM physicians continue to experience an interesting breadth of patients which was the foundation of their career choice. Senior EM physicians face clinical dilemmas and may not have ready opportunities to discuss, reflect and review their practice amongst peers. In Jan 2016 a remote senior EM peer CPD tool was introduced to allow impartial team review and reflection on a colleague's difficult clinical encounter. The tool has been welcomed and may be of interest to other EDs as an addition to their CPD

Methods

The senior ED team submitted dilemmas to the project coordinator. A SurveyMonkey link, containing a description of two local ED dilemma with management option choices listed, was emailed to the senior ED team, with a request to vote for which one action they would have decided upon in that situation. A separate but identical survey was sent to senior trainees (ST3–6 ACP) and to ED consultants, to see any differences in responses. All responses were unidentifiable. A succinct analysis of results with graphs was emailed after 10 days, together with a brief summary of the realtime decision made and patient outcome

Results

Typically surveys received responses from 9 consultants and 9 trainees. The remote online survey enabled flexible and more ready participation. Dilemma topics submitted were varied and included decisions around ceilings of care (ITU/palliation, CPR duration, elderly trauma), care without onsite specialist services (HI & raised ICP, acute aortic dissection & pericardial effusion), ECG interpretation, interactions with police. No scenario resulted in a unanimous vote of one most appropriate management choice, with splits of opinions ranging from 50:50 to 25:75. Trainee and consultant group responses were usually, but not always mirrored. The ability to compare practice against respected colleagues was assuring for the team, though the variety in responses also thought provoking

Conclusion

ED physicians encounter situations without concrete guidance to fall upon and a best intention decision must be made. This tool is useful for reflection with colleagues, personal debrief and team's CPD. In addition, the survey results initiated enthusiastic discussions around the practice of emergency medicine which at times of ED pressures can be diluted.
DOES ADDING LACTATE TO THE NEWS SCORE IMPROVE IDENTIFICATION OF SEPTIC PATIENTS?
Authors: Gunn N , Haigh C , Thomson JR
Published: November 2016

Objectives & Background

A previous audit has shown that in general with each rise in NEWS group there is an increase in serum lactate measured. However, it was noted that in the lowest NEWS Group 0–4 the average lactate was 2.5. A lactate level of >2 has been used as an initial marker of severity of illness yet these patients would be missed at triage.

We decided to look at whether adding the lactate to the NEWS group would improve the early identification of septic patients at triage.

A recent paper has used this in the context of patients with pneumonia.

Methods

We retrospectively reviewed 200 cases of adult patients who presented to the ED who had been identified as septic and had a sepsis 6 form completed. Initial NEWS scores and serum lactate levels were noted.

Results

200 cases were identified over a 6 month period–109 male; 91 female; age range 18–95 yrs, average 66.7 yrs. 3 notes were excluded as a serum lactate was not taken.

4 patients were admitted to ICU; 17 admitted to HDU and 22 patients died.

NEWS scores ranged from 1–19, average 7.4; IQR 1–NEWS 5; IQR 3–NEWS 9.

Initial serum lactate levels ranged from 0.6–15.4, average 2.7; IQR1–1.4; IQR 3– 3.

NEWSL scores ranged from 2.5–27.4, average 10.2; IQR1 –7.4; IQR 3– 12.3.

The paper by S Jo et al combined lactate with NEWS scores and used ranges –<3; 3.1–5.2; 5.3–8; and 8.1+. We have adopted the same ranges.

Numbers of patients are shown in table 1.

Table 2 shows the number of patients in each NEWS group who required critical care input or died. With each rise in NEWS group, critical care patients are identified. However, 1 patient died in the NEWS 0–4 group which would not be deemed high risk at triage.

Table 3 shows the number of patients in each NEWSL group who required critical care input or died. When adding the lactate to the NEWS score all patients were identified that required critical care or died in the highest NEWSL 8.1+ group. This group takes into account the patient in the NEWS 0–4 group who died.

The ROC curve for NEWS vs NEWSL is shown in figure1. The AUC is 0.7187 with an accuracy of 0.6617 which is deemed fair discriminatory ability for the NEWSL score.

Conclusion

The addition of lactate to the NEWS score identified all patients requiring critical care input or who died in the highest group –8.1+. This is a simpla calculation that can be performed at triage using point of care testing.

Larger studies are required to confirm its validity.

Figure 1

Table 1

Number of patients in each group

NEWS GroupsNEWSL Groups0–429<325–6483.1–5.2107–8535.3–8539+708.1+132N/A3

Table 2

Number of patients in each group requiring critical care or died

NEWS GroupITU AdmissionHDU AdmissionDied0–40015–61217–81639+2917

Table 3

Number of patients in each NEWSL group requiring critical care input or died.

NEWSL GroupITU AdmissionHDU AdmissionDied<30003.1–5.20005.3–80208.1+41522
TICKED OFF ABOUT SAFE SEDATION: A CHECKLIST IMPROVES COMPLIANCE WITH SEDATION GUIDELINES IN AN EMERGENCY DEPARTMENT
Authors: Butterfield E , SIAH J , Napier J
Published: November 2016

Objectives & Background

Emergency department (ED) procedural sedation is becoming more common, but associated adverse events have been reported. The Royal Colleges of Anaesthetists and of Emergency Medicine (RCoA and RCEM) have produced guidelines on the sedation of adults in the ED (RCoA and RCEM, 2012).

In other environments checklists have been shown to improve patient safety (WHO, 2016).

We hypothesised that introduction of a checklist would increase compliance with sedation guidelines

Methods

In an East London ED, compliance with the RCoA/RCEM sedation guidelines was audited retrospectively from January to December 2015. On 1st June 2015 a sedation checklist was introduced.

98 patients were identified from electronic patient records and data was compared between 3 groups:

▸

Patients sedated before 1st June 2015 (PreCheck): n=44

▸

Patients sedated after 1st June 2015, on whom the checklist was used (PosCheckPos): n=28

▸

Patients sedated after 1st June 2015, on whom the checklist was not used (PosCheckNeg): n=26

Results

Demographic data was similar between all the groups with no significant differences in age distribution, procedure, sedating agent, number of drugs used, the grade of the sedationist, discharge destination, or the proportion of sedations done out of hours.

No significant adverse events occurred in any of the groups.

When the checklist was used, 61% of sedations met all of the criteria for a safe sedation (ASA grading; airway assessment; fasting status and consent documented; two doctors and full monitoring). Prior to the checklist, 18% of sedations met all of the criteria.

When the checklist was used (figure 1) there was a significant improvement in the number of cases meeting the audit standard for documentation of: consent, location, staffing, fasting status, ASA grade and airway assessment.

When the checklist was not used despite being available, performance was no better than before the checklist was introduced (figure 2).

Conclusion

The sedation checklist improved standards when used, but did not improve the performance of the ED overall because those who forget the existence of the checklist seem prone to forget to document the key steps in safe sedation.

To increase compliance with RCoA and RCEM sedation guidelines the checklist needs to be a compulsory part of the set up for sedation, linked with the dispensing of sedation drugs.

Figure 1

There are significant improvements in the proportion of sedations meeting the audit standards when a checklist is used

Figure 2

When the checklist is not used, performance is no better than before it was introduced
THE IMPACT OF PHYSICIAN LED PRE-HOSPITAL CARE ON MAJOR TRAUMA MORTALITY IN CAMBRIDGESHIRE: AN OBSERVATIONAL CROSS-SECTIONAL ANALYSIS
Authors: Ragab H , Mackenzie R
Published: November 2016

Background

After decades of neglect, trauma service development in England has begun, but has focused on the in-hospital phase of the trauma care pathway, with a lack of national consensus on what constitutes the best pre-hospital care.

Objectives

(1) To perform an empirical analysis of a five year regional dataset to ascertain the relationship between physician led pre-hospital care and major trauma mortality, and interpret these results in the context of existing literature on the topic.

(2) To analyse the epidemiology of trauma and trauma related deaths in the UK context, and comparing and contrasting these findings with historical cohorts.

Methods

Impact of physician led care was analysed through multivariate logistic regression of a 5-year regional dataset, the Cambridgeshire Trauma Audit Research Project database. This multi-agency database is unique in that it is the first trauma database to have validated 100% case ascertainment, including pre-hospital data and pre-hospital deaths.

Results

There were 775 patients who sustained major trauma within this cohort. The overall mortality rate was 58%. Physicians responded to 48% and non-physician led care was delivered for 52% of cases.

Young adults, especially males, continue to be at highest risk for trauma, and road traffic accidents continue to be the most prevalent mechanism of injury.

Upon multivariate logistic regression physician led pre-hospital care was associated with a significant reduction in major trauma mortality [OR]=0.47 (95% Confidence Interval 0.23 to 0.96; p=0.038). Subgroup analysis of ‘survivors to hospital’ revealed a greater effect size [OR]=0.30 (95% Confidence Interval 0.13 to 0.68; p=0.004).

A different distribution of frequency of death per day (figure 1) along with the shift in magnitude and certainty of effect size from entire cohort to ‘survivors to hospital’ cohort analysis, is predicted by our theoretical understanding of trauma related deaths. The ‘secondary peak’ in the bimodal distribution of trauma deaths could be limited through improved pre-hospital care.

Conclusion

This empirical analysis of the first complete case ascertainment trauma dataset to include pre-hospital and in-hospital phases of trauma care, supports the hypothesis that physician led pre-hospital care reduces mortality from major trauma.

Figure 1

Time course of Trauma Mortality
EMERGENCY DEPARTMENT RE-ATTENDANCES AND TREATMENT MODIFICATIONS IN YOUNG CHILDREN WITH UNCOMPLICATED COMMUNITY-ACQUIRED PNEUMONIA: A PERUKI STUDY
Authors: Bielicki J , Sharland M , Lyttle M , Hartshorn S , Petrie J
Published: November 2016

Objectives & Background

Data on the rate of antibiotic retreatment in children with uncomplicated community-acquired pneumonia (CAP) are lacking. We conducted a service evaluation of CAP management to review assumptions for a large UK-based trial planning to recruit children with CAP in emergency departments (EDs). The primary endpoint for the trial is the need for antibiotic retreatment, and the retreatment rate was estimated to be 5% on the basis of non-UK literature.

Methods

Twenty-six EDs from Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI) recorded data on the management of 1–5 year old children presenting with lower respiratory tract infection (LRTI) who were treated with antibiotics after visiting the ED. Data were collected over a 4 week period, and information was collected on any reattendance for four weeks after the index visit on all children whether they were immediately discharged from ED, or admitted to inpatient wards. Data were descriptively analyzed to identify re-attendances and antibiotic retreatment. Retreatment was defined as modification of on-going antibiotic therapy or prescription of a new antibiotic treatment course after the initial course had been completed.

Results

In total, 936 patients (56% males) were included. Of these, 651 (70%) were discharged from the ED, while 285 (30%) were admitted. Of 651 immediately discharged patients, 97 (16%) had ≥1 re-attendance to the ED: 56 (9%) re-attended because of LRTI symptoms, and 28 (4%) were re-treated with antibiotics with treatment modification in 21 patients, and a new antibiotic prescription in 7 children. Of 285 admitted patients, 41 (15%) had ≥1 ED re-attendance, 29 (10%) re-attended because of LRTI symptoms, and 15 (5%) were re-treated with antibiotics. On-going antibiotic therapy was modified in only 5 patients, and new antibiotic treatment was prescribed to the remaining 10 patients. The overall re-attendance rate was 15% (138/936), the LRTI-related re-attendance rate was 9% (85/936), but the antibiotic re-treatment rate was lower at 5% (43/936, 26 modifications, 17 new prescriptions).

Conclusion

Among 1–5 year-olds, representations to ED within 4 weeks of an index visit for CAP were frequent, but only 1 in 20 was retreated with antibiotics. The antibiotic retreatment rate of 5% was the same as the estimates informing trial design.
DEVELOPMENT OF A HIGH-RESOLUTION INFRARED THERMOGRAPHIC IMAGING METHOD AS A DIAGNOSTIC TOOL FOR ACUTE UNDIFFERENTIATED LIMP IN YOUNG CHILDREN.
Authors: Owen R , Ramlakhan S , Burke D , Saatchi R
Published: November 2016

Objectives & Background

Acute limp is a common presenting complaint in the paediatric emergency department. There are a number of possible causes of acute limp, ranging from the minor, such as traumatic injury, to more severe conditions, such as infection or malignancy. In young children, these causes are not always easily distinguished, even with the use of radiological imaging and laboratory investigations. With this pilot study, we aimed to develop an infrared thermographic imaging technique for use as a diagnostic aid in the diagnosis and monitoring of acute undifferentiated limp in young children. Therefore, the objectives of this study were to critically evaluate the effectiveness of thermal imaging in this context, whilst developing an appropriate protocol for an emergency environment.

Methods

Following NHS ethics approval, 30 children were recruited from the Sheffield Children's Hospital ED. The participants were divided into groups based on diagnosis. Using an infrared camera, the lower limbs of the participants were imaged to record the skin surface temperature of both the affected side and unaffected side. Using predefined Regions of Interest (locations of thermographic measurement on the leg), any temperature difference between the two legs of each subject was recorded and the ability to isolate the specific region affected by injury was assessed.

Results

In all Regions of Interest assessed, the median temperature reading for the affected side was higher than that of the unaffected side. The ability of infrared thermography to isolate the specific region affected was evident on an individual basis, with particular case studies showing promise. The small sample size recruited for each group meant that tests of significant difference need to be interpreted in this context and further research is required to form clinically meaningful conclusions.

Conclusion

This pilot study has highlighted a number of potential avenues for future research into the use of thermographic imaging in an emergency setting. Repeating a similar study with a larger sample size will allow more credence to be given to the tests of significant difference. This study indicated that thermal imaging shows promise as an additional tool in the diagnosis and monitoring of acute undifferentiated limp in young children.
A QUALITATIVE FEASIBILITY STUDY TO INFORM FLUIDS IN SHOCK (FISH) – A PILOT RANDOMISED CONTROLLED TRIAL OF FLUID BOLUS THERAPY IN SEPTIC SHOCK
Authors: O'Hara C , Woolfall K , Canter R , Mouncey P , Rowan K , Lyttle M , Peters M , Inwald D , Nadel S
Published: November 2016

Objectives & Background

There is increasing evidence that fluid overload may be associated with harm in paediatric critical illness. Fluids in Shock (FiSH) is a combined feasibility and pilot randomised controlled trial (RCT) to determine if restrictive fluid bolus therapy (10 ml/kg) is more beneficial than current recommended fluid bolus therapy (20 ml/kg) in the resuscitation of children with presumed septic shock. This qualitative feasibility study aims to explore: acceptability of the proposed pilot RCT, including the prospect of research without prior consent (RWPC); other potential barriers to conduct of the pilot RCT; participant information; parental decision-making; and patient-centred outcome measures.

Methods

Qualitative interview study involving 21 parents (18 mothers, 3 fathers, 7 were bereaved) with children admitted to a UK emergency department with presumed septic shock in the last three years.

Results

All parents would have provided permission for the use of their child's data in the FiSh pilot RCT. The majority of parents were unfamiliar with RWPC, yet supported its use in FiSh and in other RCTs aiming to help improve treatments for critically ill children. Parents were concerned about the change from currently recommended treatment; yet were reassured by an explanation of the current evidence base, fluid bolus therapy and monitoring procedures. Parents made recommendations about the timing of the discussion regarding permission for use of data and the patient information materials. Bereaved parents stated that recruiters should not attempt to discuss the RCT immediately after a child's death, but supported a personalised postal ‘opt out’ approach to RWPC for FiSh. Parents prioritised outcome measures such as survival, time in hospital, time spent on machines and time to their child ‘looking or behaving more like themselves’.

Conclusion

Our qualitative feasibility study findings support the proposed FiSh pilot RCT, including the use of RWPC, amongst parents whose child has experienced septic shock. Our findings will inform the FiSh RCT including selection of a patient centred outcome measure, as well as inform development of participant information materials and site initiation training.
ANNUAL ACUTE HOSPITAL COST OF PAEDIATRIC HEAD INJURY IN AUSTRALIA – A PAEDIATRIC RESEARCH IN EMERGENCY DEPARTMENTS INTERNATIONAL COLLABORATIVE (PREDICT) STUDY
Authors: Cheek JA , Lyttle M , Oakley E , Babl F , Borland M , Dalziel K , Kanal GN , Phillips N , Gilhotra Y , Kochar A , Dalton S , McCaskill M , Furyk J , Neutze J , Dalziel SR
Published: November 2016

Objectives & Background

Children with head injuries (HIs) frequently present to acute care settings. Most injuries are mild, but a small portion of patients have clinically significant intracranial injuries. An attempt to estimate the cost of paediatric HIs using prospectively collected data has never been attempted in Australia. We aimed to estimate the total cost paediatric HI in Australia and provide an understanding of the costs associated with different causative and presentation factors.

Methods

The study was embedded in a prospective observational study of 20,255 children <18 years designed to validate three published clinical decision rules. Each patient's hospital presentation was micro-costed and then extrapolated to an annualised Australia-wide figure using Australian Independent Hospital Pricing Authority data.

Results

There were 109,729 cases of HI in children aged 0–18 years across Australia in the fiscal year 2012–2013 (1.67% of total emergency presentations). The average cost of each HI was $1348.21 [95%CI: 1173.02 to 1523.40]. The total cost of HI in Australia was $147.94 million [95% CI: 128.71 to 167.17]. Regression and generalized linear models both demonstrate that motor vehicle accidents (MVAs) and non-accidental injury (NAI) are the most significant drivers of cost, as are injuries presenting with vomiting, seizure and loss of consciousness greater than 5 minutes.

Conclusion

Paediatric head injury represents a significant cost to the Australian healthcare system. Efforts to reduce the main drivers of cost–MVAs and NAI – may reduce this.
BET 1: Trimethoprim-sulfamethoxazole in uncomplicated skin abscess
Authors: Baker Reece , Seamon Jason
Published: November 2016

A short cut review was carried out to establish whether incision and drainage followed by treatment with oral trimethoprim-sulfamethoxazole is better than incision and drainage alone at treating patients with uncomplicated skin abscesses. One hundred and ninety-seven papers were found using the reported searches, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that trimethoprim-sulfamethoxazole may help with abscess cure, and will decrease abscess formation at new sites.
BET 2: Low-dose ketamine for acute pain in the ED
Authors: Duncan Colby , Riley Brad
Published: November 2016

A short cut review was carried out to establish whether low-dose ketamine is better than morphine at safely and effectively reducing pain scores in ED patients with acute pain who do not respond to conventional therapies. One hundred and thirty-two papers were found using the reported searches, of these three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that the evidence is limited, but that ketamine can be an effective alternative or adjunct to intravenous opioid pain medications and in some instances may provide more effective pain relief when compared with opioids.
A rare and unusual cause of mammographic calcification in the breast
Authors: Robinson Andrew , Shaaban Abeer M
Published: November 2016

Clinical question

A 45-year-old woman is found, on family history screening, to have calcification within the upper outer quadrant of her right breast. A diagnostic mammotome biopsy was performed. Review the interactive digital slide and consider your diagnosis and appropriate management.

What is your diagnosis?

Collagenous spherulosis

Flat epithelial atypia with psammomatous calcification

Liesegang rings with lactational changes

Parasitic infection

Spheroid type amyloid
Randomised comparison of drug-eluting versus bare-metal stenting in patients with non-ST elevation myocardial infarction
Authors: Remkes Wouter S , Badings Erik A , Hermanides Renicus S , Rasoul Saman , Dambrink Jan-Henk E , Koopmans Petra C , The Salem HK , Ottervanger Jan Paul , Gosselink A T Marcel , Hoorntje Jan CA , Suryapranata Harry , van 't Hof Arnoud WJ
Published: November 2016

Objective

The superiority of drug-eluting stents (DES) over bare-metal stents (BMS) in patients with ST elevation myocardial infarction (STEMI) is well studied; however, randomised data in patients with non-ST elevation myocardial infarction (NSTEMI) are lacking. The objective of this study was to investigate whether stenting with everolimus-eluting stents (EES) safely reduces restenosis in patients with NSTEMI as compared to BMS.

Methods

ELISA-3 patients were asked to participate in the angiographic substudy and were randomised to DE (Xience V) or BM (Vision) stenting (ELISA-3 group). The primary end point was minimal luminal diameter (MLD) at 9-month follow-up angiography. In addition, 296 patients with NSTEMI who were excluded or did not want to participate in the ELISA-3 trial (RELI group) were randomised to DE or BM stenting and underwent clinical follow-up only (major adverse cardiac events (MACE), stent thrombosis (ST)). A pooled analysis was performed to assess an effect on clinical outcome.

Results

178 of 540 ELISA-3 patients participated in the angiographic substudy. MLD at 9 months angiography was 2.37±0.63 mm (DES) versus 1.84±0.62 mm (BMS), p<0.001. Binary restenosis occurred in 1.9% in the DES group versus 16.7% in the BMS group (RR 0.11, 95% CI 0.02 to 0.84, p=0.007). In the pooled analysis, the incidence of MACE, target vessel revascularisation and ST at 2 years follow-up in the DES versus BMS group was 12.5% versus 16.0% (p=0.28), 4.0% versus 10.4% (p=0.009) and 1.3% versus 3.0% (p=0.34), respectively.

Conclusions

In patients with NSTEMI, use of EES is safe and decreases both angiographic and clinical restenosis as compared to BMShttp://www.isrctn.com/search?q=39230163.

Trial registration number

39230163; Post-results.
Short-term heat acclimation improves the determinants of endurance performance and 5-km running performance in the heat
Authors: James Carl A. , Richardson Alan J. , Watt Peter W. , Willmott Ashley G.B. , Gibson Oliver R. , Maxwell Neil S.
Published: November 2016

This study investigated the effect of 5 days of controlled short-term heat acclimation (STHA) on the determinants of endurance performance and 5-km performance in runners, relative to the impairment afforded by moderate heat stress. A control group (CON), matched for total work and power output (2.7 W·kg−1), differentiated thermal and exercise contributions of STHA on exercise performance. Seventeen participants (10 STHA, 7 CON) completed graded exercise tests (GXTs) in cool (13 °C, 50% relative humidity (RH), pre-training) and hot conditions (32 °C, 60% RH, pre- and post-training), as well as 5-km time trials (TTs) in the heat, pre- and post-training. STHA reduced resting (p = 0.01) and exercising (p = 0.04) core temperature alongside a smaller change in thermal sensation (p = 0.04). Both groups improved the lactate threshold (LT, p = 0.021), lactate turnpoint (LTP, p = 0.005) and velocity at maximal oxygen consumption (vV̇O2max; p = 0.031) similarly. Statistical differences between training methods were observed in TT performance (STHA, −6.2(5.5)%; CON, −0.6(1.7)%, p = 0.029) and total running time during the GXT (STHA, +20.8(12.7)%; CON, +9.8(1.2)%, p = 0.006). There were large mean differences in change in maximal oxygen consumption between STHA +4.0(2.2) mL·kg−1·min−1 (7.3(4.0)%) and CON +1.9(3.7) mL·kg−1·min−1 (3.8(7.2)%). Running economy (RE) deteriorated following both training programmes (p = 0.008). Similarly, RE was impaired in the cool GXT, relative to the hot GXT (p = 0.004). STHA improved endurance running performance in comparison with work-matched normothermic training, despite equality of adaptation for typical determinants of performance (LT, LTP, vV̇O2max). Accordingly, these data highlight the ergogenic effect of STHA, potentially via greater improvements in maximal oxygen consumption and specific thermoregulatory and associated thermal perception adaptations absent in normothermic training.
Possible association between Helicobacter pylori infection and nonalcoholic fatty liver disease
Authors: Chen Chang-Xi , Mao Yu-Shan , Foster Parker , Zhu Zhong-Wei , Du Juan , Guo Chuan-Yong
Published: November 2016

Possible association between Helicobacter pylori infection (HPI) and nonalcoholic fatty liver disease (NAFLD) has been proposed by several studies with inconsistent conclusions. Here, we studied the association between HPI and NAFLD at 3 levels: (i) genetic level; (ii) small molecular level; and (iii) clinical level. Relation data between diseases, genes, and small molecules were acquired from Pathway Studio ResNet Mammalian database. Clinical data were acquired from 2263 elderly South Chinese subjects, including 603 NAFLD patients and 1660 subjects without NAFLD. Results showed that HPI and NAFLD present significantly shared genetic bases (95 genes, p value = 2.5E-72), demonstrating multiple common genetic pathways (enrichment p value ≤ 4.38E-20 for the top 10 pathways). Genetic network analysis suggested that mutual regulation may exist between HPI and NAFLD through 21 out of 95 genes. Furthermore, 85 out of the 95 genes manifested strong interaction with 12 small molecules/drugs that demonstrate effectiveness in treating both diseases. Clinical results showed that HPI rate in the NAFLD group was significantly higher than that in the group without NAFLD (51.9% vs. 43.6%; p value = 4.9E-4). Multivariate logistic regression results supported the observations and suggested that HPI served as a risk factor for NAFLD in the experiment data studied (odds ratio: 1.387, p value = 0.018). Results from this study support the hypothesis that complex biological association may exist between HPI and NAFLD, which partially explains the significant clinical co-incidence in the elderly population of south China.
CHILD WELFARE POLICY REFORM IN CHINA: HISTORICAL MILESTONES AND CURRENT EVALUATIONS
Authors: ZHU WENJUN JUNE , CHEUNG MONIT , LEUNG PATRICK
Published: November 2016

Policy milestones from 1962 to 2015 highlight China's child welfare policy development in terms of its major implementation eras, characteristics, strengths, and limitations in policy enforcement. This review captures information from government and NGO reports published in the past four decades since the formalization of the one-child policy in China. In the 1960s, as population control was determined an urgent national priority, China's central government started to examine child developmental needs as a way to alert the public about future family issues. Since then, China's child welfare policy development has been characterized by an economy-driven, government-operated, localized, and healthy-child-focused system. The applicability of the public welfare laws in China has been in line with its policy focus on child protection and ending poverty. Policy reform guidelines are proposed to focus on promoting child and family welfare.

中國兒童福利政策於1962年至2015年期間的發展里程碑，是一份分析兒童福利政策的最佳資料，解釋了兒童福利政策在中國的階段性實施，以及每個階段制定的兒童福利政策的特點和利弊。這篇論文收集并分析了從一孩政策頒布伊始至今四十餘載的政府公報和非政府組織的報告。在20世紀60年代，中國中央政府將控制人口的急劇增長定位為社會發展的當務之急，並開始研究兒童發展的需求，以提升對未來家庭問題的警覺性。從此，中國的兒童福利政策的發展凸顯出經濟驅動的、政府運作的、地區差異化的、強調兒童健康成長環境重要性的特點。中國社會公共福利政策的立法呼應了中國兒童福利政策中保護兒童和消除貧困這一中心思想。政府部門在日後編寫政策改革的導論時，必須提出如何推進兒童和家庭福利政策的完善
提升個案記錄技巧，優化服務質素
Authors: 楊 家正 , 曾 嘉儀 , 梁 少玲 , 陳 國溪
Published: November 2016

基於「基督教家庭服務中心」於二0一四年為同工舉辦的「個案記錄培訓工作坊」之內容及調查，本文就前線社工在個案記錄所面對的困難，提議多項具體技巧及意見，如分辦個案種類、運用「具體目標」原則(SMART Goal)及「三點式」寫法等。文中更選取三個真實記錄樣本，加以評點並修改。機構的經驗是「個案記錄培訓」能幫助改善工作效率及責任、提供準確的資料、便利督導及溝通並促進專業水平。
The diversification of granitoids and plate tectonic implications at the Archaean–Proterozoic boundary in the Bundelkhand Craton, Central India
Authors: Batuk Joshi Kumar , Bhattacharjee Joyeeta , Rai Gargi , Halla Jaana , Ahmad Talat , Kurhila Matti , Heilimo Esa , Choudhary Ashwini Kumar
Published: November 2016

The Bundelkhand Craton in Central India holds a large Archaean granitoid complex consisting of cores of TTG (tonalite–trondhjemite–granodiorite) gneisses of island arc or oceanic origin surrounded by abundant younger high-K calc-alkaline granitoids. Major and trace element groupings and ion probe U–Pb zircon datings of the groups show a time gap of 130 Ma between the main formation episodes of the TTGs (3.5/3.3–2.7 Ga) and the emplacement of the first high-K granitoids (2.57–2.54 Ga). Based on their geochemical diversity, the high-K calc-alkaline granitoids can be divided into low-silica high-magnesium (LSHM) granitoids such as sanukitoids and Closepet-type granitoids, and high-silica low-magnesium (HSLM) monzogranites with low-HREE and low-Eu subgroups. The former group points to mantle or mixed mantle and crustal sources, and the latter to pure crustal sources. All the varieties of the high-K granitoids formed within a narrow time span, which indicates large-scale partial melting and fluid activity in the mantle and crust, possibly resulting from a slab breakoff or delamination at the margin of an Archaean TTG continent.

Supplementary material:
Major and trace element concentrations and U-Pb results of granitoids from the Bundelkhand Craton are available at
https://doi.org/10.6084/m9.figshare.c.3576377
Detecting Sponsored Recommendations
Authors: Krishnasamy Subhashini , Sen Rajat , Shakkottai Sanjay , Oh Sewoong
Published: November 2016

With the vast number of items, Web pages, and news from which to choose, online services and customers both benefit tremendously from personalized recommender systems. Such systems additionally provide great opportunities for targeted advertisements by displaying ads alongside genuine recommendations. We consider a biased recommendation system in which such ads are displayed without any tags (disguised as genuine recommendations), rendering them indistinguishable to a single user. We ask whether it is possible for a small subset of collaborating users to detect such bias. We propose an algorithm that can detect this type of bias through statistical analysis on the collaborating users’ feedback. The algorithm requires only binary information indicating whether a user was satisfied with each of the recommended item or not. This makes the algorithm widely appealing to real-world issues such as identification of search engine bias and pharmaceutical lobbying. We prove that the proposed algorithm detects the bias with high probability for a broad class of recommendation systems when a sufficient number of users provides feedback on a sufficient number of recommendations. We provide extensive simulations with real datasets and practical recommender systems, which confirm the trade-offs in the theoretical guarantees.
Query Expansion in Resource-Scarce Languages
Authors: V Arjun Atreya , Kankaria Ashish , Bhattacharyya Pushpak , Ramakrishnan Ganesh
Published: November 2016

Retrievals in response to queries to search engines in resource-scarce languages often produce no results, which annoys the user. In such cases, at least partially relevant documents must be retrieved. We propose a novel multilingual framework,
MultiStructPRF
, which expands the query with related terms by (i) using a resource-rich assisting language and (ii) giving varied importance to the expansion terms depending on their position of occurrence in the document. Our system uses the help of an assisting language to expand the query in order to improve system recall. We propose a systematic
expansion model
for weighting the expansion terms coming from different parts of the document. To combine the expansion terms from query language and assisting language, we propose a heuristics-based
fusion model
. Our experimental results show an improvement over other PRF techniques in both precision and recall for multiple resource-scarce languages like
Marathi, Bengali, Odia, Finnish,
and the like. We study the effect of different assisting languages on precision and recall for multiple query languages. Our experiments reveal an interesting fact: Precision is positively correlated with the typological closeness of query language and assisting language, whereas recall is positively correlated with the resource richness of the assisting language.
Aneuploidy in Cancer: Seq-ing Answers to Old Questions
Authors: Knouse Kristin A. , Davoli Teresa , Elledge Stephen J. , Amon Angelika
Published: November 2016

Aneuploidy, the state of having gained or lost chromosomes, is a hallmark of cancer. Approximately 90% of tumors have gained or lost at least one chromosome. In spite of aneuploidy occurring as frequently as, if not more often than, disruption of the p53 pathway, whether and how aneuploidy influences tumorigenesis is still poorly understood. Here, we take advantage of large-scale tumor sequencing efforts to assess karyotypic alterations across many cancer types and review recent sequencing studies that show how karyotypes change in space and time. We further summarize findings that describe the effects of aneuploidy on untransformed cells, the mechanisms by which aneuploidy could drive tumorigenesis, and the potential to target aneuploidy for cancer therapy.
The Role of Chromatin-Associated Proteins in Cancer
Authors: Helin Kristian , Minucci Saverio
Published: November 2016

The organization of the chromatin structure is essential for maintaining cell-type-specific gene expression and therefore for cell identity. This structure is highly dynamic and is regulated by a large number of chromatin-associated proteins that are required for normal development and differentiation. Recurrent somatic mutations have been found with high frequency in genes coding for chromatin-associated proteins in cancer, and several of these are required for cancer maintenance. In this review, we discuss recent advances in understanding the role of chromatin-associated proteins in transcription, development, and cancer. Specifically, we focus on selected examples of proteins belonging to the histone methyltransferase, histone demethylase, or bromodomain families, for which specific small molecule inhibitors have been developed and are in either preclinical or clinical trials.
Phylogeny and Evolution of Lepidoptera
Authors: Mitter Charles , Davis Donald R. , Cummings Michael P.
Published: November 2016

Until recently, deep-level phylogeny in Lepidoptera, the largest single radiation of plant-feeding insects, was very poorly understood. Over the past two decades, building on a preceding era of morphological cladistic studies, molecular data have yielded robust initial estimates of relationships both within and among the ∼43 superfamilies, with unsolved problems now yielding to much larger data sets from high-throughput sequencing. Here we summarize progress on lepidopteran phylogeny since 1975, emphasizing the superfamily level, and discuss some resulting advances in our understanding of lepidopteran evolution.
Insect Pathogenic Fungi: Genomics, Molecular Interactions, and Genetic Improvements
Authors: Wang Chengshu , Wang Sibao
Published: November 2016

Entomopathogenic fungi play a pivotal role in the regulation of insect populations in nature, and representative species have been developed as promising environmentally friendly mycoinsecticides. Recent advances in the genome biology of insect pathogenic fungi have revealed genomic features associated with fungal adaptation to insect hosts and different host ranges, as well as the evolutionary relationships between insect and noninsect pathogens. By using species in the Beauveria and Metarhizium genera as models, molecular biology studies have revealed the genes that function in fungus-insect interactions and thereby contribute to fungal virulence. Taken together with efforts toward genetic improvement of fungal virulence and stress resistance, knowledge of entomopathogenic fungi will potentiate cost-effective applications of mycoinsecticides for pest control in the field. Relative to our advanced insights into the mechanisms of fungal pathogenesis in plants and humans, future studies will be necessary to unravel the gene-for-gene relationships in fungus-insect interactive models.
Transcatheter Aortic Valve Replacement: State of the Art and Future Directions
Authors: Eleid Mackram F. , Holmes David R.
Published: November 2016

Transcatheter aortic valve replacement (TAVR) is a transformational and rapidly evolving treatment for patients with aortic stenosis who require valve replacement. Novel technological advancements have made this percutaneous minimally invasive therapy a first-line treatment for many patients at extreme risk for conventional cardiac surgery. New devices and improvements in existing devices have reduced procedural complications, and scientific trials are investigating the role of TAVR in lower-risk aortic stenosis populations, in patients with aortic regurgitation, and in patients with bicuspid aortic valve disease. Finally, there is intense interest in identifying patients in whom the risk-benefit ratio of TAVR is not favorable and should not be performed.
Recovery responses of testosterone, growth hormone, and IGF-1 after resistance exercise
Authors: Kraemer William J. , Ratamess Nicholas A. , Nindl Bradley C.
Published: November 2016

The complexity and redundancy of the endocrine pathways during recovery related to anabolic function in the body belie an oversimplistic approach to its study. The purpose of this review is to examine the role of resistance exercise (RE) on the recovery responses of three major anabolic hormones, testosterone, growth hormone(s), and insulin-like growth factor 1. Each hormone has a complexity related to differential pathways of action as well as interactions with binding proteins and receptor interactions. Testosterone is the primary anabolic hormone, and its concentration changes during the recovery period depending on the upregulation or downregulation of the androgen receptor. Multiple tissues beyond skeletal muscle are targeted under hormonal control and play critical roles in metabolism and physiological function. Growth hormone (GH) demonstrates differential increases in recovery with RE based on the type of GH being assayed and workout being used. IGF-1 shows variable increases in recovery with RE and is intimately linked to a host of binding proteins that are essential to its integrative actions and mediating targeting effects. The RE stress is related to recruitment of muscle tissue with the glandular release of hormones as signals to target tissues to support homeostatic mechanisms for metabolism and tissue repair during the recovery process. Anabolic hormones play a crucial role in the body’s response to metabolism, repair, and adaptive capabilities especially in response to anabolic-type RE. Changes of these hormones following RE during recovery in the circulatory biocompartment of blood are reflective of the many mechanisms of action that are in play in the repair and recovery process.