bluuebunny/crossref_metadata_2025 huggingface dataset:
TOLERABILITY OF PREDNISOLONE AND DEXAMETHASONE IN CHILDREN IN SAUDI ARABIA
Authors: Aljebab Fahad , Alanazi Mofadhi , Choonara Imti , Conroy Sharon
Published: August 2016

Background

Corticosteroids are used to treat a variety of medical conditions including acute asthma and croup where they are often given in short-courses. Epidemiological studies in Saudi Arabia show an increasing prevalence of respiratory diseases such as asthma in the past three decades.1 This study aimed to evaluate the tolerability and palatability of oral prednisolone and dexamethasone in children in Saudi Arabia. Both drugs are available in different formulations from different pharmaceutical companies.

Methods

Prospective observational and interview study. The palatability of the oral corticosteroids was evaluated by asking children and their parent's opinions of the taste and acceptability of the medication soon after drug administration. Children were asked to point at the appropriate face on a 10-cm visual analogue scale depicting five degrees of pleasure: 1 ‘dislike very much, 2 ‘dislike a little’, 3 ‘not sure’, 4 ‘like a little’ and 5 ‘like very much’.2 The tolerability of the drugs, in particular nausea, vomiting and abdominal pain was also evaluated by direct questioning of the parent/patients after each drug administration, and at the end of the course. Data was collected over three months, February to April 2015. Patients aged 2–18 years with any condition being treated with oral prednisolone or dexamethasone in hospital were approached to participate.

Results

122 patients (89 with asthma and 33 with croup) age range 2–11 years (mean=4.3) were recruited. 52 patients were given prednisolone base tablets, 37 patients were given prednisolone sodium phosphate syrup and 33 patients dexamethasone oral solution.

The palatability score was lowest for the prednisolone base tablet (Mean rating=1.12), (prednisolone sodium phosphate group, Mean=1.62, 95% CI −0.75, −0.26; P=0.000001) (dexamethasone group, Mean=1.97, 95% CI −1.11, −0.6; P=0.000001). Dexamethasone was rated the most palatable (prednisolone sodium phosphate, 95% CI 0.08, 0.62; P=0.012). Nausea and vomiting occurred only in patients given prednisolone base tablets (24 and five patients respectively). Both were statistically more frequent when compared with the prednisolone sodium phosphate group (only four patients had nausea) (95% CI 0.19, 0.52; P=0.000001 and 95% CI 0.1, 0.18; P=0.024 respectively). In the dexamethasone group only two patients had nausea. Abdominal pain was reported in 13 patients given prednisolone sodium phosphate syrup compared to eight patients in the prednisolone tablet group (95% CI 0.02, 0.38; P=0.032). In the dexamethasone group eight patients had abdominal pain.

Conclusions

Dexamethasone was the most palatable preparation though it did cause abdominal pain in nearly one quarter of patients. Prednisolone base tablets were rated the least palatable preparation and were also the least well tolerated.
OPINIONS OF USERS OF PHARMACY SERVICE PROVIDED TO PICU
Authors: Isaac Rhian , Gerrard Astrid , Bazaz Kevin
Published: August 2016

Background

Pressures to open pharmacy services 7 days a week, with no financial input for these extra resources, has knock on effects that may dilute accessibility to clinical pharmacists in specialist areas.

Aims

The aim of this survey was to assess opinions of the users of the current pharmacy services to PICU and the planned extended hours provision.

Method

An e-survey was sent to PIC Consultants, Advanced Nurse Practitioners, and Senior Nursing Staff following a six month period of increased clinical pharmacists time allocation to PIC. Free-text area was added to each multiple choice question.

Results

Twenty-four staff responded, 14 prescribers and 10 senior nurses

Presence of PICU trained clinical pharmacist on morning ward rounds was considered essential by 19 (79%) respondents and desirable by 4 (17%). Attendance on the afternoon round was deemed essential by 14 (59%) and desirable by 8 (33%) of respondents.

Comments on the benefits of pharmacists on ward rounds included:

“Enabling a second professional review of the patient overall—it prevents forced direction from the consultant and the pharmacists are empowered to ask us to reconsider. Very useful to have this safety and reality check.”

“Essential for the guidance of drug usage and drug chart review which improves safety, benefit of advice for use with specialist patients, best cost approach, multiple benefits.”

Roles expected as routine from the clinical pharmacist included patient safety (100%), managing parenteral nutrition (80%), advice on intravenous therapy e.g. compatibility (100%), education of the multidisciplinary team (96%), management of long term medicines e.g. sedation withdrawal (83%), and therapeutic drug monitoring control (83%).

Only 6 respondents felt the PICU patient would benefit from extending access to dispensary only over weekends, 11 felt that there was no benefit, and 6 respondent unsure.

Provision of the pharmacy on call service which involves both supply and clinical advice, was felt sufficient to the requirements of the PICU patient by less than a third of repondents,56% feeling the current service insufficient. Comments on the on call service included.

“difficult to get experienced advice on weekends”

“need access to pic pharmacists officially.”

“we may direct queries to the on call pharmacy staff but 9 times out of 10 theses queries are redirected to our PICU pharmacists. Our questions are answered at any time of the weekend”

Ninety one percent answered positively to the final question asked about extending the current clinical pharmacy service from 5 to 7 days per week. Comments included.

“PICU is a 24 hr, 7 day a week service…how we can provide adequate care to children if this valuable service is only provided 5 days a week.”

Conclusion

Pharmacy is a valued service on PICU, where the service users support increased access and attendance on certain ward rounds by specifically PICU trained pharmacist.
AN AUDIT TO ASSESS THE TIMINGS OF TTAS AND INPATIENT ORDERS IN PAEDIATRICS; FROM WRITING, TO SCREENING, TO DISPENSING, AND TO LEAVING DISPENSARY
Authors: Hale Ami , Christiansen Nanna , Calvert Heather
Published: August 2016

Aim

To assess the time it takes for paediatric TTA and inpatient orders to be dispensed and sent to ward. This is to establish if the Trust is meeting an operational Key Performance Indicator (KPI).

Standards (KPIs)

▸ 85% of urgent items (TTAs) dispensed within 1 hour.

▸ 85% of non-urgent items (most inpatient orders) dispensed within 3 hrs.

Method

To audit the time it takes for TTAs and inpatient orders to be screened, sent to dispensary, labelled, dispensed, checked, and leave dispensary. Data collection took place over 5 days and focused on TTAs and inpatient orders coming from high turnover paediatric wards.

Data was collected on: time to verify, time logged into dispensary, time for labelling, time for checking, and time to leave dispensary.

Exclusion criteria: TTAs/ inpatient orders that contain controlled drugs, requires a dosette box, or is ordered out of hours.

Results

TTA results:

The time from writing to screening of TTAs averages 1 hour 34 minutes. However, this may be inaccurate as it requires the doctor to select ‘sign and send to pharmacy’. If not selected, the clock has started, but the TTA is not visible to pharmacy.

It took on average 2 hrs for all items from being logged in to being checked (n=12). The standard is 1 hour. The rate limiting steps were time to screen and time to label (each of which took approx. 1 hour 30 mins).

The majority of the dispensing time is spent labelling, with an average time from logging in to labelling being 1 hour 25 minutes. The dispensing and checking was quick with an average of 36 minutes.

Inpatient results

Inpatient orders took on average 5 hrs 51 minutes for the items to leave dispensary after they had been logged in (n=22). The standard for non-urgent work is 3 hrs.

Time to screen was not recorded as the doctors do not record the time of prescribing on the inpatient drug chart. There is only a 6 minute delay between faxing orders and it being logged in, therefore no problem identified at that stage.

The majority of time was spent labelling, with an average time from logging in to labelling being 1 hour 56 minutes.

Conclusion

Standards are not being met. The rate limiting steps appears to be labelling in dispensary.

Proposals

▸ Additional staff labelling at peak times

▸ Slow dispensing system, liaise with IT to see if improvements can be made

▸ Unable to have more labelling terminals as the robot only has three shoots

▸ Induction teaching to include importance of sending TTAs to pharmacy after writing

▸ Re-audit in 3 months

Limitations

Lack of data

The screening time for TTAs is misleading as it captures the time from writing (rather than time of sending to pharmacy), until the time screened.

No data on time taken for items to arrive back onto the ward, or if medicines collected or delivered by porter.
OPTIMISATION OF PHARMACY CONTENT IN PAEDIATRIC ONCOLOGY AND HAEMATOLOGY CLINICAL TRIAL PROTOCOLS. EXPERIENCE OF CHEMOTHERAPY PHARMACY ADVISORY SERVICE (CPAS) FROM 2011 TO PRESENT
Authors: Greer Rachel , Harvey Sally
Published: August 2016

Aim

Clarity and accuracy of the pharmacy aspects of cancer clinical trial protocols is essential. Inconsistencies and ambiguities in protocols have the potential to delay research and jeopardise both patient safety and the collection of credible data. The Chemotherapy and Pharmacy Advisory Service (CPAS) was established in 2007 by the UK National Cancer Research Network, currently known as National Institute for Health Research Clinical Research Network, to improve the quality of pharmacy-related content in cancer clinical trial protocols. This abstract describes the scope of CPAS, its methodology of mandated protocol review and an analysis of the issues found and reported in paediatric oncology and haematology trials.

Method

All paediatric oncology and haematology clinical trial protocols from 2011 to present were included in this study. A review checklist was developed by CPAS and used by the review panel, consisting of pharmacists, doctors and nurses, to standardise the evaluation of all protocols. Once completed, all reviews were collated and any queries and inconsistencies were fed back to Chief Investigators and study sponsors. The most common remarks made at protocol review were summarised and categorised through retrospective analysis. It is at the discretion of the study Sponsor and Chief Investigator to accept any recommendations or amendments based on the findings. In order to evaluate the impact of the service, Chief Investigators were asked to respond to queries made at protocol review and make appropriate changes to their protocols. Responses from Chief Investigators have been collated and acceptance rates determined.

Results

A total of 13 paediatric protocols were reviewed during this period. The mean number of comments per protocol was 32 and these mainly concerned the drug regimen, support medication, dose calculation, drug information and administration. Eleven of the Chief investigators returned responses to their protocols reviews. All responses were positive with an overall acceptance rate of 82% of the proposed protocol changes.

Conclusion

Review by CPAS of pharmacy content of paediatric oncology and haematology clinical trial protocols prior to final approval is feasible and exposes many undetected clinically relevant issues that could hinder efficient trial conduct and/or patient safety. This analysis has highlighted that the majority of suggestions were deemed clinically significant and effectively incorporated into the final protocols. The refinement of existing and development of further pharmacy-related guidance documents by CPAS might support more effective and safer clinical research.
Challenges of treating incidental synchronous bilateral breast cancer with differing tumour biology
Authors: Esclovon Jonathan Walter , Ponder Melissa , Aydin Nail , Misra Subhasis
Published: August 2016

A 59-year-old woman with right breast mass was diagnosed with invasive ductal carcinoma (IDC). Workup consisted of bilateral diagnostic mammogram and ultrasound (US); both showed a right breast mass with normal left breast. Core biopsy showed IDC with estrogen receptor negative (ER−)/progesterone receptor negative (PR−) and HER2/neu positive receptor status. The patient underwent carboplatin-based chemotherapy with Herceptin. The mass completely resolved. The patient desired to proceed with bilateral total mastectomy with right sentinel lymph node biopsy (SLNB). Pathology showed complete resolution of the right-sided breast mass without malignancy in right SLN. Incidentally, IDC was found in the left breast specimen, which was ER+/PR+ and HER 2/neu negative. Tumour board consensus was to obtain a left axilla US with MRI in 6 months if the US was unremarkable. Biologically different synchronous bilateral breast cancer poses a difficult clinical challenge for management due to differing responses to treatment. Use of MRI may be a diagnostic option in women who choose contralateral prophylactic mastectomy.
Utility of wireless motility capsule and lactulose breath testing in the evaluation of patients with chronic functional bloating
Authors: Triadafilopoulos George
Published: August 2016

Background

The precise aetiology of chronic bloating remains poorly understood and underlying gastroparesis, small bowel bacterial overgrowth and colonic inertia may, individually or collectively, play a role.

Aims

In this retrospective cohort analysis of symptomatic patients with chronic persistent bloating, we determined the clinical utility of wireless motility capsule and lactulose breath test in further defining the underlying aetiology for functional bloating.

Methods

Consecutive patients with chronic bloating underwent clinical assessment, wireless motility capsule testing and lactulose breath testing using standard protocols.

Results

52 patients qualified for inclusion in this analysis, fulfilling Rome III criteria for functional bloating. Most patients (54%) had an abnormal wireless motility capsule study; of those, 11.5% had evidence of gastroparesis, 7.7% had small bowel transit delay, 15.8% had colonic inertia, 3.8% had delayed gastric and small bowel transit, 5.6% had combined gastric and colonic transit delay, 3.8% had delayed small bowel and colonic transit, and 5.6% had delayed gastric, small bowel and colon transit times. Using clinical questionnaires the median scores for bloating, constipation and eructation were not significantly different. Neither constipation nor eructation was specific to gastroparesis or colonic inertia but bloating was numerically more prevalent and severe in patients with delayed small bowel transit. 40% of patients had positive lactulose breath test but had no distinguishing clinical characteristics.

Conclusions

Chronic functional bloating may reflect underlying gastroparesis, small intestinal bacterial overgrowth or colonic inertia. Wireless motility capsule and lactulose breath test are useful in the assessment of patients with bloating and should be considered during evaluation.
Respiratory rate and pulse oximetry derived information as predictors of hospital admission in young children in Bangladesh: a prospective observational study
Authors: Garde Ainara , Zhou Guohai , Raihana Shahreen , Dunsmuir Dustin , Karlen Walter , Dekhordi Parastoo , Huda Tanvir , Arifeen Shams El , Larson Charles , Kissoon Niranjan , Dumont Guy A , Ansermino J Mark
Published: August 2016

Objective

Hypoxaemia is a strong predictor of mortality in children. Early detection of deteriorating condition is vital to timely intervention. We hypothesise that measures of pulse oximetry dynamics may identify children requiring hospitalisation. Our aim was to develop a predictive tool using only objective data derived from pulse oximetry and observed respiratory rate to identify children at increased risk of hospital admission.

Setting

Tertiary-level hospital emergency department in Bangladesh.

Participants

Children under 5 years (n=3374) presenting at the facility (October 2012–April 2013) without documented chronic diseases were recruited. 1-minute segments of pulse oximetry (photoplethysmogram (PPG), blood oxygen saturation (SpO2) and heart rate (HR)) and respiratory rate were collected with a mobile app.

Primary outcome

The need for hospitalisation based on expert physician review and follow-up.

Methods

Pulse rate variability (PRV) using pulse peak intervals of the PPG signal and features extracted from the SpO2signal, all derived from pulse oximetry recordings, were studied. A univariate age-adjusted logistic regression was applied to evaluate differences between admitted and non-admitted children. A multivariate logistic regression model was developed using a stepwise selection of predictors and was internally validated using bootstrapping.

Results

Children admitted to hospital showed significantly (p<0.01) decreased PRV and higher SpO2variability compared to non-admitted children. The strongest predictors of hospitalisation were reduced PRV-power in the low frequency band (OR associated with a 0.01 unit increase, 0.93; 95% CI 0.89 to 0.98), greater time spent below an SpO2of 98% and 94% (OR associated with 10 s increase, 1.4; 95% CI 1.3 to 1.4 and 1.5; 95% CI 1.4 to 1.6, respectively), high respiratory rate, high HR, low SpO2, young age and male sex. These variables provided a bootstrap-corrected AUC of the receiver operating characteristic of 0.76.

Conclusions

Objective measurements, easily obtained using a mobile device in low-resource settings, can predict the need for hospitalisation. External validation will be required before clinical adoption.
Relationship between occupational stress and job burnout among rural-to-urban migrant workers in Dongguan, China: a cross-sectional study
Authors: Luo Hao , Yang Hui , Xu Xiujuan , Yun Lin , Chen Ruoling , Chen Yuting , Xu Longmei , Liu Jiaxian , Liu Linhua , Liang Hairong , Zhuang Yali , Hong Liecheng , Chen Ling , Yang Jinping , Tang Huanwen
Published: August 2016

Objectives

In China, there have been an increasing number of migrant workers from rural to urban areas, and migrant workers have the highest incidence of occupational diseases. However, few studies have examined the impact of occupational stress on job burnout in these migrant workers. This study aimed to investigate the relationship between occupational stress and job burnout among migrant workers.

Design

This study used a cross-sectional survey.

Setting

This investigation was conducted in Dongguan city, Guangdong Province, China.

Participants

3806 migrant workers, aged 18–60 years, were randomly selected using multistage sampling procedures.

Primary and secondary outcome measures

Multistage sampling procedures were used to examine demographic characteristics, behaviour customs and job-related data. Hierarchical linear regression and logistic regression models were constructed to explore the relationship between occupational stress and burnout.

Results

Demographics, behaviour customs and job-related characteristics significantly affected on burnout. After adjusting for the control variable, a high level of emotional exhaustion was associated with high role overload, high role insufficiency, high role boundary, high physical environment, high psychological strain, high physical strain, low role ambiguity, low responsibility and low vocational strain. A high level of depersonalisation was associated with high role overload, high role ambiguity, high role boundary, high interpersonal strain, high recreation, low physical environment and low social support. A low level of personal accomplishment was associated with high role boundary, high role insufficiency, low responsibility, low social support, low physical environment, low self-care and low interpersonal strain. Compared to the personal resources, the job strain and personal strain were more likely to explain the burnout of rural-to-urban migrant workers in our study.

Conclusions

The migrant workers have increased job burnouts in relation to occupational stress. Relieving occupational stress and maintaining an appropriate quantity and quality of work could be important measures for preventing job burnout among these workers.
Poised for take-off – research activities within a hospice collaborative
Authors: Leung Joanne
Published: August 2016

Background

Four adult hospices within one region are working in partnership as a Hospice Collaborative (the Collaborative), the Collaborative has sought strategic funding for a research practitioner to support research activities since late 2015. To further develop the embryonic research work in the locality, the Collaborative is anticipated to build partnerships with external organisations to exchange professional knowledge and expertise (Hospice UK, 2013).

Aims

To support and develop research activities across the Collaborative

To identify opportunities to work in partnership with external organisations

Method

Members of an existing local research group provide expertise from various backgrounds, including primary care services, universities and research institutes. This research group has fostered partnerships between the Collaborative and external organisations to exchange expertise, information and knowledge in palliative and end-of life care.

Results

An initial collaborative work can be demonstrated by the planned art workshop between one of the hospices within the Collaborative and a local university, to explore the latent thoughts and feelings about death and dying with patients and carers. Other planned collaboration works include organising a research design workshop to aid hospice staff with their fundamental research skills. The recruitments of the NIHR Portfolio studies and potential organic collaborative projects are expected to rise across the Collaborative, resulting from research ideas being circulated amongst the research group.

Conclusion

Through the continuing research development of hospice staff in the locality, it is expected that the research activities will continue to grow across the Collaborative as well as between external organisations.

Reference

Hospice UK.Future needs and preferences for hospice care: challenges and opportunities for hospices. A working paper of the Commission into the Future of Hospice Care; 2013https://www.hospiceuk.org/docs/default-source/default-document-library/future-needs-and-preferences-for-hospice-care-challenges-and-opportunities-for-hospices.pdf. Accessed May 29, 2016
Responding 24/7: an evaluation of urgent admission requests to the hospice
Authors: Downham Esther , Carduff Emma , Whyte Graham
Published: August 2016

Introduction

Provision of 24/7 palliative care is a national priority. Hospices endeavour to respond to the palliative care needs of patients and families timeously, though resources are limited.

Aim

This study aimed to evaluate urgent admission requests to the hospice, via the on-call doctor.

Methods

Data on time of call; reason for and source of referral (GPs, community nurses, patients and families); whether the patient was known to the hospice; and details about the decision to admit were collected prospectively over three months.

Results

There were 131 admissions to the hospice. Fifty-seven requests for urgent admission were recorded, the majority for symptom control (n = 34). Thirty-eight (67%) were considered appropriate requests - defined as patients with specialist palliative care needs that could not be met elsewhere. Twenty (53%) appropriate requests were admitted the same day, and 10 (26%) the following. Eight patients (21%) were not admitted because of bed or staff shortages; four were directed to the acute sector as an alternative place of care.

Nineteen (33%) requests were not accepted, mostly because they were considered clinically inappropriate. However, six (11%) were provided with support and advice which enabled patients to remain in their current setting.

Conclusions

There is a need for direct access to a specialist palliative care doctor as this service is frequently used. Most appropriate requests for urgent admission were admitted within one day, suggesting a responsive service. Education for healthcare professionals is needed to ensure appropriate hospice referral, enabling patients to achieve their preferred place of care.

References

Palliative and end of life care Priority Setting Partnership. Putting patients, carers and clinicians at the heart of palliative and end of life care research: The James Lind Alliance; 2015

Ritchie L. Pulling together: transforming urgent care for the people of Scotland. Edinburgh, UK: Scottish Government; 2015
Out of hours palliative care support across boundaries: a review of the 24 hour advice line for south east wales from marie curie hospice cardiff and the vale
Authors: Osborn Hannah , Hayes Jo
Published: August 2016

Introduction

Marie Curie Hospice Cardiff and Vale runs a 24 hour specialist palliative care telephone advice line for patients, relatives and healthcare professionals covering the whole of South East Wales. It supports the fully established 7/7 Clinical Nurse Specialist (CNS) palliative care service across Wales. This is managed by staff nurses on the inpatient unit, coordinating with the relevant hospital or community CNS to provide ongoing support and follow up, with medical advice provided by the on call palliative medicine consultant.

Method

A retrospective review of 12 months advice calls April 2015–16.

Results

A total of 521 calls were recorded with an average of 43.4 calls per month. Only 135 of these were from patients previously known to Marie Curie. 35.6% of calls were from relatives, 5% from patients, 10.9% from ward nurses, 4% from DNs, 14% from GPs, 14.8% from hospital doctors, and 13.1% from clinical nurse specialists. The majority of patients were based in the community setting (66%) compared to inpatient (30%). Most popular type of advice required was symptom control, other types included psychological support, practical advice and medication queries. The calls were average length of 9.53 minutes (79.1 hours in 12 months), with the majority of calls falling over the weekend period.

Conclusion

This review demonstrates that Marie Curie Hospice Cardiff and the Vale is working collaboratively with other organisations in the area to extend support and advice to patients, relatives and healthcare professionals beyond its usual patient population 24/7.
Making sense of advanced cancer: using narrative at the end of life to identify information and supportive care needs
Authors: Baker Nicky , Armour Kathy , Redwood Sabi , Meystre Chantal , Dawson Angus
Published: August 2016

Introduction

Narrative research methods are widely used in social sciences to gain insight into illness experiences and social constructions of health. Qualitative analysis of narrative interviews are increasingly utilised to improve knowledge of individuals’ unmet needs at the end of life. However, use of storytelling to understand concepts of hope and meaning has been relatively underexplored in palliative care settings.

Aims

Explore the experiences of hospice patients with advanced cancer and their close relatives, and the impact of these on cancer beliefs.

Methods

Semi-structured interviews were conducted with 14 patients with breast, bowel or lung cancer in the last weeks or months of life, and their close family members. The social science literature and theory of narrative coherence guided qualitative analysis using a constant comparison method.

Results

Patient narratives followed a pattern of initial confusion and chaos at the time of diagnosis which later transcended to accounts focused on creating sense, hope and meaning. Leaving a legacy was an important part of fostering hope in the face of acceptance of dying. In contrast, narratives from relatives were dominated by persistent chaos, exemplified by a sense of helplessness and fear. Diagnostic delays, awareness of their own mortality and perceptions of ‘feeling out of the loop’ exacerbated these negative experiences, which frequently resulted in cancer fatalism and information avoidance.

Conclusion

Narrative analysis of individuals’ stories can facilitate development of client-centred palliative care services. Case studies are presented that demonstrate important points at which information provision and supportive care could be improved.
Are there too few women presenting at emergency medicine conferences?
Authors: Carley Simon , Carden Richard , Riley Rebecca , May Natalie , Hruska Katrin , Beardsell Iain , Johnston Michelle , Body Richard
Published: August 2016

Introduction

There is a perception that women are under-represented as speakers at emergency medicine (EM) conferences. We aimed to evaluate the ratio of male to female speakers and the proportion of presenting time by gender at major international EM conferences.

Methods

Conference programmes of the major English-speaking EM conferences occurring from 2014 to 2015 were obtained. The number of presentations, the gender of the speaker and the duration of each presentation were recorded.

Results

We analysed eight major EM conferences. These included 2382 presentations, of which 29.9% (range 22.5%–40.9%) were given by women. In total, 56 104 min of presentations were analysed, of which 27.6% (range 21%–36.7%) were delivered by women. On average, presentations by women were 95 s shorter than presentations by men (23 vs 21 min 25 s).

Conclusions

Male speakers exceed female speakers at major EM conferences. The reasons for this imbalance are likely complex and multifactorial and may reflect the gender imbalance within the specialty.
BET 2: Diagnosing acute myocardial infarction in the presence of ventricular pacing: can Sgarbossa criteria help?
Authors: Jothieswaran Arunan , Body Richard
Published: August 2016

The Sgarbossa criteria can be used to identify patients who have acute myocardial infarction (AMI) in the presence of left bundle branch block, which obscures the usual changes associated with ST elevation myocardial infarction. Patients with ventricular paced rhythm have ECG changes with similar morphology to left bundle branch block. A short-cut systematic review was carried out to establish whether the Sgarbossa criteria can accurately diagnose AMI in the presence of ventricular paced rhythm. Three 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 that
PERCEIVED AREAS FOR FUTURE INTERVENTION AND RESEARCH ADDRESSING CONVEYANCE DECISIONS AND POTENTIAL THREATS TO PATIENT SAFETY: STAKEHOLDER WORKSHOPS
Authors: O'Hara Rachel , Johnson Maxine , Hirst Enid , Weyman Andrew , Shaw Deborah , Mortimer Peter , Newman Chris , Storey Matthew , Turner Janette , Mason Suzanne , Quinn Tom , Shewan Jane , Siriwardena A Niroshan
Published: August 2016

Background

As part of a study examining systemic influences on conveyance decisions by paramedics and potential threats to patient safety, stakeholder workshops were conducted with three Ambulance Service Trusts in England. The study identified seven overarching systemic influences: demand; priorities; access to care; risk tolerance; training, communication and resources. The aim of the workshops was to elicit feedback on the findings and identify perceived areas for future intervention and research. Attendees were also asked to rank the seven threats to patient safety in terms of their perceived importance for future attention.

Methods

A total of 45 individuals attended across all the workshops, 28 ambulance service staff and 17 service user representatives. Discussions were audio-recorded, transcribed and thematically analysed. A paper based paired comparison approach was used to produce an ordinal ranking to illustrate the relative prioritisation of issues. Analysis included testing for internal consistency and between-rater agreement for this relatively small sample.

Findings

The two highest ranking priorities were training and development, as well as access to care. The areas for intervention identified represent what attendees perceived as feasible to undertake and relate to: care options; cross boundary working; managing demand; staff development; information and feedback; and commissioning decisions. Perceived areas for research specifically address conveyance decisions and potential threats to patient safety. 17 areas for research were proposed that directly relate to six of the systemic threats to patient safety.

Conclusions

Feedback workshops were effective in the validation of findings as well as providing an opportunity to identify priorities for future interventions and research. They also facilitated discussion between a variety of Ambulance Service staff and service user representatives. Ongoing collaboration between members of the research team has enabled some of the research recommendations to be explored as part of a mutually agreed research agenda.
COMPLICATIONS ASSOCIATED WITH SUPRAGLOTTIC AIRWAY USE IN AN URBAN AMBULANCE SERVICE: A CASE SERIES
Authors: Edwards Tim
Published: August 2016

Background

Current resuscitation guidelines deemphasise the role of endotracheal intubation (ETI) in cardiac arrest. Although supraglottic airways (SGA) are increasingly used in the management of prehosptial cardiac arrest, there is limited data relating to adverse events in practice.

Methods

Cases reported to an ambulance service medical directorate involving adverse events associated with SGA use in cardiac arrest were logged from April 2014–October 2015. Prehospital clinical notes were reviewed to determine patient demographics, details of adverse events, clinical course and patient disposition.

Results

A total of 6 cases were reported. All patients were male and aged between 35–83 years. The majority of cases (n=4) were associated with a history of choking and the supraglottic device was removed to facilitate ETI due to poor ventilation. In all these cases, laryngoscopy revealed the presence of food obscuring the glottis which was removed under direct vision. None of these patients presented in a shockable rhythm and 3 experienced sustained return of spontaneous circulation. In another case, insertion of the supraglottic airway resulted in traumatic avulsion of teeth necessitating direct removal under laryngoscopy. This patient presented in ventricular fibrillation following chest pain and achieved ROSC at the scene. The final case involved a 35 years male with an extensive history of deliberate self-harm who received ventilation via SGA throughout the resuscitation attempt. A plastic bag was found compacted into the airway at post mortem.

Conclusions

The majority of adverse events associated with SGA use in cardiac arrest related to airway obstruction following choking. ROSC in a number of these patients suggests this may have been a reversible cause of cardiac arrest. Future guidelines should emphasise the need for laryngoscopy to exclude foreign body airway obstruction prior to SGA insertion in appropriate cases.
STAKEHOLDER ENGAGEMENT IN THE DESIGN OF A NOVEL PRE-HOSPITAL ACUTE STROKE ASSESSMENT
Authors: Lally Joanne , McClelland Graham , Exley Catherine , Ford Gary , Price Christopher
Published: August 2016

Background

Outcomes for stroke patients can be improved by rapid identification and assessment, but delays commonly occur due to the availability of clinical information and brain imaging. We sought to develop a novel paramedic-led intervention to reduce scene to needle time for stroke patients suitable for thrombolysis.

Methods

Over 12 months we undertook group interviews and consultation in North East England, North West England and Wales involving patient representatives (n=20), paramedics, emergency department and stroke service hospital staff (n=100). The primary aim was to understand the impact of organisational boundaries, service pressures and traditional professional roles upon a new paramedic approach to stroke assessment. Secondly, to develop a clinical trial protocol for later evaluation of the proposed new paramedic approach. All interviews were digitally recorded, transcribed and analysed using open then focussed coding.

Results

Participant feedback supported an intervention which transgressed organisational and professional boundaries.

Modifications were made following participant views about logistical, ethical and governance issues:

▸ The protocol was changed to reflect operational barriers restricting paramedics taking patients directly to the CT scan room.

▸ Participants advocated obtaining research consent after admission in order to address concerns over treatment delays, and supported a trial protocol which allowed data collection from patients that died before consent was feasible.

▸ Paramedics would provide additional information at patient handover directly to the stroke team or A&E staff rather than attempt to convey more during pre-notification.

Conclusions

Following the interviews significant alterations were made to the intervention and protocol in order to improve trial feasibility, acceptability and data quality. This emphasizes the importance of engaging with ambulance services, other clinical teams and patients during the development of pre-hospital research protocols.
PRE-HOSPITAL TRAUMA RESEARCH…MAKING IT HAPPEN
Authors: Reeves Emma , Mitchell Natalie
Published: August 2016

Background

The Brain Biomarker after Trauma Cohort Study (BBATS) investigates potential biomarkers in traumatic brain injury, for guiding diagnosis, prognosis and treatment of brain injury. It has been running for 19 months. Blood samples must be obtained within 60 minutes (i.e. the ‘Golden Hour’) of traumatic injury. The National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC) trauma research team recruit patients at the scene of injury. This requires extensive collaboration with the ambulance service in order to achieve maximum recruitment in this cohort of patients.

Methods

Medical Emergency Response Incident Team (MERIT) training was conducted at the Queen Elizabeth Hospital, Birmingham (QEHB) and the West Midlands Ambulance Service by means of audio-visual presentations and group discussions. Awareness of the study in the Emergency Department (ED) of QEHB was ensured by regular training sessions with relevant staff. Ready-made blood bottle packs were delivered to the MERIT air ambulance base. The trauma research nursing team were available 24 hours a day, attending all trauma activations in ED. Delivery of quarterly interim results and recruitment progress is fed back to the ambulance team and ED staff.

Results

Trauma research nurses screened 481 patients for eligibility into BBATS. 72 (15%) were recruited within the first 19 months and of these only 42% were recruited during working hours, Monday to Friday 09:00–17:00. 409 patients did not meet inclusion criteria. Only 3 patients declined enrolment.

Conclusions

Pre-hospital enrolment of trauma patients into BBATS has been successfully undertaken through coordinated activity between the SRMRC trauma research nursing team and pre-hospital practitioners. However a large proportion of screened trauma patients are not recruited due to lack of blood sample during the ‘Golden Hour’. Achieving research in the pre-hospital setting is possible with clear infrastructure and collaboration established from the outset.
TRANSIENT ISCHAEMIC ATTACK 999 EMERGENCY REFERRAL (TIER): FEASIBILITY TRIAL
Authors: Rees Nigel , Bulger Jenna , Dewar Richard , Edwards Adrian , Evans Bridie , Moore Chris , Porter Alison , Seagrove Anne , Sewell Bernadette , Snooks Helen , Watkins Alan , Whitmann Shirley , Ali Khalid , Ford Gary , Pryce Alan , Quinn Tom
Published: August 2016

Background

Studies demonstrate TIA patients are at risk of further TIAs, stroke and death. TIA incidence is unknown, however estimated at 35 per 100,000 people annually in the UK, costing approximately £7 billion. Many TIA patients call 999, are assessed, stabilised and conveyed to Emergency Department (ED). Rapid assessment of TIA severity and risk and intervention is emerging as the new standard for TIA care leading to alternative pathways with direct referral to specialist services. However, uncertainties exist over this new model of care.

We will develop and assess feasibility of paramedic assessment and referral of low-risk TIA patients directly to TIA clinic for early review, thus providing timely specialist review without: adverse consequences; inconvenience of ED attendance; unnecessary cost to the NHS.

Methods

This feasibility trial is designed to test the methods of a pragmatic cluster randomised trial with a qualitative component. To develop the treatment protocol, training and referral processes, working with clinicians/stakeholders, we will conduct:

– survey across UK ambulance services to find referral pathways for low-risk TIA patients

– systematic review of TIA prehospital care

– paramedic focus groups pre-implementation

Then:

– randomise paramedics (intervention/control)

– recruit patients

– interview patients, key clinicians and service managers

– collect routine data

– hold paramedic focus groups post-implementation

We will:

– measure uptake and compliance with treatment protocols

– validate TIA assessment tool

– analyse qualitative data

– pilot recruitment processes

– test data collection methods

– estimate key outcomes effect size to inform full trial sample size calculation

Results

Will inform full trial development using criteria: intervention acceptability to practitioners and patients; trial design feasibility; outcome data completeness.

Conclusions

▸ If indicated, full trial conducted

▸ If not, but positive results – advise intervention development for immediate implementation

▸ If not, but negative results – advise delivery of intervention should cease.
NON RANDOMISED CONTROL STUDY OF THE EFFECTIVENESS OF A NOVEL PAIN ASSESSMENT TOOL FOR USE BY PARAMEDICS
Authors: Iqbal Mohammad , Spaight P Anne , Kane Ros , Asghar Zahid , Siriwardena A Niroshan
Published: August 2016

Background

Eighty percent of patients presenting to ambulance services present with pain. Pain is sometimes inadequately assessed and treated. Effective pain management can improve patient outcomes and experience. Previous qualitative research suggested that numerical verbal pain scores, usually used to assess pain in the ambulance setting, were poorly understood. We developed a new tool, the ‘Patient Reported Outcome Measure for Pain Treatment’ (PROMPT), to address this need. Initial testing showed that PROMPT had reliability and (face, content and predictive) validity. We aimed to investigate the effectiveness of PROMPT.

Methods

We used a non-randomised control group design in adult patients with chest pain or injury treated by intervention paramedics using PROMPT compared with control paramedics following usual practice for pain outcomes (reduction in pain score, use of analgesia). Routine data from electronic patient records were used to measure outcomes. We collected baseline rates of outcomes in patients treated by intervention and control paramedics, in a seven month period one year previously, to adjust for secular trends. The study was conducted in East Midlands Ambulance Service. We used regression analysis to compare groups for differences in pain score change and use of analgesics correcting for baseline rates and demographic differences.

Results

Twenty-five intervention paramedics used PROMPT (of 35 who were trained in its use) treating 300 patients over a seven month period. Data for these and 848 patients treated by 106 control paramedics were entered into SPSS and STATA12 for analysis. Mean reductions in pain score ( p<0.001) and use of analgesics was significantly greater (p<0.001) in patients managed by paramedics using PROMPT compared with those receiving usual care after adjusting for patient age, sex, clinical condition and baseline rates.

Conclusion

Use of the PROMPT resulted in greater reductions in pain score and increased use of analgesics compared with usual care.
Cerebral aneurysm treatment: modern neurovascular techniques
Authors: Jiang Bowen , Paff Michelle , Colby Geoffrey P , Coon Alexander L , Lin Li-Mei
Published: August 2016

Endovascular treatment of cerebral aneurysm continues to evolve with the development of new technologies. This review provides an overview of the recent major innovations in the neurointerventional space in recent years.
Improving assessment of Pandalus stocks using a seasonal, size-structured assessment model with environmental variables. Part I: Model description and application
Authors: Cao Jie , Chen Yong , Richards R. Anne
Published: August 2016

Pandalus species display the following features that make it difficult to apply traditional age-based stock assessment models: (i) difficulty of determining age in the absence of hard parts retained through the molt; (ii) sex change in which individuals mature first as males and then transform to females; and (iii) potentially strong influence of environmental conditions on recruitment population dynamics. In this context, we propose a seasonal, size-structured assessment model dedicated to stock assessment of hermaphroditic Pandalidae. The modeling framework incorporates a submodel for changes of length at sex transformation and functions to incorporate environmental effects on recruitment dynamics. The model can be directly fitted to length-structured data, overcoming the length to age conversion problem. The model has a seasonal time step that allows it to account for seasonal variations in biological processes and fishing patterns. The model provides stock assessment outputs, such as fishing mortality and stock biomass estimates, and sex-specific abundance-at-length. The model is applied to the exploited shrimp stock of Pandalus borealis in the Gulf of Maine as an example of its utility. The model proposed in this study is flexible and generic and can be applied to many other exploited stocks.
Fusion of Gaussian Process Kernel Regressors for Fault Prediction in Intelligent Energy Systems
Authors: Alamaniotis Miltiadis , Tsoukalas Lefteri H.
Published: August 2016

Integration of energy systems with machine intelligence technologies advances the new generation of intelligent energy systems. One feature of intelligent energy systems is their ability to predict a future fault state (prognosis), and thus support control actions. This paper introduces a prognostic framework based on concepts originating from the machine learning universe and proceeds to assess the performance of the prognostics algorithms with statistical methods aiming to formulate a linear predictor whose coefficients are the solution of a multi-objective optimization problem. Prediction is achieved through independent Gaussian process kernel regressors put together as terms of a linear forecaster. In this novel framework the available data is used to train the regression models whose degradation predictions cover a predetermined time period and have the form of a predictive distribution whose mean and variance values are computed for future moments. Thus, given the observed data points one may search for the most probable values of other quantities of interest, or the values at different points from those measured. The feasibility of the cascading prognostics methodology is demonstrated via a turbine blade degradation example. This implementation is characterized by advantages that include the utilization of an optimization process that simultaneously determines the lowest possible values in a set of different statistical measures and the employment of a set of kernels for modeling various data features and capturing the system dynamics.
Physics in the early universe
Authors: Huang Qing-Guo
Published: August 2016

In this paper, I will give a brief overview of the physics in the early universe, in particular, the inflation scenario. The predictions and the latest constraints on the inflation models will be discussed in detail.