bluuebunny/crossref_metadata_2025 huggingface dataset:
Systemic Cytokine Profiles in Strongyloides stercoralis Infection and Alterations following Treatment
Authors: Anuradha Rajamanickam , Munisankar Saravanan , Bhootra Yukti , Jagannathan Jeeva , Dolla Chandrakumar , Kumaran Paul , Shen Kui , Nutman Thomas B. , Babu Subash
Published: November 2015

Strongyloides stercoralis
is a soil-transmitted helminth organism that infects ∼50 to 100 million people worldwide. Despite its widespread prevalence, very little is known about the immune response that characterizes human
S. stercoralis
infection. To study the systemic cytokine profile characteristic of
Strongyloides
infection, we measured the circulating levels of a large panel of pro- and anti-inflammatory cytokines in asymptomatic, infected individuals (
n
= 32) and compared them to those in uninfected, controls (
n
= 24). Infected individuals exhibited significantly lower circulating levels of proinflammatory cytokines (gamma interferon [IFN-γ], tumor necrosis factor alpha [TNF-α], and interleukin-1β [IL-1β]) and significantly higher levels of anti-inflammatory cytokines (IL-4, IL-5, IL-9, IL-10, IL-13, IL-27, IL-37, and transforming growth factor β [TGF-β]). Moreover, treatment of
Strongyloides
infection resulted in a significant reversal of the cytokine profile, with increased levels of proinflammatory (IFN-γ, TNF-α, IL-2, IL-17A, IL-17F, IL-22, IL-23, and IL-1β) and decreased levels of anti-inflammatory (IL-4, IL-5, IL-9, IL-10, IL-13, IL-27, IL-37, and TGF-β) cytokines following treatment. Thus,
S. stercoralis
infection is characterized by alterations in the levels of systemic cytokines, reflecting major alterations in the underlying immune response to this chronic helminth infection.
csrT
Represents a New Class of
csrA
-Like Regulatory Genes Associated with Integrative Conjugative Elements of Legionella pneumophila
Authors: Abbott Zachary D. , Flynn Kaitlin J. , Byrne Brenda G. , Mukherjee Sampriti , Kearns Daniel B. , Swanson Michele S.
Published: November 2015

Bacterial evolution is accelerated by mobile genetic elements. To spread horizontally and to benefit the recipient bacteria, genes encoded on these elements must be properly regulated. Among the legionellae are multiple integrative conjugative elements (ICEs) that each encode a paralog of the broadly conserved regulator
csrA
. Using bioinformatic analyses, we deduced that specific
csrA
paralogs are coinherited with particular lineages of the type IV secretion system that mediates horizontal spread of its ICE, suggesting a conserved regulatory interaction. As a first step to investigate the contribution of
csrA
regulators to this class of mobile genetic elements, we analyzed here the activity of the
csrA
paralog encoded on
Legionella pneumophila
ICE-βox. Deletion of this gene, which we name
csrT
, had no observed effect under laboratory conditions. However, ectopic expression of
csrT
abrogated the protection to hydrogen peroxide and macrophage degradation that ICE-βox confers to
L. pneumophila
. When ectopically expressed,
csrT
also repressed
L. pneumophila
flagellin production and motility, a function similar to the core genome's canonical
csrA
. Moreover,
csrT
restored the repression of motility to
csrA
mutants of
Bacillus subtilis
, a finding consistent with the predicted function of CsrT as an mRNA binding protein. Since all known ICEs of legionellae encode coinherited
csrA
-type IV secretion system pairs, we postulate that CsrA superfamily proteins regulate ICE activity to increase their horizontal spread, thereby expanding
L. pneumophila
versatility.

IMPORTANCE
ICEs are mobile DNA elements whose type IV secretion machineries mediate spread among bacterial populations. All surveyed ICEs within the
Legionella
genus also carry paralogs of the essential life cycle regulator
csrA
. It is striking that the
csrA
loci could be classified into distinct families based on either their sequence or the subtype of the adjacent type IV secretion system locus. To investigate whether ICE-encoded
csrA
paralogs are bona fide regulators, we analyzed ICE-βox as a model system. When expressed ectopically, its
csrA
paralog inhibited multiple ICE-βox phenotypes, as well as the motility of not only
Legionella
but also
Bacillus subtilis
. Accordingly, we predict that CsrA regulators equip legionellae ICEs to promote their spread via dedicated type IV secretion systems.
Extremely high HIV-1 viral load in a patient with undiagnosed clinical indicator disease for HIV infection
Authors: Flanagan Stuart , De Saram Sophia , Dhairyawan Rageshri
Published: November 2015

We report a case of a new diagnosis of HIV with an extremely high viral load presenting with HIV encephalopathy, in a 54-year-old woman who had been treated with 2 years of extended high-dose immunosuppressant therapy for a recalcitrant pruritic rash before diagnosis.
Septic arthritis and subsequent fatal septic shock caused byVibrio vulnificusinfection
Authors: Emamifar Amir , Asmussen Andreasen Rikke , Skaarup Andersen Nanna , Jensen Hansen Inger Marie
Published: November 2015

Vibrio vulnificusis a rare but potential fatal bacterium that can cause severe infections. Wound infections, primary sepsis and gastroenteritis are the most common clinical features. Septic arthritis caused byV. vulnificusis an atypical presentation that has been reported in only two case reports; however, it has not been previously noted in Denmark. The authors report a case of septic arthritis caused byV. vulnificusin an immunocompromised patient. The disease progressed to severe sepsis and subsequent death within 10 h of admission.
Salmonella newportcausing osteomyelitis in a patient with diabetes
Authors: Weston Natasha , Moran Ed
Published: November 2015

Salmonellais a foodborne pathogen that commonly causes intestinal symptoms. Bacteraemia and extraintestinal infections have been documented within the literature, and are more frequently associated with immunodeficiency and general debilitation. We discuss the case of a previously well 36-year-old man who presented with a septic knee and new-onset diabetes. Imaging confirmed osteomyelitis and a Brodie's abscess, with blood and tissue cultures revealing the isolateSalmonella enterica newport. He denied any previous gastrointestinal symptoms, recent travel, change in usual dietary habit or symptoms of diabetes. So far there have only been three reported cases ofS. newportcausing osteomyelitis. We discuss the incidence ofSalmonellainfections, including extraintestinal symptoms, its relation to immunodeficiency and the disease burden ofS. newport.
Transcatheter closure of direct right pulmonary artery to left atrial communication using vascular plug
Authors: Kumar Vipin , Varghese Mithun Jacob , George Oommen K
Published: November 2015

A direct right pulmonary artery to left atrial fistula is a rare congenital condition in which patients usually present with isolated cyanosis in the absence of abnormal cardiovascular findings. We report the percutaneous closure of such a defect in a young woman who presented with severe cyanosis. This was achieved without making a conventional venovenous loop and was performed using an Amplatzer vascular plug. We believe, in patients with a suitable anatomy, closure with vascular plug without a venovenous loop should be the method of choice for treating this malady in view of the technical ease.
Persistent thrombocytopaenia in a young man with splenomegaly, rebound thrombocytosis after splenectomy and subsequent pulmonary embolism: splenic littoral cell angioma and associated events
Authors: de Ridder Gustaaf Gregoire , Galeotti Jonathan , Carney John , Wang Endi
Published: November 2015

Littoral cell angioma (LCA) is a rare endothelial cell neoplasm in the spleen. Although many cases of LCA are asymptomatic, some present with signs and symptoms related to splenomegaly, whereas others manifest with haematological abnormalities, including anaemia and/or thrombocytopaenia (ie, hypersplenism). We report a case of LCA presenting with chronic thrombocytopaenia, probably due to splenic sequestration of platelets or phagocytosis of platelets by neoplastic cells. Following therapeutic splenectomy, the patient suffered from a marked rebound thrombocytosis and subsequently developed pulmonary embolisms. He was treated with anticoagulant therapy combined with antiplatelet therapy, and his symptoms were quickly resolved. This case emphasises an exclusion of primary splenic disorders in patients with chronic thrombocytopaenia, especially in those with splenomegaly and the contemplation of thromboembolism prophylaxis postsplenectomy.
Palliative care coding practices in Canada since the introduction of guidelines and the HSMR indicator
Authors: Fekri Omid , Amuah Joseph Emmanuel , Herasimovich Viachaslau , Chaudhary Zeerak , Leeb Kira , Gurevich Yana
Published: November 2015

Objectives

This study examines palliative care (PC) coding practices since the introduction of a national coding standard and assesses a potential association with hospital standardised mortality ratio (HSMR) results.

Setting

Acute-care hospitals in Canada.

Participants

∼16 million hospital discharges recorded in Canadian Institute for Health Information (CIHI)'s Discharge Abstract Database from April 2006 to March 2013.

Primary and secondary outcome measures

In-hospital mortality, patient characteristics and service utilisation among all hospitalisations, HSMR cases and palliative patients.

Methods

We assessed all separations in the Discharge Abstract Database between fiscal years 2006–2007 and 2012–2013 for PC cases at national, provincial and facility levels. In-hospital mortality was measured among all hospitalisations (including HSMR cases) and palliative patients. We calculated a variant HSMR-PC that included PC cases.

Results

There was an increase in the frequency of PC coding over the study period (from 0.78% to 1.12% of all separations), and year-over-year improvement in adherence to PC coding guidelines. Characteristics and resource utilisation of PC patients remained stable within provinces. Crude mortality among HSMR cases declined from 8.7% to 7.3%. National HSMR declined by 22% during the study period, compared with a 17% decline in HSMR-PC. Provincial results for HSMR-PC are not significantly different from regular HSMR calculation.

Conclusions

The introduction of a national coding standard resulted in increased identification of palliative patients and services. Aside from PC coding practices, we note numerous independent drivers of improving HSMR results, notably, a significant reduction of in-hospital mortality, and increase in admissions accompanied by a greater number of coded comorbidities. While PC impacts the HSMR indicator, its influence remains modest.
BET 2: role of vinegar in Irukandji syndrome
Authors: Doshi Deepak , Foëx Bernard A , Nataly Yogesh
Published: November 2015

A shortcut review was carried out to establish whether dousing areas of contact with vinegar could relieve the symptoms of Irukandji syndrome. Four studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is there is a lack of evidence for effectiveness and the latest local guidelines should be followed.
BET 1: Intravenous tranexamic acid in the treatment of acute epistaxis
Authors: Fox Hannah , Hunter Fiona
Published: November 2015

A short-cut review was carried out to establish whether intravenous tranexamic acid is beneficial in managing acute epistaxis. Seven papers were found in Medline, Embase and the Cochrane Library using the reported searches, but none presented any evidence to answer the clinical question. It is concluded that there is no evidence to support or refute the use of intravenous tranexamic acid in acute epistaxis and that local advice should be followed.
Prediction modelling for trauma using comorbidity and ‘true’ 30-day outcome
Authors: Bouamra Omar , Jacques Richard , Edwards Antoinette , Yates David W , Lawrence Thomas , Jenks Tom , Woodford Maralyn , Lecky Fiona
Published: November 2015

Background

Prediction models for trauma outcome routinely control for age but there is uncertainty about the need to control for comorbidity and whether the two interact. This paper describes recent revisions to the Trauma Audit and Research Network (TARN) risk adjustment model designed to take account of age and comorbidities. In addition linkage between TARN and the Office of National Statistics (ONS) database allows patient's outcome to be accurately identified up to 30 days after injury. Outcome at discharge within 30 days was previously used.

Methods

Prospectively collected data between 2010 and 2013 from the TARN database were analysed. The data for modelling consisted of 129 786 hospital trauma admissions. Three models were compared using the area under the receiver operating curve (AuROC) for assessing the ability of the models to predict outcome, the Akaike information criteria to measure the quality between models and test for goodness-of-fit and calibration. Model 1 is the current TARN model, Model 2 is Model 1 augmented by a modified Charlson comorbidity index and Model 3 is Model 2 with ONS data on 30 day outcome.

Results

The values of the AuROC curve for Model 1 were 0.896 (95% CI 0.893 to 0.899), for Model 2 were 0.904 (0.900 to 0.907) and for Model 3 0.897 (0.896 to 0.902). No significant interaction was found between age and comorbidity in Model 2 or in Model 3.

Conclusions

The new model includes comorbidity and this has improved outcome prediction. There was no interaction between age and comorbidity, suggesting that both independently increase vulnerability to mortality after injury.
CVLA STUDY: CAPILLARY AND VENOUS LACTATE AGREEMENT—A PILOT OBSERVATIONAL STUDY
Authors: Datta D , Grahamslaw J , Gray AJ , Graham C
Published: November 2015

Objectives & Background

Blood lactate measurement is used as a marker of the severity of illness in patients presenting to the Emergency Department (ED): higher lactate levels are associated with increased mortality. Arterial lactate is the gold standard of measurement, however is increasingly being substituted by peripheral venous lactate (PV-LACT) measurement.

Capillary lactate (CAP-LACT) measurement has been used in the paediatric ED and in sports science; however it has not been thoroughly tested in the adult ED. Until recently there has not been a medically certified point-of-care meter to use in clinical settings. The Nova Biomedical StatStrip Lactate meter can measure CAP-LACT with a disposable strip system similar to the routine measurement of capillary glucose in the ED. CAP-LACT has the potential to allow quick lactate recording by all triage staff with minimal equipment, whilst being more acceptable to the patient as an investigation.

We aim to collect pilot data investigating the agreement between CAP-LACT and PV-LACT in the ED. This will allow us to determine feasibility and statistical power for the design of a definitive study.

Methods

We performed a prospective observational cohort study of 99 consented patients between October and December 2014 requiring PV-LACT measurement as part of their routine clinical care to a single UK NHS ED (110,000 adult attendances annually). Paired CAP-LACT and PV-LACT (in mmol/L) was recorded, and level of agreement determined by Bland-Altman analysis.

Results

The median lactate measurements were 1.3 for PV-LACT and 1.6 for CAP-LACT (table 1). Bland-Altman analysis noted a mean difference (CAP-LACT-PV-LACT) of 0.23 mmol/L, with 95% limits of agreement from −1.86 to 2.33 (figure 1). Median PV-LACT tourniquet time was 1 minute, with median time between samples being 4 minutes (interquartile range 2–4 minutes) (table 2). Only 4 samples had a lactate greater than 4 mmol/L.

Conclusion

The results show that there is potential for CAP-LACT to replace other methods of lactate measurement. However the wide 95% limits of agreement and lack of high lactate values means further definitive studies need to be conducted before we can use CAP-LACT in routine practice. The pilot data will allow the design of this definitive study. Capillary lactate could potentially revolutionise triage by allowing wider minimally invasive screening of patients presenting to the ED.

Figure 1

Bland–Altman plot of agreement between capillary and peripheral venous lactate.

Table 1

Descriptive statistics for lactate measurements

1st quartileMedian3rd quartileVenous0.91.32.2Capillary11.62.4Table 2

Patient characteristics

DemographicsNumber of patients99Age in years: mean (sd)57.4 (18.7)Gender=Male (n)5630 day outcome (number of patients)Dead4 Alive95Venous sample tourniquet time (number of patients)<1 minute3 1 minute71 2 minutes15 ≥3 minutes10
EXCELLENCE THROUGH DESIGN—IMPROVING THE MASSIVE HAEMORRHAGE PROTOCOL
Authors: Carrington S , Turner C , Burton J , Woolrich-Burt L
Published: November 2015

Objectives & Background

There has been an increasing use of massive haemorrhage protocols (MHP) within our trust. A number of clinical incidents were noted around roles/responsibilities when MHPs were run. Design failures (latent errors) were felt to contribute to these. Most MHPs are untested and are reliant on clear protocols, good communication and efficient team work. We proposed that running drills of our MHP in the ED setting would allow us to identify the latent errors and human factors that exist in our MHP then addressing these.

Methods

We proposed a 2 stage process where initially we tested functionality then identified and changed aspects of the system.

Functionality

We ran 5 in-situ, real time MHP simulations involving the relevant members of the MDT in the ED. The 20 minute scenarios were followed by a structured human factors debrief. This allowed us to establish latent errors that were affecting the MHP. Results were then collated and codified from the sessions to allow planning of teaching for ED and non-ED staff.

Redesign

Following this a card redesign was identified as being necessary. We used the principles of negative space, contrast, proximity and the pictorial superiority effect. A cluster randomised recall trial was then conducted at an F2 teaching session (66 participants), with participants blinded to the other version of the cards. A trauma video was shown (thoracotomy) and recall measured after this. Data analysed by an author blinded to both the study design and the data collection. GAfREC permission given by R+D.

Results

HF/Ergonomics phase

1. Difficulty identifying team members/roles

2. Communication difficulties-same task being undertaken by multiple staff members

3. Notes/ID labels not given to trauma team leader (TTL). TTL felt to be unapproachable

4. Porters not feeling able to identify themselves

5. Action cards and protocol not used-text heavy

6. Staff not realising action cards were double sided

7. Blood forms unavailable

8. Poor prioritisation/labelling of the crossmatch sample

9. Pre-arrival preparation steps being omitted

Card redesign phase

18 people recalled all the important information – all used the new cards. 0 people in the old card group recalled all the information. 66 of the f2s (100%) preferred new design of card.

Conclusion

HF principles helped identify areas for improvement. Utilising design principles appears to have had significant impact on the effectiveness of the cards.
TIME TRENDS IN INTRACRANIAL BLEEDING AND NEW ORAL ANTICOAGULANT PRESCRIPTION
Authors: Hogg K , Stiell I , Bahl B
Published: November 2015

Objectives & Background

Dabigatran, rivaroxaban and apixaban were approved for stroke prevention in the past 4 years. Phase 3 studies reported a lower risk of intracranial bleeding compared to warfarin however there is little real-life data to validate this. We assessed time trends in oral anticoagulant (OAC) associated intracranial bleeding between 2009 and 2013. We compared bleeding rates to provincial OAC prescription trends.

Methods

ICD-10 codes were used to identify all atraumatic intracranial bleeds presenting to our neurosurgical centre (covering a population of 1.3 million). Trained researchers extracted data on anticoagulant medication in the week prior to diagnosis of intracranial bleed. Provincial prescription data for OACs were obtained from IMS Brogan CompuScript Market Dynamics. The primary outcome was the incident OAC-associated intracranial bleed time trend between 2009 and 2013. The secondary outcomes were the non-OAC associated intracranial bleed time trend, and the provincial OAC prescription trends.

Results

2050 patients presented with atraumatic intracranial bleeds. 371 (18%) patients were prescribed an anticoagulant, of which 335 were OACs. There was an increasing trend over time in the rate of anticoagulant associated bleeding (p=0.009) and non-anticoagulant associated bleeding (p=0.063). Warfarin accounted for a disproportionately large number of all OAC-associated bleeds compared to prescription prevalence. Dabigatran, rivaroxaban and apixaban accounted for a smaller proportion of OAC bleeds when compared to prescription prevalence.

Conclusion

We found an increasing number of patients treated for intracranial bleeding over time. Warfarin accounted for a disproportionate number of intracranial bleeds and the new oral anticoagulants, fewer than expected.
A COMPARISON OF TIDAL AND INCENTIVE BREATH COLLECTION METHODS FOR THE DETERMINATION OF BREATH VOLATILES CONCENTRATION
Authors: Anderson K , Coats T , Monks P , White I , Pandya H , Beardsmore C , Skinner J
Published: November 2015

Objectives & Background

Exhaled Volatile Organic Compounds (eVOCs) have been used to identify patients with many diseases including pseudomonas infection and lung cancer. Breath for eVOC analysis is conventionally collected from one or more deep exhalations. The long controlled exhalation of the American Thoracic Association nitric oxide protocol has been the commonest method used in breath research. However, some patients may be unable or unwilling to perform deep exhalations. Movement of breath analysis from the laboratory to the bedside requires a patient-friendly method for collecting breath samples, especially if breath analysis is to be tested in the relatively uncontrolled environment of an Emergency Department. Continuous monitoring of VOC spectra throughout the breath cycle during tidal breathing has the potential to provide an easier method of sample collection in the clinical situation. This study was designed to compare single controlled exhalation with tidal breathing.

Methods

Exhaled breath volatile organic compounds were measured to compare two methods of breath collection in emergency care; the standard single prolonged exhalation (incentive test) and relaxed breathing (tidal test). 125 patients with minor conditions were recruited from the Emergency Department and samples were collected in real-time using an on-line PTR-ToF-MS coupled to Loccioni breath collection apparatus. A Matlab program was used to extract the spectra of the alveolar portion of breath and measure the abundance of each eVOC.

Results

The total amount of eVOCs detected by the two methods was highly correlated (R2=0.91), with the incentive method giving slightly higher overall eVOC levels than the tidal breath method (mean of differences=98,749 NCPS, P<0.0001). Although the total VOCs were highly correlated, there was a large amount of unexplained variation in the spectra. The tidal breath test had a much higher completion (99% compared with 75% for the incentive test), which was due to the greater reliability (less complex sampling equipment) and greater ease of use by patients.

Conclusion

Following this study we recommend the use of a tidal breath sampling method in future studies of emergency care patients to prevent selection bias.
ARE TRAUMA TEAM LEADERS ANY GOOD AT PREDICTING NEED FOR WHOLE BODY SCANS?
Authors: Bowman R , Turner C
Published: November 2015

Objectives & Background

With increasing demands on the NHS and also radiology time, we wondered if the EM trauma team leaders were able to accurately assess whether patients required a whole body scan (and thus if we could reduce the health burden of numbers of scans done).

Methods

Over a 3 month period from February to May 2015 a simple questionnaire was completed as part of the trauma chart documentation at a major trauma centre in the West Midlands. This was filled in by the trauma team leader (TTL). The TTL was asked to predict if the scan was going to be significantly abnormal and also the main reasons for the scan being done (mechanism/abnormal physiology etc).

Data was collected and collated at the end of the study and tables produced to show High/Low Gestalt and actual outcome.

Significance of injury was decided on the basis of change of treatment or requiring admission under a specialty team other than EM. All trauma scans were eligible and no exclusion criteria were specified.

Results

98 completed forms were able to be used, (of a potential 180).

For the 98 cases where the forms were filled and the patient met our trigger for a trauma team, TTL sensitivity and specificity were calculated.

Sensitivity was 77.42% (58.9% to 90.41%), Specificity was 86.67% (69.28% to 96.24%).

Likelihood Ratio

LR (positive test)=5.80 (2.52 to 14.80)

LR (negative test)=0.26 (0.12 to 0.47)

The primary reasons for exclusion were incomplete documentation and trauma scans not being done (patients for whom trauma chart documentation was used but who did not meet the preset criteria).

Conclusion

Although TTLs are reasonably accurate when it comes to deciding who should have a full trauma scan we are not sufficiently good (as a group) to determine whether a scan should go ahead on clinical acumen alone. Although disappointing in some ways this should give us further evidence in our discussions with radiology colleagues about the need for a major trauma CT scan.

We are good, but not quite good enough to avoid the scan.
ANALYSING VARIATION IN STAFFING LEVELS, ATTENDANCES AND PERFORMANCE AGAINST THE 4-HOUR TARGET USING DATA FROM THE ROYAL COLLEGE OF EMERGENCY MEDICINE'S SENTINEL SITE SURVEY
Authors: Morris T , Mason S , O'Keeffe C
Published: November 2015

Objectives & Background

The achievement of safe and sustainable staffing levels has been highlighted as a major priority by the Royal College of Emergency Medicine's (RCEM) STEP campaign in the interests of reducing exit block and its associated problems. This study used data from the RCEM Sentinel Site Survey (SSS) to analyse variation and associations between staffing, numbers of attendees and performance against the 4-hour target in 12 emergency departments (EDs) in England.

Methods

A convenience sample of 12 EDs recorded the number of hours worked by all grades of staff on 20.03.14. The number attendances in each department was used to adjust for department size, and to calculate how long each staff grade could be expected to spend with the average patient in each department. SitRep data from NHS England was used to measure departmental performance against the 4-hour target in the week 17–23 March 2014.

Results

Having adjusted for attendances, variation was seen in all staffing grades between departments. The least variation between departments was observed in consultant hours per patient (mean=8.4 minutes, range=8.4 minutes). The most variation was observed in nurse hours per patient (mean=75 minutes, range=63 minutes). For doctors, core trainees (CT1-3) showed the most variation in hours per patient (mean=14.4 minutes, range=31.2 minutes).

A significant association was observed between numbers of attendances and the number of hours worked by doctors (Spearman's Rank=0.643, P=0.024). This association was not seen between nursing hours and attendances (Spearman's Rank=0.071, P=0.077). No significant association was observed between staffing levels per patient and performance against the 4-hour target (P=0.829, P=0.186 for doctors and nurses respectively).

Conclusion

After adjusting for attendances variation in staffing hours can be seen in all EDs. Hours worked by doctors were seen to be associated with attendances, however hours worked by nurses were not. The number of staff hours recorded in departments was not significantly associated with departmental performance against the 4-hour target. Further analysis in a greater number of EDs across the UK would provide greater insight into variability in numbers of staff, and how this impacts patients attending the department.
HIV TESTING IN A DISTRICT GENERAL HOSPITAL'S EMERGENCY DEPARTMENT
Authors: Smith C , Kendall R
Published: November 2015

Objectives & Background

Princess Royal University Hospital (PRUH) is in Bromley, where local HIV prevalence is 2.5 in 1000.1National guidelines recommend considering HIV screening in certain hospital settings, where prevalence is greater than 2 in 1000.2It is estimated that 24% of people with HIV remain undiagnosed,3with clear benefits of early diagnosis including decreased morbidity, mortality, and healthcare cost. Screening programmes in emergency departments (EDs) may be useful but present challenges,4and pilots have run in large EDs5 but we are unaware of similar schemes in smaller EDs.

Methods

For five days in November 2014 between 8 am and 8 pm, we offered an HIV blood test to all patients aged 18–75 attending PRUH ED's walk-in triage. Participants were informed of the result two to three weeks later, and asked for feedback about the study. Any positive results would be followed up by HIV specialist services.

Questionnaires regarding perceived acceptability and relevance of testing were distributed to staff working in the department.

Results

112 patients were eligible for the test; of these, 88 (78.6%) accepted and 24 (21.4%) declined. Of the 88 tests performed, we established an accurate result in 76. All 76 (100%) patients tested negative for HIV. We were able to inform 68 patients of their negative result; of the other 8 patients, 2 had died and 6 were not contactable.

Results from patient questionnaires showed patients most commonly declined due to recent testing, or perceived low risk status.

The majority of staff questionnaire respondents felt routine HIV testing in the ED was beneficial and acceptable.

Conclusion

Our results confirm patient acceptability of routine HIV testing in EDs, demonstrated by the high uptake of testing. We did not establish any HIV positive results, which was expected given the sample size and local prevalence. We showed routine HIV testing in EDs is feasible and has a high level of staff acceptability, both of which are promising for continuing routine HIV screening in PRUH. We hope to extend the screening to all medical admissions to the hospital, as recommended by current national guidelines.
CORRELATION BETWEEN TRANSCUTANEOUS AND ARTERIAL CO2 PARTIAL PRESSURES IN ACUTE CARE
Authors: Ward E , Hussain S , Coats T
Published: November 2015

Objectives & Background

Partial pressures of carbon dioxide (pCO2) and oxygen (pO2) in arterial blood are used in emergency department (ED) settings to assess disease severity and guide management. Measurement is usually performed via arterial blood gas (ABG) analysis which is painful and invasive. Transcutaneous monitoring (TCM) of blood gases has been used extensively in neonates as an alternate means of measuring pCO2 and pO2 though its use in adults is not well researched. A good correlation is seen between TCM and ABG analysis of pCO2 in ideal conditions in highly selected patients. This study evaluated the relationship between TCM and ABG analysis in a “real world” emergency care situation.

Methods

Breathless patients presenting to the ED at the Leicester Royal Infirmary requiring ABG analysis were considered for inclusion to the study. In suitable patients the TCM4 monitor (Radiometer) was attached as per manufacturer's instructions to measure tcpCO2 and tcpO2 at the time of ABG analysis. Patient demographics and clinical observations were noted. Data was initially analysed using Microsoft Excel, and Bland Altman analysis was performed using GraphPad Prism.

Results

Paired measurements were recorded from 21 patients. The relationship between tcpCO2 and PaCO2 (see Figure) showed a strong correlation (R2=0.9), with a weaker correlation for O2 (R2=0.5). Bland Altman analysis showed a mean difference for pCO2 of −0.82kPa, with 95% limits of agreement from −2.49 to +0.84 kPa. For O2 the mean difference was 0.46 kPa (95% limits −5.72 to +6.64). Skin perfusion and BMI had no effect on the accuracy of TCM. TCM tracings must be evaluated for signal quality before a reading can be interpreted (in the same way that pulse oximetry readings are only valid if there is a ‘good’ trace). Electrode failure due to non-adherence of the fixation ring was common, often requiring re-application. In contrast to ABG sampling, TCM was very acceptable to patients with no reports of discomfort.

Conclusion

Pragmatic ‘real world’ use of TCM in unselected emergency care patients does not show as close a relationship as previous studies however limits of agreement indicate that tcpCO2 is likely to be clinically useful in an ED setting. For pO2 the agreement was weaker however in clinical care pCO2 is often a larger determinant of treatment. A clinical trial is needed to compare standard care (current BTS COPD guideline) against treatment directed by TCM.

Figure 2

The relationship between tcpCO2 and PaCO2 (n=21).
WHAT DO THEY DO OUT THERE?
Authors: Turner C , Turner J
Published: November 2015

Objectives & Background

It is a frequent source of frustration to many clinicians (and others) that they do not understand what each other do all day. This can result in unnecessary antagonism and frustration. As a relatively new (and evolving) specialty EM has the potential to be poorly understood by other clinicians and groups.

We aimed to break down the activities of consultants on shop floor shifts so that they might be better understood both internally and externally to our department.

Methods

This is a single site, convenience sample (all consultant shifts covered), 2 month study in a MTC. GAfREC approval was given. A group of 6 medical students were identified and trained in methodology for using our locally derived consultant activity tool.

We decided upon an iterative method of recording consultant activity. Consultant activity was recorded in 4 hour blocks, with minute by minute subdivision.

A recording tool revision occurred after 12 hours, with minor changes. Results were entered into Excel and are shown below.

Results

48 hours of shop floor consultant time have been observed. The most common task was discussing or reviewing patients- 26% 15% of the shift is spent dealing with operational issues in the department.

Consultants are interrupted approx 17 times per hour. 14% of the shift is spent actively (explicitly) teaching Both running trauma and performing procedures take about 4% of the time each.

Conclusion

Shop floor shifts require consultants to be performing a myriad of different tasks. Task saturation is clearly a risk and interruptions are frequent.

Operational issues take up a significant amount of time but reassuingly the single most time consuming activity is direct patient care (through discussion or actually seeing the patient).

Further work around the psychological toll and techniques used to promote resilience in the consultant body would be valuable.
SEEING IS BELIEVING: THE LIVECITY AMBULANCE E-HEALTH TELEMEDICINE PROJECT
Authors: Gilligan P , Amadi-Obi A , Sheung P , Alrmawi A , Gasem J , Tynan C , Khashab A , Gannon S , Mutawa A , Eswararaj M , Little R , Padki A , Houlihan A , Owens N , Morris D , Merriman W , O'Donnell C
Published: November 2015

Objectives & Background

The European Commission funded LiveCity Project e-health research involved a multidisciplinary team including telecommunication engineers, network engineers, hardware and software engineers, paramedics, nurses, doctors and research scientists. The intention had been to use off the shelf hardware and open access software to establish an internet based audiovisual communication over a 3 G network between the communication hub in the Emergency Department and the site of the emergency. It was intended to assess the feasibility of providing pre-hospital telemedicine and to assess it's clinical impact.

Methods

The 289 control patients were recruited in the Emergency Department by a member of the research team whilst the 34 patients in the intervention arm who underwent a telemedicine consultation were recruited by a researcher who accompanied the ambulance to the site of the emergency. The quality of audio-visual communication was monitored throughout each of the 34 patient's pre-hospital telecommunication consultations. The impact of the telemedical interaction on patient care was assessed.

Results

The deployment of the wearable device in the field was associated with a number of significant challenges Including server and network issues associated with a failure to establish a link or loss of signal. The hardware evidenced issues with battery failure in the camera or hard drive, over heating of the hard drive, damage to the dongle, tearing of the back packs, breaks at connection points to the hard drive. There was an issue of delay between the audio feed and the video feed and a delay created by the encryption of both. There was freezing of images, pixilation of images, degradation of sound quality, loss of signal with movement. There was looping of the audio signal. In 33 of 34 patients the telemedical consultation was compromised by technological challenges but it was possible to obtain clinically useful information.

Conclusion

Bespoke wearable hardware and software need to be developed for telemedicine in the pre-hospital environment.A 3 G network does not reliably support continuous uninterrupted audio-visual telemedicine in the pre-hospital setting. Paramedics infrequently require medical oversight but when they do it needs to work first time every time.
IDENTIFYING WORKPLACE STRESSORS IN THE EMERGENCY DEPARTMENT—AN EXPLORATORY STUDY
Authors: Basu S , Yap C , mason S
Published: November 2015

Objectives & Background

Stress amongst ED staff has been studied previously with observational research conducted since the 1980s. Many have measured outcomes of exposure to stress such as mental ill-health and more recently burnout. The factors which underlie workplace stress in the ED however are not well understood. This study aims to explore these issues in more detail.

Methods

The HSE stress indicator tool was administered to all staff working in the ED at the Northern General Hospital in Sheffield in November 2014 (Doctors, Nurses, Support Workers, Admin, Orderlies and Domestics). Results were analysed using the HSE analysis tool which compared our results against 136 other surveyed organisations in the UK. Following the survey, six focus groups containing a mixture of professional groups were held in which results were presented, factors underpinning observed results were discussed and issues that were not identified in the questionnaire highlighted. A more detailed questionnaire was developed.

Results

Overall response rate was 66%. All six staff groups identified high levels of demand and low levels of control over their work. Nursing staff displayed the highest levels of stress across the seven domains of the tool with little difference with respect to seniority of grade. Junior doctors displayed the lowest levels of stress of all professional groups. Higher levels of stress were seen in consultants than other medical grades. Orderlies and domestics whilst scoring higher on the demand/control domains, scored similarly to other groups with respect to support and relationships with colleagues (Table 1). Focus groups with staff identified issues relating to effort-reward imbalance and organisational justice which were not covered by the HSE tool. A more detailed questionnaire including these models of stress will be administered in July 2015 and to a control group from another hospital department which will be presented at the conference if the abstract is accepted.

Conclusion

This exploratory study has identified differences in the origins and nature of workplace stressors affecting professional groups in our ED. If they are to be successful, interventions aimed at tackling workplace stress in the ED should take account of these differences. Further work should explore whether our results reflect those of other EDs and develop appropriately tailored intervention to address this issue on a wider scale.

Figure 1
THE DOCTOR WILL SEE YOU NOW: A STUDY OF PERSPECTIVES ON TELEMEDICINE IN THE PRE-HOSPITAL ENVIRONMENT
Authors: Gilligan P , Houlihan A , Padki A , Amadi-Obi A , Owens N , Khashab A , Mutawa A , Eswararaj M , Gannon S , Alrmawi A , Gasem J , Sheung P , Tynan C , Little R , Merriman W , O'Donnell C , Morris D , Chochliouros I
Published: November 2015

Objectives & Background

The LiveCity Project funded by the European Commission included the development of hardware and software and the provision of a telecommunication infrastructure with high-speed internet to allow for an encrypted audio-visual video communication from the site of an emergency to the Emergency Department. Having previously performed a questionnaire based study on telemedicine amongst paramedics we extended our research to examine if Doctors, nurses and patients in the Emergency Department felt it would be beneficial and would want and accept telemedicine in pre-hospital emergency care.

Methods

Two separate seventeen item questionnaires were developed by the research team in consultation with the key stakeholders for patients and staff. Two members of the research team approached doctors, nurses and patients in the Emergency Department to consent them to enrolment in the study. Statistical analysis was performed using SPSS software. The comments and statements from the qualitative data were analysed using simple thematic analysis.

Results

100% (56) of patients said they would like the technology used if they were in an ambulance and possibly suffering a stroke or a major injury, and 96.3% (54) said they would like it used if they were possibly suffering a heart attack. 83.3% (n=10) of doctors and 89% (n=16) of nurses were in favour of using pre-hospital video platform technology in stroke, Myocardial infarction and major trauma. The potential benefits were felt to be in diagnosis of time-dependent illnesses, time management in the ED, increased hospital preparedness for incoming patients and increased triage efficiency. Nurses and Doctors expressed concern that there may be difficulty operating the technology in situations such as adverse weather conditions, low light levels and in remote areas without network coverage. Concerns regarding potential breaches in patient confidentiality were noted.

Conclusion

99% of patients, 92% of Doctors and 94% of nurses saw the potential of an audio-visual link from the pre-hospital environment to the Emergency Department. Stakeholder enthusiasm for pre-hospital telemedicine must be met with the technological requirements to provide such a service. As noted by one patient a pre-hospital audio-visual link to the Emergency Department could be a “potentially a life saving service”.
AUDIT STANDARDS IN PAEDIATRIC SEVERE SEPSIS
Authors: Mackenhauer J , Cantle F
Published: November 2015

Objectives & Background

Severe sepsis in the paediatric population is a rare, but serious condition that requires prompt recognition and management in the Emergency Department. Whereas severe sepsis in the adult population is being continuously monitored using standardized quality measures, data on performance in the paediatric population is sparse in our institution. We hypothesized that performance can be measured using available data sources. The aim of this study was to measure baseline performance using the RCEM adult-sepsis audit standards in the paediatric population with severe sepsis.

Audit result: Paediatric severe sepsis

Audit standardRCEM adult standardAudit result paediatrics (n= 19)Missing data (n) Vital signs recorded fully within 15 mins100%47%0Capillary glucose recorded in ED (anytime) 100%84%1Intravensous fluid bolus given within 1 hour75%42%1Serum lactate measured in ED (anytime)100%89%1Antibiotics within 1 hour of arrival50%42%1Blood cultures obtained prior to antibioticsStandard (%) not defined by RCEM37%0Urine dip obtained in EDNot part of RCEM standard21%1Assessment by doctors within 30 minsNot part of RCEM standard84%1

Methods

This is a single-centre descriptive study from a university hospital with 30,000 A&E-paediatric attendances per year. Data were collected from January 2012 through April 2015. Inclusion criteria were children (<16y) admitted through the A&E with direct transfer to paediatric ITU with evidence of sepsis in the A&E. Cases were identified by ICD diagnosis of sepsis upon discharge from PICU. We did not include transfers from other hospitals.

Baseline data was collected from the electronic patient system: Age, gender, pre-morbid conditions, as well as in-hospital mortality and length of stay (LOS). The RCEM standards for adult sepsis, as well as adapted measures, were extracted from the scanned hand written ED charts: Timing of bedside assessment by doctor, blood cultures, antibiotics, and fluids. Measurements of lactate and blood glucose.Monitoring of vital signs upon arrival, and documentation of urine dip and presumed focus of infection.

Results

We identified 19 cases of paediatric sepsis admitted through the A&E. 13 of 19 cases (68%) were male, median age was 70 days and 8 of 19 (42%) were born at term with no significant past medical history. Median LOS in hospital was 5 days, and all patients (100%) survived to discharge. Please see table for audit results.

Conclusion

Available data sources can be used to measure baseline performance in the paediatric population with severe sepsis. We did not fulfil any of the RCEM adult-sepsis audit standards. Timeliness of vital signs and administration of first fluid bolus seem to be amongst the biggest challenges in our institution. Further research is needed to investigate if continuous monitoring on these measures will improve performance.
DELAYED PRESENTATION HEAD INJURIES: WHICH PATIENTS PRESENTING AFTER 24 HOURS NEED A SCAN?
Authors: Marincowitz C , Townend W
Published: November 2015

Objectives & Background

NICE guidelines are used to triage the 1.4 million patients attending the ED with head injury in England and Wales annually for CT imaging. These guidelines are based on research conducted in populations presenting within 24 hours of injury. We therefore postulated that they might not apply to those presenting later in the same way.

Objectives:

1) Estimate the proportion of CT head scans requested for patients presenting more than 24 hours after injury.

2) Compare the CT abnormality rate within and after 24 hours of injury.

3) Compare the use of the NICE guidelines and their sensitivity for intracranial injury within and after 24 hours.

Methods

We reviewed ED trauma CT head requests from Hull Royal Infirmary for 6 months from Nov 2011. Requests were matched to ED records where possible. Correlation between the presence of a NICE indication and traumatic intra-cranial injuries was assessed (Pearson Chi-square test- SPSS 22).

Results

676 scans were performed for adult head trauma. 8.6% showed a traumatic abnormality; 1.2% required neurosurgery and 0.3% died. 650 records were available. The proportion of CT head scans completed for head injury patients presenting after 24 hours of injury was 15.5% (12.7–18.3% (95% CI). The CT abnormality rate was 8.4% (6.1–10.7% 95 CI) within and 9.9% (4.1–15.7% 95% CI) after 24 hours. 13.7% of CT scans within 24 hours and 38.6% of CT scans after were completed in patients with no NICE indication. Within 24 hours, NICE guidelines predicted 45/46 intracranial injuries (97.8% sensitivity [87–99.9% 95% CI]) and 7/10 injuries after (Sensitivity 70% [35.4–91.9% 95% CI]). The correlation between NICE indication and CT head abnormality for patients presenting within 24 hours (Chi-Square P=0.018) was not found in those presenting later (Chi-Square P=0.556).

Conclusion

15.5% (12.7–18.3% (95% CI) of scanned patients presented after 24 hours. The abnormality rate was similar to that found in those presenting earlier. NICE guidelines were less predictive in this group. A different approach for such patients may be required.