bluuebunny/crossref_metadata_2025 huggingface dataset:
Ecoenzymatic stoichiometry reveals soil P limitation under biochar addition in a reclaimed mine area in Shanxi Province, China
Authors: He Linru , Yan Meifang , Fan Lina
Published: April 2023

Extracellular enzymatic activity plays an important role in carbon (C), nitrogen (N), and phosphorous (P) cycling, and consequently, serves as an indicator for soil function. However, microbial activities are inhibited in degraded lands due to nutrition limitations, which pose a challenge to ecological management. We investigated the effects of maize biochar addition (1, 3, and 5%) on soil and enzyme stoichiometries in a post‐mining area in Shanxi province. The results showed that soil organic C and total N increased significantly with increasing biochar addition, leading to significant increases in soil C:P (by 157.9%) and N:P (by 76.1%) under 5% of addition. Biochar addition stimulated enzyme activities significantly, and the maximum of enzyme activities occurred in treatment of 5% addition. Soil enzyme C:N increased significantly following biochar addition, while enzyme C:P and N:P decreased at 5% biochar addition. Vector analysis indicated that microbial activity tended to be limited by soil N before addition, whereas it was limited by P availability at high biochar addition. This was mainly because that biochar addition could promote sorption of P and lower P bioavailability in soil. Our research suggested that biochar application could substantially improve soil nutrition status and microbial activity in infertile land, however, it would likely result in imbalances between substrate stoichiometry and microbial demand. The result might provide a reference for the management of biochar application during soil restoration.
The comparative achievement explanation of artistic value
Authors: Dunkle Ian D.
Published: April 2023

There is broad agreement in aesthetics that some artworks are greater than others despite bearing equivalent (or lesser) aesthetic value. One explanation of this difference in artistic value is that creation of the greater artwork represents a greater achievement. The aim of this article is to refine this explanation and to defend it against recent criticisms. First, I present a prima facie case in favor of the achievement explanation. Second, I draw on the history of photography to motivate three objections to it: namely, that it wrongly excludes (1) lucky, (2) easy, and (3) failed creations from being artistically great. Third, I present my refined version of the achievement explanation and show how it avoids these objections. On my view, an artistic achievement consists in creating a work it would have been especially hard for comparable artists to create. Finally, I raise and address several additional objections. In responding these objections, I argue, among other things, that my explanation of artistic value enhances our understanding of good‐bad art: specifically, it allows us to see how good‐bad art is artistically great despite being aesthetically flawed.
Complete Mitochondrial Genome Sequence of an Australian Little Crow (Corvus bennetti)
Authors: Sarker Subir
Published: April 2023

This study reports the complete mitochondrial genome sequence of an Australian little crow (
Corvus bennetti
). The circular genome has a size of 16,895 bp and contains 13 protein-coding genes, 22 tRNA genes, and two rRNA genes. The study provides a reference mitochondrial genome of a little crow for further molecular studies.
Supplemental Material: Inherited anthropogenic disturbance and decadal sediment dynamics in a mountain fluvial system: The case of the Marecchia River canyon, Northern Apennines
Authors: Llena Manel , et al.
Published: April 2023

Composed of 2 tables and 10 figures. 
Maternal mortality in Colombia during the COVID-19 pandemic: time series and social inequities
Authors: Castañeda-Orjuela Carlos , Hilarion Gaitan Liliana , Diaz-Jimenez Diana , Cotes-Cantillo Karol , Garfield Richard
Published: April 2023

Objective

The impact of the COVID-19 pandemic goes beyond morbidity and mortality from that disease. Increases in maternal mortality have also been described but have not been extensively studied to date. This study aimed to examine changes in maternal mortality and identify correlates and predictors of excess maternal mortality in Colombia during the pandemic.

Setting

Analysis of data from the national epidemiological surveillance databases of Colombia (Sivigila).

Participants

Deaths among 6342 Colombian pregnant women who experienced complications associated with pregnancy, childbirth or the perperium during 2008–2020 were included in this study. For inequalities analysis, a subsample of 1055 women from this group who died in 2019 or 2020 years were analysed.

Methods

We collected data from the national surveillance system (Sivigila) on maternal mortality. Analysis was carried out in two stages, starting with a time series modelling using the Box-Jenkins approach. Data from Sivigila for 2008–2019 were used to establish a baseline of expected mortality levels. Both simple and complex inequality metrics, with the maternal mortality ratios (MMRs), were then calculated using the Multidimensional Poverty Index as a socioeconomic proxy.

Results

Maternal deaths in 2020 were 12.6% (95% CI −21.4% to 95.7%) higher than expected. These excess deaths were statistically significant in elevation for the months of July (97.4%, 95% CI 35.1% to 250.0%) and August (87.8%, 95% CI 30.5% to 220.8%). The MMR was nearly three times higher in the poorest municipalities compared with the most affluent communities in 2020.

Conclusions

The COVID-19 pandemic had considerable impact on maternal health, not only by leading to increased deaths, but also by increasing social health inequity. Barriers to access and usage of essential health services are a challenge to achieving health-related Sustainable Development Goals.
Revision of the Advanced Cancer Patients’ Distress Scale (ACPDS): a mixed-methods study among palliative patients and healthcare professionals in Germany
Authors: Züger Andrea , Fischbeck Sabine , Weber Martin , Mai Sandra
Published: April 2023

Objectives

To revise the 37-item Advanced Cancer Patients’ Distress Scale (ACPDS) regarding its content, comprehensibility, applicability, and relevance by healthcare professionals (HCPs) and patients in order to enhance an existing instrument that is appropriate for the needs of patients with advanced cancer admitted to palliative care.

Design

A preliminary revision of items regarding psychometric indices and relevance to initially shorten the scale, complemented by cognitive interviews with patients combining think-aloud and verbal-probe techniques and an HCP focus group on the detected remaining items. Interviews and the focus group were audio-recorded, transcribed verbatim and analysed using MAXQDA.

Setting

The study took place at a German palliative care unit.

Participants

10 patients were interviewed (50% female) and 6 HCPs (3 physicians, 2 nurses and 1 psychologist) participated in the focus group.

Outcome Measures

Comprehensibility, applicability, and relevance of the ACPDS were evaluated.

Results

Based on the psychometric revision, a reduced number of 17 items was discussed by the HCP focus group and within cognitive interviews with patients. For the rest of the analysis of the HCP focus group and the patient interview data, the introduction of the ACPDS was simplified and adapted to everyday language. As recommended by HCPs and patients, the example question was replaced. Nine items were reworded to boost clarity, openness, redundancy and mitigation. Three items were eliminated, and another three items were added.

Conclusion

With this revised 17-item version of the ACPDS, we constructed an instrument that seems to be appropriate for the needs of patients with advanced cancer in a palliative care setting. In the next step, the shortened scale will be tested on psychometric data and validated by a large sample of inpatients on palliative care suffering from advanced cancer.

Trial registration number

DRKS ID: DRKS00022425.
Hidden educational inequalities in high blood pressure and high blood glucose levels in Kerala: evidence from the National Family Health Survey (2019–2021)
Authors: Sharma Santosh Kumar , Nambiar Devaki , Joseph Jaison
Published: April 2023

Objective

This study assesses educational inequalities in measured as well as self-reported high blood pressure (BP) and high blood glucose (BG) in the southern Indian state of Kerala, which is known to have high chronic disease morbidity.

Design

The present findings are drawn from a large-scale, nationally representative cross-sectional study.

Settings and participants

India’s Demographic and Health Survey (conducted in 2019–2021) had data on 36 526 individuals aged 15 years and above in the state of Kerala, India.

Primary and secondary outcomes measures

Measured high BP and BG; self-reported high BP and BG; as well as self-reported BP and BG testing. Descriptive statistics, bivariate analysis, along with multivariate statistics, were used. Educational inequalities were assessed through absolute and relative complex measures of inequality, namely the Slope Index of Inequality (SII) and Relative Concentration Index (RCI), respectively, with 95% CIs.

Results

The largest margin of inequality in Kerala, between the least and the most educated groups, was observed for measured high BP (57.7% and 17.6%). Measured high BP (SII −45.4% (95% CI –47.3% to –43.4%); RCI −26.6% (95% CI –27.9% to –25.3%)), self-reported high BP (SII −34.5% (95% CI –36.3% to –32.7%); RCI −19.0% (95% CI –20.1% to –17.9%)). High BG levels were concentrated among those with lower educational attainment (SII −26.6% (95% CI –28.6% to –24.7%); RCI −15.7% (95% CI –16.9% to –14.5%)), represented by negative SII and RCI values.

Conclusions

The study findings suggest that research and programme efforts need to be redoubled to determine what is driving greater vulnerability to non-communicable diseases among population with lower educational attainment on the one hand and the possible role that improving education access can be on health outcomes, on the other hand. Further research should explore relevant intersections with low education.
Examining Indigenous emergency care equity projects: a scoping review protocol
Authors: Marchand Tyara , Daodu Oluwatomilayo , MacRobie Ali , Green-Dowden Stephen , Brindle Mary
Published: April 2023

Introduction

Indigenous peoples across the globe face inequitable access to high-quality care. Emergency departments are the first point of access for many Indigenous peoples and are the interface between the individual and the healthcare system. There is a reliance on emergency services due to a lack of primary healthcare, a history of mistreatment from providers and increased disease complexity. As such, a potential place for health equity reform is within these departments and other acute care settings. It is the purpose of this review to determine what projects have occurred that address emergency care inequities in four countries such as Australia, Canada, New Zealand and the USA and explore their successes and failures.

Methods and analysis

Using search strategies developed with a research librarian, publications will be identified from indexed databases including Medline, Embase, Web of Science, Cochrane Central, CINAHL and Scopus. Grey literature will also be searched and scanned for inclusion. To be included in the review, articles must describe interventions developed to address Indigenous health equity occurring within emergency care settings. Articles will include both programme descriptions and programme evaluations and be quality appraised by analysing study design and Indigenous research methodologies.

Ethics and dissemination

This review does not require ethics approval. This protocol describes a review that attempts to map Indigenous health equity interventions taking place within emergency care settings. It will contribute to Indigenous health scholarship and equity research. Results will be made available in multiple dissemination methods to ensure accessibility by researchers and community members.
Rethinking standards on prison cell size in a (post)pandemic world: a scoping review
Authors: Dahiya Simran , Simpson Paul Leslie , Butler Tony
Published: April 2023

Objective

To describe the current international, regional and national standards on prison cell spatial density and the evidence for the association between COVID-19 transmission and prison crowding measures to provide recommendations on prison cell spatial density standards for a (post) pandemic world.

Design

Scoping review.

Data sources

PubMed, ProQuest, Informit, Criminal Justice Abstracts, Cochrane, Web of Science, Scopus, EMBASE, Google Scholar and Google were searched up to November 2021.

Eligibility criteria

Guidelines were included provided they described standards of prison accommodation with respect to prison cells. Studies were included provided they examined an association between COVID-19 cases and a crowding measure.

Data extraction and synthesis

Data were extracted by one reviewer and cross-checked by another. Quantitative and qualitative data on prison cell standards and characteristics of studies examining an association between COVID-19 and prison crowding were collected.

Findings were synthesised qualitatively.

Results

Seventeen reports and six studies met eligibility criteria. International and regional standards on cell spatial density were mostly qualitative, with two quantifiable international standards located (3.4 m2and 3.5 m2per person for multiple occupancy cells), and two quantifiable regional standards located (4 m2per person (Europe) and 5.75 m2or 4 m2per person (Australia and New Zealand)). Country-based standards varied substantially, ranging from 1.25 m2per person (Pakistan) to 10 m2per person (Netherlands). Consideration of airborne transmission of disease in prisons were mostly overlooked or absent to rationalise standards. There was consistent evidence that prison crowding measures were associated with COVID-19 transmission/cases.

Conclusion

Considering the physics of respiratory emissions, we recommend prison cell spatial density standards be updated to reflect graded levels of risk that consider other factors that combine to inform airborne transmission risk. Decarceration strategies should be considered and become vital if standards are not met.
Highlighting the importance of healthy sleep patterns in the risk of adult asthma under the combined effects of genetic susceptibility: a large-scale prospective cohort study of 455 405 participants
Authors: Xiang Bowen , Hu Mengxiao , Yu Haiyang , Zhang Yike , Wang Qing , Xue Fuzhong
Published: April 2023

Background

Individuals with asthma usually have comorbid sleep disturbances; however, whether sleep quality affects asthma risk is still unclear. We aimed to determine whether poor sleep patterns could increase the risk of asthma and whether healthy sleep patterns could mitigate the adverse effect of genetic susceptibility.

Methods

A large-scale prospective study was performed in the UK Biobank cohort involving 455 405 participants aged 38–73 years. Polygenic risk scores (PRSs) and comprehensive sleep scores, including five sleep traits, were constructed. A multivariable Cox proportional hazards regression model was used to investigate the independent and combined effects of sleep pattern and genetic susceptibility (PRS) on asthma incidence. Subgroup analysis across sex and sensitivity analysis, including a 5-year lag, different covariate adjustments and repeat measurements were performed.

Results

A total of 17 836 individuals were diagnosed with asthma during over 10 years of follow-up. Compared with the low-risk group, the HRs and 95% CIs for the highest PRS group and the poor sleep pattern group were 1.47 (95% CI: 1.41 to 1.52) and 1.55 (95% CI: 1.45 to 1.65), respectively. A combination of poor sleep and high genetic susceptibility led to a twofold higher risk compared with the low-risk combination (HR (95% CI): 2.22 (1.97 to 2.49), p<0.001). Further analysis showed that a healthy sleep pattern was associated with a lower risk of asthma in the low, intermediate and high genetic susceptibility groups (HR (95% CI): 0.56 (0.50 to 0.64), 0.59 (0.53 to 0.67) and 0.63 (0.57 to 0.70), respectively). Population-attributable risk analysis indicated that 19% of asthma cases could be prevented when these sleep traits were improved.

Conclusions

Individuals with poor sleep patterns and higher genetic susceptibility have an additive higher asthma risk. A healthy sleep pattern reflected a lower risk of asthma in adult populations and could be beneficial to asthma prevention regardless of genetic conditions. Early detection and management of sleep disorders could be beneficial to reduce asthma incidence.
BET 2: Diagnostic value of ultrasound in determining lateral ligament injury of the ankle
Authors: Hayes Russ , Callaghan Michael
Published: April 2023

A short cut review was carried out to establish whether diagnostic ultrasound can accurately diagnose integrity of the lateral ligament complex in comparison to MRI. Two studies were directly relevant to the question using the described search methodology. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. Despite the utility of ultrasound there is no certainty of its advantage over MRI for injuries of the anterior talofibular ligament.
BET 1: Follow-up phone calls and compliance with discharge instructions in elderly patients discharged from the emergency department
Authors: Nasser Laila , Stratton Tara
Published: April 2023

A short-cut review was carried out to establish whether follow-up phone calls improved compliance with follow-up and discharge instructions given to the elderly on discharge from the emergency department. 211 papers were found using the reported searches, of which 5 presented the best available 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 telephone follow-up can identify non-compliance with discharge instructions in the elderly, but there is currently no evidence to show that it actually improves it
BET 2: Safety and efficacy of low-dose ketamine versus opioids for acute pain management in the ED
Authors: BinKharfi Mohammed , AlSagre Ali
Published: April 2023

A short cut review was carried out to establish whether low-dose ketamine is a safe and effective alternative to opioids in ED patients in acute severe pain. 76 papers were found using the reported searches, of which seven 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 low-dose ketamine can be an effective and safe alternative to opioids in acute pain management.
Curious CXR
Authors: Pluck Graham , Friedman Max , McGrath Henrietta
Published: April 2023

A 98-year-old man with 2 days of headache, nausea, malaise and unsteadiness was referred to the ED by his GP with a suspicion of an intracranial bleed. His medical history included atrial fibrillation (AF) (taking warfarin). Observations were SpO2 95% on air, RR24, HR88, BP210/104, GCS14, Temp 34.3. On examination he had bilateral creps and was sleepy but not confused. A septic screen was undertaken and intravenous ceftriaxone given. His CTH was essentially normal. His CXR is shown in figure 1.Figure 1

Anteropsterior(AP) CXR at presentation.

Question

What is the diagnosis?

Acute collapse and consolidation secondary to pneumonia.

Spontaneous haemothorax.

Acute consolidation with underlying old TB.

Traumatic lung contusions.
010 Diagnostic accuracy of pulmonary embolism (PE) rule-out strategies in pregnancy
Authors: Goodacre Steve , Nelson-Piercy Catherine , Hunt Beverley , Fuller Gordon
Published: April 2023

Recent studies suggest that combinations of clinical probability assessment and D-dimer can safely rule out suspected PE in pregnant women. Van der Pol (NEJM 2019) reported that a pregnancy-modified YEARS algorithm and D-dimer ruled out PE in 195/498 (39%) and Righini (Ann Intern Med 2018) reported that the Geneva score and D-dimer ruled out PE in 46/395 (12%) without adverse outcome. We undertook a secondary analysis of pregnant women with suspected PE prospectively recruited to the DiPEP study to determine the diagnostic accuracy of these strategies.

The DiPEP study collected data and blood samples from pregnant/postpartum women with suspected PE across 11 UK hospitals and with diagnosed PE from all UK hospitals over 18 months. We selected prospectively recruited pregnant women who had definitive diagnostic imaging for analysis. We used clinical data and D-dimer results to determine whether the van der Pol and Righini strategies would recommend further investigation and imaging results to determine whether this would detect or miss PE.

We analysed 219 prospectively enrolled patients, including 12 (4.6%) with PE. The van der Pol strategy indicated no PE in 96/219 (43.8%), but this would have included 5/12 false negative cases with PE. Sensitivity for PE was 58.3% (95% CI 28.6–83.5%) and specificity 44.0% (37.1–51.0%). The Righini strategy indicated no PE in 46/219 (21.0%) but this would have missed 3/12 cases with PE. Sensitivity was 75.0% (21.9–98.7%) and specificity 20.8% (15.6–27.1%).

Strategies using clinical probability and D-dimer do not accurately rule out PE in pregnancy. The absence of adverse events in the published management studies may reflect lack of statistical power to detect clinically important adverse event rates. We therefore recommend against using clinical probability assessment and D-dimer testing to rule out suspected PE in pregnancy.
011 High-sensitivity cardiac troponin on presentation to rule out myocardial infarction (HiSTORIC): a stepped-wedge cluster randomised controlled trial
Authors: Gray Alasdair
Published: April 2023

Background

High-sensitivity troponin (hs-cTn) assays enable MI to be ruled out earlier, but the effectiveness and safety of this approach is uncertain. We compared a conventional pathway using the 99th centile and serial testing at presentation and at 6–12 hours, with a rapid rule out pathway that uses lower hs-cTn concentrations to risk stratify patients at presentation and earlier serial testing.

Method and results

A 6-centre stepped-wedge, cluster RCT was completed, evaluating the efficacy/safety of implementation of a rapid rule out pathway using a hs-cTnI assay. Consecutive patients were identified, with suspected ACS who had a hs-cTnI concentration within the normal range at presentation in 3 phases. During the validation phase, patients were assessed using the standard care pathway with serial hs-cTnI testing at presentation and 6–12 hours. All centres were randomized in a stepped-wedge fashion to the novel pathway, where MI is ruled out if hs-cTnI is <5 ng/L at presentation or between 5 ng/L and the 99th centile with a change <3 ng/L at 3 hours. Sequential hypothesis testing evaluated the superiority of the novel pathway for a primary efficacy endpoint of length of stay, and non-inferiority for a primary safety endpoint of MI or cardiac death 30 days following discharge.

Conclusions

From Nov 2014 to Dec 2016, 36,322 patients with suspected ACS and hs-cTnI concentrations <99th centile at presentation were identified. All patients were followed up for at least one year. Median lengths of stay and the proportion with MI or cardiac death 30 days following discharge before and after implementation of the pathway will be reported. Non-inferiority for the primary safety endpoint will be concluded if the upper limit of the one-sided 95% CI is below the non-inferiority margin of 0.5%. The proportion of patients discharged directly from ED and proportion with MI or cardiac death one year following discharge will be reported.
014 Shared decision making: T-MACS choice for chest pain patients in the ED
Authors: Ward Abigail , Berg Patricia van den , Body Richard
Published: April 2023

The concept of shared decision making (SDM) has gained increasing attention across healthcare fields including emergency care, with a focus shift towards patient-centred medicine.

With cardiac chest pain accounting for approximately 6% of all emergency department (ED) attendances we aimed to co-design a personalised decision aid based on the established Troponin-only Manchester Acute Coronary Syndromes (T-MACS) prediction model to increase patient involvement in the decision making on serial troponin testing and follow up.

The T-MACS Choice decision aid was co-designed with patient and physician involvement in 7 stages using a mixed-methods approach (figure 1) at the Manchester Royal Infirmary (MRI) from March to May 2017. The initial prototype was developed based on a) a literature review of SDM, b) the AHRQ health literacy toolkit and c) the International Patient Decision Aid Standards instrument.

Abstract 014 Figure 1

T-MACS choice development flowchart

In subsequent stages the prototype was improved based on feedback provided by the PRIMER patient and public involvement group, three SDM expert clinicians, focus groups interviews involving 26 members from patient groups with a history of cardiac problems, questionnaires from 29 emergency physicians and 14 patients presenting to MRI ED with chest pain and admitted for serial troponin testing.

The final T-MACS Choice decision aid is personalised for the individual patient, reflecting their distinct risk group with the relevant choice options (figure 2).

Abstract 014 Figure 2

T-MACS choice

In the initial development stages the most common themes identified were the importance of a personalised design and the use of clear, understandable language avoiding medical jargon. Both patients and physicians highlighted the importance of including information on heart health and prevention. In the final stages both sides agreed that T-MACS Choice had the right amount of information, was clear and engaging patients in the decision making.

Further research on clinical implementation of T-MACS Choice is needed to determine its impact on patient choice and safety.
018 Clinician prediction of cardiac arrhythmia in patients presenting to the ED with palpitation or pre-syncope
Authors: Reed Matt , Grubb Neil , Lang Chris , O’Brien Rachel , Simpson Kirsty , Padarenga Mia , Grant Alison , Tuck Sharon , Keating Liza , Coffey Frank , Jones Lucy , Harris Tim , Lloyd Gavin , Gagg James , Smith Jason
Published: April 2023

The IPED study showed that use of a smartphone-based event recorder in ED patients presenting with palpitation or pre-syncope, increased the number of patients in whom an ECG was captured during symptoms over five-fold to more than 55% at 90 days (Reed MJet al. Lancet eClinical Medicine 2019; 8: 37–46).

This pre-planned analysis looked at the ability of ED clinicians to predict cardiac arrhythmia in patients presenting to the ED with palpitation or pre-syncope.

Pre-planned sub study analysis of a randomised controlled multi-centre trial. Participants ≥16 years old presenting to 10 UK hospital EDs with palpitation or pre-syncope whose underlying ECG rhythm during these episodes remained undiagnosed after ED assessmentwere enrolled. The treating ED clinician was asked to rate the likelihood of underlying cardiac arrhythmia ranging from 1 (least likely) to 10 (most likely). Participants were then randomised to either an intervention group using a smartphone-based event recorder or a standard care control group. Primary endpoint of this sub study was symptomatic cardiac arrhythmia at 90 days.

243 patients were enrolled. 6 patients had no ED clinician likelihood rating recorded and two further patients were lost to follow-up leaving 235 available for analysis. There were 12 patients recording a symptomatic cardiac arrhythmia at 90 days. These were atrial fibrillation (8), SVT (3), sinus bradycardia (<40 bpm; 1) and atrial flutter (1). One patient recorded 2 categories of arrhythmia. The AUC for prediction of cardiac arrhythmia was 0.81 (95% CI; 0.71–0.90). An ED clinician likelihood rating of 5 or more had 92% sensitivity and 59% specificity for predicting cardiac arrhythmia.

Abstract 018 Figure 1

ROC analysis of ED clinician likelihood rating for symptomatic cardiac dysrhythmia at 90 days

Conclusion

ED clinicians are able to predict the liklihood of cardiac arrhythmia in patients presenting to the ED with palpitation or pre-syncope with reasonable accuracy.
021 Emergency department hypertension, is it real? A systematic review and meta-analysis
Authors: Reynard Charles , Oliver Govind , Berg Patricia van den , Naguib Mina , Body Richard
Published: April 2023

Background

In 2017 15,379,166 patients attended emergency departments (ED) across the U.K. Attention is focussed on how EDs are struggling to cope with rising demand. However, each attendance presents an ideal screening opportunity for the nation’s second largest cause of avoidable mortality; cardiovascular disease. We sought to evaluate a common cardiovascular prognostic factor measured in the ED.

We aimed to conduct a systematic review of the prevalence and reliability of ED hypertensive readings.

Method and results

The review was conducted in accordance with the PRISMA and was registered on PROSPERO. We planned to conduct a meta-analysis if the data was suitable. Searches were conducted using pre-determined terms using MEDLINE and Embase databases. A hand search of the grey literature was also conducted. Studies eligible for inclusion were those: peer reviewed, conducted in the last 20 years, included a general population, and written in English. Risk of Bias was assessed by the QUIPS tool, and overall quality by GRADE. Searches, screening, data extraction, risk of bias and GRADE assessment were all conducted by two independent researchers.

Conclusions

The search identified 1,071 results, after title and abstract review 47 underwent full text review. A further 26 were excluded following full text review (table 1).

Abstract 021 Table 1

Characteristics of the included studies

R = retrospective, P = prospective, EPR = electronic patient record, F/U = follow up, H = High risk of bias M = moderate risk of bias, L = Low risk of bias

The outcome of prevalence was extracted from 13 studies. They were dominated numerically by McNaughtonet al’s study of 701,952,422 patients, with the next largest having 7,238. A meta-analysis was conducted and confirmed the prevalence finding of the largest study at 0.24 (95% CI 0.02–0.45) (see figure 1).

Abstract 021 Figure 1

The persistence at follow of hypertensive ED readings was extracted from 7 studies, a random effects model was conducted demonstrating a pooled persistence of 0.55 (95% CI 0.34–0.75) (see figure 2).

Abstract 021 Figure 2

Hypertension is common and the persistence of it at follow up adds credibility to ED’s public health potential.
023 For how long should we monitor ED palpitation patients in the outpatient setting?
Authors: Reed Matt , Grubb Neil , Lang Chris , O’Brien Rachel , Simpson Kirsty , Padarenga Mia , Grant Alison , Tuck Sharon , Keating Liza , Coffey Frank , Jones Lucy , Harris Tim , Lloyd Gavin , Gagg James , Smith Jason
Published: April 2023

Background

The IPED study showed that use of a smartphone-based event recorder (AliveCor) in ED patients presenting with palpitation or pre-syncope, increased the number of patients in whom an ECG was captured during symptoms over five-fold to more than 55% at 90 days (Reed MJet al. Lancet eClinical Medicine 2019; 8: 37–46). The pocket sized AliveCor (now Kardia) mobile (AliveCor, San Francisco, USA) is a monitoring device that requires the patient to trigger the ECG recording. With minimal training, two fingers from each hand are placed on the monitor (which can be connected to the back of a smartphone) for 30 s to take an ECG recording.

This pre-planned analysis looked at the time to symptomatic rhythm detection in the intervention (AliveCorgroup)to determine the optimum AliveCor device monitoring period in the outpatient setting.

Method and results

Pre-planned sub study analysis of a randomised controlled multi-centre trial. Participants ≥16 years old presenting to 10 UK hospital EDs with palpitation or pre-syncope whose underlying ECG rhythm during these episodes remained undiagnosed after ED assessment were enrolled. Time to symptomatic rhythm detection was recorded and analysed.

Conclusions

243 participants were recruited over an 18-month period. A symptomatic rhythm was detected at 90 days in 69 (n=124; 55.6%; 95% CI 46.9–64.4%) participants in the intervention (AliveCor) group.

92.8% of patients who recorded a symptomatic rhythm during the 90 day period recorded this rhythm during the first 28 days (figure 1/table 1).

Abstract 023 Figure 1

Time to symptomatic rhythm detection in the intervention (AliveCor) group (n=69)

Abstract 023 Table 1

Cumulative symptomatic rhythm detection in the intervention (AliveCor) group (n=69)

Conclusion: ED palpitation patients discharged with a smartphone-based event recorder such as the AliveCor should be reviewed after 4 weeks to enable efficient device usage and timely treatment if required. Patients in whom a diagnosis has not been made can be re-reviewed at 90 days. (1541 characters/285 words)
028 A comparison of the MACS-ECG algorithm versus contemporary computer algorithms
Authors: Morris Niall , Body Richard
Published: April 2023

Background

The Manchester Acute Coronary Syndromes ECG (MACS-ECG) model was derived and validated with the aim of providing an objective measure of ECG ischemia in the setting of suspected non-ST-elevation myocardial infarction. We wanted to produce an objective measure to improve existing clinical decision aids such as TMACS or the HEART score. To establish whether the MACS-ECG model warrants further study we compared the diagnostic performance against existing computer algorithms.

The MACS-ECG model was derived in a single center cohort and combined a nuanced interpretation of repolarization abnormalities with novel signs of ischemia. These variables were selected using backward logistic regression using SPSS with the primary outcome being NSTEMI.

This model was validated in a secondary analysis of the Bedside Evaluation of Sensitive Troponin study (BEST). We recruited patients from 17 Emergency Departments. We included adults with a suspected ACS. We excluded patients with STEMI or obvious non-cardiac cause.

The primary outcome was NSTEMI, using the Fourth universal definition of myocardial infarction.

In the validation study we also coded the ECG machines interpretation as acute ischemia, infarction or no statement.

When the existing ECG algorithms produce an ‘acute ischemia’ statement, the sensitivity (Sn) was 13.3% (8.2–20.0%), specificity (Sp) 93.9% (92.1–95.5%), positive predictive value (PPV) 27.9% (19.1–39.0%) and negative predictive value (NPV) 86.0% (85.2 86.8%).

An ‘infarction’ statement produced Sn 21.0% (14.6–28.6), Sp 88.3% (85.8–90.4%), PPV 24.0% (17.9–31.4%) and NPV 86.3% (85.3–87.3%).

Combining infarction and ischemia produces the following diagnostic characteristics: Sn 34.3% (26.5–42.7%), Sp 82.2% (79.4–84.8%), PPV 25.4% (20.6–30.9%) and NPV 87.6% (86.2–88.9%).

The MACS-ECG model was more specific and sensitive than existing computer algorithims. When it produced an ‘acute ischemia’ statement, the Sn was 22.4% (15.8–30.1%), Sp 95.2% (93.5–96.6%), PPV 45.1% (34.8–55.8%) and NPV 87.4% (86.4–88.4%).
003 Identifying risk of maltreatment in burn injuries in children less than 5 years old
Authors: Javaid Assim , Kemp Alison , Hollén Linda
Published: April 2023

Background

10% of all burns arise from physical abuse or neglect. It can be difficult to identify cases where non-accidental injury should be suspected and Emergency Department (ED) clinicians have a short time to assess a child. Children less than 5 years of age are most at risk of burn injuries, with scalds and contact burns being the most common burn type amongst this group. This study analyses cases of scalds and contact burns that present to ED to determine whether there are any significant differences between factors involved in accidental burns and those referred to social services.

Method and results

A prospective multicentred study was conducted from August 2015 to September 2018. Data were collected from 20 hospital sites across England and Wales for all children who presented with a burn. Children who were less than 5 years old and had suffered a scald or contact burn were included in this study. Comparison of the proportions of cases affected by different agents, mechanisms and locations of injury were made between accidental cases (non-CP) and those cases for which a child protection referral was made (CP) to determine whether there were any significant differences. Chi-squared testing was used for this comparison and statistical significance was set at p<0.05.

Conclusions

After exclusion criteria were applied, 2056 cases were identified; 1045 non-CP scalds, 103 CP scalds, 816 non-CP contact burns and 92 CP contact burns. Scalds;Hot Waterscalds andUnwitnessedscalds were statistically significantly more likely in CP cases. Contact burns; burns involvingIrons, burnsIndependent of the Child,Unwitnessedburns and burns to the head or trunk were more likely in CP cases than in non-CP cases.

There are a number of statistically significant differences between non-CP and CP cases that may alert ED clinicians to consider referral to social services.
034 Early cardiovascular dysfunction drives in-hospital trauma mortality
Authors: Carden Rich , Lockey David , Brohi Karim
Published: April 2023

Background

Improvements in trauma resuscitation practice have reduced the early in-hospital mortality from haemorrhage and its immediate sequelae. Early cardiovascular dysfunction (CVD) is a poorly understood and under-recognised major contributor to contemporary trauma deaths. The objective of this study was to demonstrate the prevalence and impact of CVD in a population of trauma patients without catastrophic TBI.

A review of data collected prospectively at a UK Major Trauma Centre from 2008–2018. Adult trauma patients over the age of 15 were included. CVD was defined as a score of 4 on admission or day 1 of admission using the cardiovascular component of the SOFA score.

1042 patients were included, of which 125 (12%) had CVD. The 28-day mortality rate in the total population was 4.8%, and of those 64% had CVD. CVD was associated with a blunt mechanism of injury (81.6%), male gender (81.6%), and a high injury severity score (median=27). In the CVD group the major haemorrhage protocol was activated in 76.8% of patients, and 73.6% received more than 4 units of red blood cells in the first 24 hours.

Early CVD was more prevalent than any other single-system dysfunction assessed with the SOFA. All deaths with single organ failure in a SOFA domain other than cardiovascular had concurrent CVD. In predicting 28-day mortality, CVD had an AUROC of .882 (CI=0.810–0.955,p=0.000), odds ratio of 57.2, and sensitivity and specificity of 86.7% and 89.7% respectively. Multiple regression analysis identified admission base deficit, admission systolic blood pressure and heart rate, increased age, blunt mechanism, increased injury severity score, and 24-hour crystalloid administration as strong predictors of developing CVD.

Abstract 034 Figure 1

Early SOFA domain and mortality

Abstract 034 Figure 2

Prevalence of CVD and its contribution to other organ dysfunction

Abstract 034 Table 1

Demographics

CVD is the contemporary driver of in-hospital non-head injured trauma mortality. The resuscitation phase is the window of opportunity for discovery of novel treatments.
038 Junior doctors’ perceptions and experiences of the emergency department departmental handover: a qualitative study
Authors: Park Emily , Roy Susie , Skinner Janet
Published: April 2023

Background

Irregular patient volumes, high patient transit and limitless presentations means that Emergency Department (ED) handovers differ from other specialities. Therefore, a degree of handover unfamiliarity results for junior doctors.

There is a high prevalence of stress and burnout in both junior doctors and doctors working in Emergency Medicine. Despite this, no literature was identified exploring if handover can be a source of stress. The aim of this study was to explore junior doctors’ perceptions of ED handover and to investigate if it is considered a stressful experience.

Non-probabilistic sampling methods were used to recruit doctors working at or below the grade of Speciality Trainee year 2 (ST2) or equivalent in the ED of a major acute teaching hospital. Qualitative, semi-structured interviews were undertaken between March and April 2019 exploring participants’ experiences of ED handover. Interviews were recorded and transcribed verbatim. Using NVivo 12 software, data were analysed thematically using an inductive-deductive approach.

10 interviews were undertaken and four themes were identified from the data: ‘stress decreases as familiarity increases’ which included familiarising with handover structure, content and purpose; ‘time pressure is an ongoing stressor’ representing the perceived need to efficiently handover during busy periods and at shift end; ‘handover as a solace’ relating to opportunities to both learn and socialise and ‘it’s nice to be nice’ reflecting the importance of civility.

Junior doctors find aspects of ED handover stressful. These include: wanting to make a good impression; unfamiliarity; time pressures and the negative effects of hierarchy. However, handover can also help to ameliorate stress by facilitating opportunities for socialisation, education and morale boosting. Important recommendations for future practice regarding departmental handover can be made, most notably, the need to create a civil and pleasant working environment where doctors can flourish.

Abstract 038 Figure 1

Four themes explained

Abstract 038 Figure 2

Recommendations for future handovers
042 Scottish code red audit report 2015–2017
Authors: Reed Matt , Cooke Claire , McMahon Niall , Hands Katie , Henderson Susan , Knight Eleanor , Latif Munsor , Littlewood Nicola , Todd Naomi , McGarvey Margaret , Hughes Neil , Donald Michael , Rowley Megan , Innes Catherine , Lockhart Symon
Published: April 2023

The Scottish Transfusion and Laboratory Support in Trauma (TLST) group previously audited all National Code Red activations between June 1st 2013 and October 31st 2015, generating a number of recommendations to be adopted to optimise the transfusion support given to patients following major trauma in Scotland. A repeat audit was undertaken for all patients for whom a Code Red was activated between 1st November 2015 and 31st December 2017.

A clinical and transfusion lead for each centre entered anonymised data onto a secure electronic database (REDCAP; http://www.project-redcap.org) the server of which is held within the University of Edinburgh. This database was maintained by the Edinburgh study team. Each of Scotland’s pre-hospital trauma teams who take patients to hospitals where Code Red Policy is in place, and the receiving hospitals, agreed to enter data into the National Code Red audit for all patients for whom a Code Red was activated during the study period. The project was deemed a service evaluation by the South East Scotland Research Ethics committee (Ref: NR/1408AB11) and therefore did not require full ethics submission. The project was also registered with each hospital’s clinical effectiveness/governance teams where available, and a favourable Caldicott opinion was obtained.

Abstract 042 Figure 1

Flow chart showing transfusion events and outcomes of code red patients

Abstract 042 Figure 2

Ratio of the mean number of concentrated red cells (CRC) and fresh frozen plasma (FFP) transfused to code red patients at 30 minute intervals

Abstract 042 Table 1

66 activations (24 South-East of Scotland, 32 West, 10 East). Mean age 45 years, 88% male patients. 93% of Code Red patients received blood components with a 300% increase in pre-hospital transfusion (48 patients; 73%); median time from 999 call to Code Red activation reduced to 37 minutes from 70 minutes; 78% patients received pre-hospital TXA (improved from 70%). CRC:FFP ratios improved in comparison to 2013–15. Survival to discharge increased (63% to 66%) despite increased ISS.

Code Red practice has improved since our last audit. There are still improvements to be made in TXA administration and time to blood products.
046 Whose pain are we treating? A study comparing ED patients’ expectations of analgesia with ED doctors’ preconceptions
Authors: Raman Rajendra , Fleming Laura
Published: April 2023

An audit at a Scottish DGH found that large numbers of Emergency Department (ED) patients were being sent home with ‘To Take Out’ (TTO) boxes of Co-Codamol (30/500 mg) – a concerning finding given rising rates of prescription opioid addiction in the UK. Informal conversations suggested that many clinicians were prescribing high-dose codeine because ‘patients expect to be given something they can’t buy over the counter’. A survey-based study was therefore designed to explore this assumption.

A short survey (figure 1) was developed to explore ED patients’ expectations of analgesia and knowledge of common painkillers. In the first stage of the study, the survey was circulated among 25 ED prescribers who were asked how they thought ‘most patients’ with mild to moderate pain would answer these questions. In the second stage, 50 ED patients with mild to moderate pain were asked to complete the survey. Prescribers’ and patients’ answers were then compared.

Abstract 046 Figure 1

There was a significant difference between how prescribers thought ‘most patients’ would answer and how most patients actually answered the questions. Fewer patients expected to be sent home with painkillers than the prescribers predicted (figure 2), and patients were prepared to tolerate significantly more pain than prescribers expected (figure 3). A relatively high number of patients were aware of the addictive potential of codeine, yet some were unaware of the addictive potential of morphine, while others thought that paracetamol and ibuprofen were also addictive. Almost all patients indicated that if a painkiller could lead to addiction, they would expect their ED doctor to inform them of this risk.

Abstract 046 Figure 2Abstract 046 Figure 3

These results suggest that strong painkillers are sometimes given out on the mistaken assumption that this is what patients expect. Involving patients in shared decision making about TTO analgesia may be a useful strategy to reduce ED opioid dispensing.