bluuebunny/crossref_metadata_2025 huggingface dataset:
IMAGING DIAGNOSIS—MULTIMODALITY FINDINGS IN AN ADULT DOG WITH PRIMARY SARCOMA OF THE PULMONARY ARTERY AND MYOCARDIAL METASTASES
Authors: Stieger‐Vanegas Susanne M. , Bottorff Bryan , Sisson David , Löhr Christiane V.
Published: November 2015

Intravascular pulmonary artery sarcomas in combination with myocardial metastasis are rare in dogs. We describe the radiographic, echocardiographic, and electrocardiographic‐gated (ECG‐gated) computed tomographic angiography (CTA) findings in a dog with pulmonary artery sarcoma. All imaging studies demonstrated severe main pulmonary artery enlargement. Echocardiography and ECG‐gated CTA revealed a mass occluding the lumen of the right pulmonary artery. In addition, CTA revealed focal left ventricular myocardial contrast enhancement and parenchymal lung changes. Postmortem examination confirmed the presence of a large thrombus associated with arteriosclerosis and an intravascular sarcoma in the right pulmonary artery with metastases to the myocardium, lungs and brain.
Model-based waveform design for optimal detection: A multi-objective approach to dealing with incomplete a priori knowledge
Authors: Hamschin Brandon M. , Loughlin Patrick J.
Published: November 2015

This work considers the design of optimal, energy-constrained transmit signals for active sensing for the case when the designer has incomplete or uncertain knowledge of the target and/or environment. The mathematical formulation is that of a multi-objective optimization problem, wherein one can incorporate a plurality of potential targets, interference, or clutter models and in doing so take advantage of the wide range of results in the literature related to modeling each. It is shown, via simulation, that when the objective function of the optimization problem is chosen to maximize the minimum (i.e., maxmin) probability of detection among all possible model combinations, the optimal waveforms obtained are advantageous. The advantage results because the maxmin waveforms judiciously allocate energy to spectral regions where each of the target models respond strongly and each of the environmental models affect minimal detection performance degradation. In particular, improved detection performance is shown compared to linear frequency modulated transmit signals and compared to signals designed with the wrong target spectrum assumed. Additionally, it is shown that the maxmin design yields performance comparable to an optimal design matched to the correct target/environmental model. Finally, it is proven that the maxmin problem formulation is convex.
In Vitro
Effects of Polyphosphate against Prevotella intermedia in Planktonic Phase and Biofilm
Authors: Jang Eun-Young , Kim Minjung , Noh Mi Hee , Moon Ji-Hoi , Lee Jin-Yong
Published: November 2015

Polyphosphate (polyP) has gained a wide interest in the food industry due to its potential as a decontaminating agent. In this study, we examined the effect of sodium tripolyphosphate (polyP3; Na
5
P
3
O
10
) against planktonic and biofilm cells of
Prevotella intermedia
, a major oral pathogen. The MIC of polyP3 against
P. intermedia
ATCC 49046 determined by agar dilution method was 0.075%, while 0.05% polyP3 was bactericidal against
P. intermedia
in time-kill analysis performed using liquid medium. A crystal violet binding assay for the assessment of biofilm formation by
P. intermedia
showed that sub-MICs of polyP3 significantly decreased biofilm formation. Under the scanning electron microscope, decreased numbers of
P. intermedia
cells forming the biofilms were observed when the bacterial cells were incubated with 0.025% or higher concentrations of polyP3. Assessment of biofilm viability with LIVE/DEAD staining and viable cell count methods showed that 0.05% or higher concentrations of polyP3 significantly decreased the viability of the preformed biofilms in a concentration-dependent manner. The zone sizes of alpha-hemolysis formed on horse blood agar produced by
P. intermedia
were decreased in the presence of polyP3. The expression of the genes encoding hemolysins and the genes of the hemin uptake (
hmu
) locus was downregulated by polyP3. Collectively, our results show that polyP is an effective antimicrobial agent against
P. intermedia
in biofilms as well as planktonic phase, interfering with the process of hemin acquisition by the bacterium.
Drug-Drug Interactions between Sofosbuvir and Ombitasvir-Paritaprevir-Ritonavir with or without Dasabuvir
Authors: King Jennifer R. , Dutta Sandeep , Cohen Daniel , Podsadecki Thomas J. , Ding Bifeng , Awni Walid M. , Menon Rajeev M.
Published: November 2015

The combination of ombitasvir (an NS5A inhibitor), paritaprevir (an NS3/4A inhibitor) coadministered with ritonavir (r), and dasabuvir (an NS5B nonnucleoside polymerase inhibitor), referred to as the 3D regimen, and the combination of ombitasvir-paritaprevir-r, referred to as the 2D regimen, have demonstrated high efficacy with and without ribavirin in hepatitis C virus (HCV)-infected subjects. These regimens have potential for coadministration with sofosbuvir (nucleoside NS5B inhibitor) in the treatment of HCV. This phase 1, drug-drug interaction, open-label, multiple-dose study enrolled 32 healthy subjects to receive the 3D or 2D regimen in combination with sofosbuvir. Doses of study drugs were as follows: ombitasvir-paritaprevir-r, 25/150/100 mg daily (QD); dasabuvir, 250 mg twice daily (BID); and sofosbuvir, 400 mg QD. Blood samples were collected on study days 7, 14, and 21 for evaluating drug interaction at steady state. The effect of the 3D and 2D regimens on the pharmacokinetics of sofosbuvir and its circulating metabolite GS-331007 and vice versa was assessed by a repeated-measures analysis. Exposures of the 3D and 2D regimens were similar (≤20% change) during coadministration with sofosbuvir and during administration alone. Sofosbuvir exposures were 61% to 112% higher with the 3D regimen and 64% to 93% higher with the 2D regimen than with sofosbuvir alone. GS-331007 total exposures were 27% and 32% higher with the 3D and 2D regimens, respectively, than with sofosbuvir alone. Increases in sofosbuvir and GS-331007 exposures likely resulted from breast cancer resistance protein (BCRP) and/or P glycoprotein (P-gp) transporter inhibition by paritaprevir and ritonavir. No subjects discontinued the study due to study drug-related adverse events. No dose adjustment is recommended for 3D, 2D, or sofosbuvir in clinical trials exploring the safety and efficacy of the combination. (This study has been registered at ClinicalTrials.gov under registration no. NCT02356562 and NCT02292719.)
A Conserved Inhibitory Mechanism of a Lycorine Derivative against Enterovirus and Hepatitis C Virus
Authors: Guo Yu , Wang Yaxin , Cao Lin , Wang Peng , Qing Jie , Zheng Qizhen , Shang Luqing , Yin Zheng , Sun Yuna
Published: November 2015

Enterovirus 71 (EV71) (
Picornaviridae
family) and hepatitis C virus (HCV) (
Flaviviridae
family) are the causative agents of human hand, foot, and mouth disease (HFMD) and hepatitis C, resulting in a severe pandemic involving millions of infections in the Asia-Pacific region and worldwide. The great impact of EV71 and HCV on public health highlights the need to further our understanding of the biology of these two viruses and develop effective therapeutic antivirals. Here, we evaluated a total of 32 lycorine derivatives and demonstrated that 1-acetyllycorine suppressed the proliferation of multiple strains of EV71 in various cells. The results of the drug resistance analysis revealed that 1-acetyllycorine targeted a phenylalanine (F76) in EV71 2A protease (2A
pro
) to stabilize the conformation of a unique zinc finger. Most interestingly, the zinc binding site in EV71 2A
pro
is the exclusive homolog of HCV NS3 among all viruses. Further analysis revealed that 1-acetyllycorine also inhibits HCV with high efficacy, and the mutation on R118 in HCV NS3, which corresponds to F76 in EV71 2A
pro
, confers the resistance of HCV to 1-acetyllycorine. These results revealed a conserved mechanism of 1-acetyllycorine against EV71 and HCV through targeting viral proteases. We also documented the significant synergistic anti-EV71 and anti-HCV effects of 1-acetyllycorine with reported inhibitors, supporting potential combination therapy for the treatment of EV71 and HCV infections.
Multipurpose Prevention Approaches with Antiretroviral-Based Formulations
Authors: Jean-Pierre Ninochka , Barnable Patrick , Kizima Larisa , Rodríguez Aixa , Seidor Samantha , Cooney Michael L. , Clark Meredith R. , Doncel Gustavo F. , Robbiani Melissa , Zydowsky Thomas M. , Teleshova Natalia , Fernández-Romero José A.
Published: November 2015

We compared the preclinical safety and efficacy of tenofovir (TFV) 1% gel with that of MZC gel [containing 50 μM MIV-150, 14 mM Zn(O
2
CCH
3
)
2
(H
2
O)
2
, and 3% carrageenan] through a series of
in vitro
,
ex vivo
, and
in vivo
assays. The two gels showed good antiviral therapeutic indexes (50% cytotoxic concentration/50% effective concentration ratios; range, >25 to 800). MZC showed greater anti-simian-human immunodeficiency virus reverse transcriptase (SHIV-RT) activity than TFV 1% gel in rhesus macaque vaginal explants. MZC protected mice from vaginal herpes simplex virus 2 (HSV-2) challenge (
P
< 0.0001), but the TFV 1% gel did not.
Activity of Fosfomycin against Extended-Spectrum-β-Lactamase-Producing Uropathogens in Patients in the Community and Hospitalized Patients
Authors: Linsenmeyer Katherine , Strymish Judith , Weir Susan , Berg Gretchen , Brecher Stephen , Gupta Kalpana
Published: November 2015

Few oral antibiotics exist for the empirical treatment of extended-spectrum β-lactamase (ESBL) urinary tract infections (UTI). In this study, we sought to determine the activity of fosfomycin against ESBL-producing uropathogens from patients at 3 Veterans Affairs (VA) facilities between 2010 and 2013. Among the ESBL uropathogens, 19.9% were fosfomycin resistant.
Klebsiella
species were more likely than
Escherichia coli
to be resistant (46% versus 4%;
P
< 0.001). Fosfomycin remains active against a majority of the ESBL uropathogens, although resistance among
Klebsiella
spp. was higher than that in previous reports.
ALL2
, a Homologue of
ALL1
, Has a Distinct Role in Regulating pH Homeostasis in the Pathogen Cryptococcus neoformans
Authors: Jain Neena , Bouklas Tejas , Gupta Anjali , Varshney Avanish K. , Orner Erika P. , Fries Bettina C.
Published: November 2015

Cryptococcus neoformans
is a facultative intracellular fungal pathogen that has a polysaccharide capsule and causes life-threatening meningoencephalitis. Its capsule, as well as its ability to survive in the acidic environment of the phagolysosome, contributes to the pathogen's resilience in the host environment. Previously, we reported that downregulation of allergen 1 (
ALL1
) results in the secretion of a shorter, more viscous exopolysaccharide with less branching and structural complexity, as well as altered iron homeostasis. Now, we report on a homologous coregulated gene, allergen 2 (
ALL2
).
ALL2
's function was characterized by generating null mutants in
C. neoformans
. In contrast to
ALL1
, loss of
ALL2
attenuated virulence in the pulmonary infection model. The
all2
Δ mutant shed a less viscous exopolysaccharide and exhibited higher sensitivity to hydrogen peroxide than the wild type, and as a result, the
all2
Δ mutant was more resistant to macrophage-mediated killing. Transcriptome analysis further supported the distinct function of these two genes. Unlike
ALL1
's involvement in iron homeostasis, we now present data on
ALL2
's unique function in maintaining intracellular pH in low-pH conditions. Thus, our data highlight that
C. neoformans
, a human-pathogenic basidiomycete, has evolved a unique set of virulence-associated genes that contributes to its resilience in the human niche.
A 43-year-old woman presenting with subacute, bilateral, sequential facial nerve palsies, then developing pseudotumour cerebri
Authors: O'Connor Laura , Croxson Glen , McCluskey Peter , Halmagyi Gabor Michael
Published: November 2015

A patient presented elsewhere with what appeared to be a simple, unilateral, chronic suppurative otitis media and then developed an ipsilateral facial palsy. She soon developed the same problem on the other side. At the time, a brain MRI had been ordered but the clinician did not review it with a radiologist. The surgical specimens were not sent for histopathology. When transferred to our institution 3 months later, the patient had severe bilateral papilloedema due to intracranial hypertension due to missed cerebral venous sinus thrombosis. Further surgery revealed that the pathology in the temporal bone was B-cell lymphoma, which, fortunately, responded to chemoradiotherapy. There was good resolution of the facial palsies, but the patient has severe permanent visual loss due to optic atrophy.
An example of prompt and appropriate multidisciplinary management leading to an exceptionally good outcome: a case complicated by amniotic fluid embolism
Authors: Patel Deesha , Osakwe Osaeloke , Ghosh Sayanti
Published: November 2015

Amniotic fluid embolism (AFE) is a rare and serious phenomenon; we describe a rare case of AFE occurring after a second trimester surgical termination in a private clinic, which, with prompt transfer and appropriate multidisciplinary management, had an exceptionally good outcome. The patient developed hypotension, respiratory arrest and disseminated intravascular coagulopathy following the procedure but with aggressive management she made a full recovery without any neurological or long-term sequelae.
Successful re-implantation of implantable collamer lens after management of post-ICL methicillin-resistantStaphylococcus epidermidisendophthalmitis
Authors: Kaur Manpreet , Titiyal Jeewan S , Sharma Namrata , Chawla Rohan
Published: November 2015

A 29-year-old man presented with acute onset pain, redness and diminution of vision in the right eye 5 days after implantation of an implantable collamer lens (ICL). A diagnosis of postoperative endophthalmitis was made based on examination and ultrasonography. A vitreous tap was taken and intravitreal antibiotics (vancomycin 1 mg/0.1 ml+piperacillin-tazobactam 225 µg/0.1 mL) were administered. The vitreous culture revealed presence of methicillin-resistantStaphylococcus epidermidis. There was minimal improvement after 48 h; hence the ICL was explanted and repeat injection of intravitreal antibiotics administered. Following this, the endophthalmitis resolved and the patient achieved a corrected distance visual acuity of 20/25 4 weeks later. A repeat implantation of ICL was performed 9 months after the first surgery, following which the patient regained uncorrected distance visual acuity of 20/20. To our knowledge, this is the first case in which an ICL was re-implanted after successful resolution of endophthalmitis.
Diagnosing Potentially Preventable Hospitalisations (DaPPHne): protocol for a mixed-methods data-linkage study
Authors: Passey Megan E , Longman Jo M , Johnston Jennifer J , Jorm Louisa , Ewald Dan , Morgan Geoff G , Rolfe Margaret , Chalker Bronwyn
Published: November 2015

Introduction

Rates of potentially preventable hospitalisations (PPH) are used as a proxy measure of effectiveness of, or access to community-based health services. The validity of PPH as an indicator in Australia has not been confirmed. Available evidence suggests that patient-related, clinician-related and systems-related factors are associated with PPH, with differences between rural and metropolitan settings. Furthermore, the proportion of PPHs which are actually preventable is unknown. The Diagnosing Potentially Preventable Hospitalisations study will determine the proportion of PPHs for chronic conditions that are deemed preventable and identify potentially modifiable factors driving these, in order to develop effective interventions to reduce admissions and improve measures of health system performance.

Methods and analysis

This mixed methods data linkage study of approximately 1000 eligible patients with chronic PPH admissions to one metropolitan and two regional hospitals over 12 months will combine data from multiple sources to assess the: extent of preventability of chronic PPH admissions; validity of the Preventability Assessment Tool (PAT) in identifying preventable admissions; factors contributing to chronic PPH admissions. Data collected from patients (quantitative and qualitative methods), their general practitioners, hospital clinicians and hospital records, will be linked with routinely collected New South Wales (NSW) Admitted Patient Data Collection, the NSW Registry of Births, Death and Marriages death registration and Australian Bureau of Statistics mortality data. The validity of the PAT will be assessed by determining concordance between clinician assessment and that of a ‘gold standard’ panel. Multivariable logistic regression will identify the main predictor variables of admissions deemed preventable, using study-specific and linked data.

Ethics and dissemination

The NSW Population and Health Services Research Ethics Committee granted ethical approval. Dissemination mechanisms include engagement of policy stakeholders through a project Steering Committee, and the production of summary reports for policy and clinical audiences in addition to peer-review papers.
Improving confidence and competence of healthcare professionals in end-of-life care: an evaluation of the ‘Transforming End of Life Care’ course at an acute hospital trust
Authors: Selman Lucy , Robinson Vicky , Klass Lara , Khan Shaheen , George Rob , Shepherd Kate , Burman Rachel , Koffman Jonathan
Published: November 2015

Background

UK policymakers, clinicians and public wish to see improvements in end-of-life care (EoLC). However, healthcare professionals’ skills and knowledge to deliver high-quality care are often lacking. Since May 2012, palliative care staff in an inner-city tertiary hospital have run a 2-day Transforming End of Life Care (TEoLC) course to improve EoLC confidence, and competence among hospital and community staff.

Aim

To evaluate course participants’ self-rated confidence, competence and knowledge of EoLC topics.

Evaluation design

A before-and-after design using self-completion questionnaires, precourse and postcourse. 14 self-assessment questions examined confidence, understanding and knowledge of EoLC topics. Mean change scores and paired t tests were calculated and free-text responses analysed thematically.

Participants

236 staff members completed the course between May 2012 and April 2014. 42% worked in hospitals and 55% in the community; the most frequent staff roles were qualified nurses (49%), senior nurses (16%) and general practitioners (15%).

Results

All 14 self-assessment topics improved significantly (p<0.001); most improved was ‘understanding and implementing Fast Track discharge’. Qualitative data showed increased knowledge and confidence in EoLC, particularly in communication, commitment to team work and holistic care. Overall, 217 (92%) participants would recommend the course and 215 (98%) indicated it would influence their practice.

Conclusions

The TEoLC course improved participants’ self-rated confidence, competence and knowledge in EoLC. Findings have utility beyond the UK in light of the international policy recommendations to improve the palliative care skills of generalist healthcare providers.
The changing face of major trauma in the UK
Authors: Kehoe A , Smith J E , Edwards A , Yates D , Lecky F
Published: November 2015

Aim

Major trauma (MT) has traditionally been viewed as a disease of young men caused by high-energy transfer mechanisms of injury, which has been reflected in the configuration of MT services. With ageing populations in Western societies, it is anticipated that the elderly will comprise an increasing proportion of the MT workload. The aim of this study was to describe changes in the demographics of MT in a developed Western health system over the last 20 years.

Methods

The Trauma Audit Research Network (TARN) database was interrogated to identify all cases of MT (injury severity score >15) between 1990 and the end of 2013. Age at presentation, gender, mechanism of injury and use of CT were recorded. For convenience, cases were categorised by age groups of 25 years and by common mechanisms of injury. Longitudinal changes each year were recorded.

Results

Profound changes in the demographics of recorded MT were observed. In 1990, the mean age of MT patients within the TARN database was 36.1, the largest age group suffering MT was 0–24 years (39.3%), the most common causative mechanism was road traffic collision (59.1%), 72.7% were male and 33.6% underwent CT. By 2013, mean age had increased to 53.8 years, the single largest age group was 25–50 years (27.1%), closely followed by those >75 years (26.9%), the most common mechanism was low falls (39.1%), 68.3% were male and 86.8% underwent CT.

Conclusions

This study suggests that the MT population identified in the UK is becoming more elderly, and the predominant mechanism that precipitates MT is a fall from <2 m. Significant improvements in outcomes from MT may be expected if services targeting the specific needs of the elderly are developed within MT centres.
A profile of suspected child abuse as a subgroup of major trauma patients
Authors: Davies Ffion C , Coats Timothy J , Fisher Ross , Lawrence Thomas , Lecky Fiona E
Published: November 2015

Introduction

Non-accidental injury (NAI) in children is an important cause of major injury. The Trauma Audit Research Network (TARN) recently analysed data on the demographics of paediatric trauma and highlighted NAI as a major cause of death and severe injury in children. This paper examined TARN data to characterise accidental versus abusive cases of major injury.

Methods

The national trauma registry of England and Wales (TARN) database was interrogated for the classification of mechanism of injury in children by intent, from January 2004 to December 2013. Contributing hospitals’ submissions were classified into accidental injury (AI), suspected child abuse (SCA) or alleged assault (AA) to enable demographic and injury comparisons.

Results

In the study population of 14 845 children, 13 708 (92.3%, CI 91.9% to 92.8%) were classified as accidental injury, 368 as alleged assault (2.5%, CI 2.2% to 2.7%) and 769 as SCA (5.2%, CI 4.8% to 5.5%). Nearly all cases of severely injured children suffering trauma because of SCA occurred in the age group of 0–5 years (751 of 769, 97.7%), with 76.3% occurring in infants under the age of 1 year. Compared with accidental injury, suspected victims of abuse have higher overall injury severity scores, have a higher proportion of head injury and a threefold higher mortality rate of 7.6% (CI 5.51% to 9.68%) vs 2.6% (CI 2.3% to 2.9%).

Conclusions

This study highlights that major injury occurring as a result of SCA has a typical demographic pattern. These children tend to be under 12 months of age, with more severe injury. Understanding these demographics could help receiving hospitals identify children with major injuries resulting from abuse and ensure swift transfer to specialist care.
EXTERNAL VALIDATION OF THE MANCHESTER ACUTE CORONARY SYNDROMES (MACS) DECISION RULE
Authors: Carlton E , Body R , Greaves K
Published: November 2015

Objectives & Background

The Manchester Acute Coronary Syndromes (MACS) decision rule has been shown to be a powerful diagnostic tool in emergency department (ED) patients with suspected acute coronary syndromes (ACS). It has the potential to improve system efficiency by identifying patients suitable for discharge after a single blood draw, for high-sensitivity troponin and heart-type fatty acid binding protein analysis, at presentation to the ED. We aimed to externally validate the MACS decision rule and establish its diagnostic accuracy as a discharge tool in a new set of prospectively recruited ED patients.

Methods

In this post-hoc analysis of a prospectively recruited single-centre cohort we included consecutive ED patients ≥18 years with suspected ACS. Testing for heart-type fatty acid binding protein and high-sensitivity troponin T was undertaken on serum drawn on arrival and clinical features required to calculate the MACS rule recorded. The primary outcome was major adverse cardiac events (MACE) within 30 days (acute myocardial infarction (AMI), death or revascularisation). The secondary outcome was AMI alone, adjudicated using 6 h troponin results.

Results

Of the 782 participants included, 78 (10.0%) developed MACE and 61 (7.8%) had an AMI. Of participants, 133 (17.0%) were identified as ‘very low risk’ and therefore suitable for immediate discharge with a 0% incidence of MACE or AMI. The sensitivity was 100% (95% CI 95.4–100) for MACE at 30 days and 100% (95% CI 94.1–100) for AMI. Of the ‘high risk’ group, 53.3% had a MACE within 30 days (Figure 1). The area under the ROC curve was 0.87 (95% CI 0.83–0.91) for the MACS rule in the prediction of MACE (Figure 2).

Conclusion

In this prospectively recruited cohort, the MACS decision rule identifies a significant proportion of patients who are suitable for immediate discharge after a single blood draw at presentation, with a 0% risk of MACE. The rapid assessment and discharge of these patients is likely to reduce healthcare resource burden and costs.

Figure 1

Rates of AMI and MACE stratified by the MACS rule risk groups.

Figure 2

Receiver operating characteristic (ROC) curve showing the diagnostic accuracy of the MACS rule.
THE SIMPLIFIED MORTALITY IN SEVERE SEPSIS IN THE EMERGENCY DEPARTMENT (MISSED) SCORE TO RISK STRATIFY ED SEPSIS
Authors: Sivayoham N , Holmes P , Cecconi M , Rhodes A
Published: November 2015

Objectives & Background

In patients with sepsis, early intervention in the emergency department (ED) has been shown to reduce mortality. Early treatment requires early risk stratification. The criteria defining shock identifies some of the sickest patients. But not all patients who go on to die present with shock. Other scoring systems are available but they are labour intensive to use in a busy ED. The MISSED (Mortality in Severe Sepsis in the ED) score is a simple and easy to use score that was derived and validated to risk stratify ED patients with sepsis. But the population studied were ED patients admitted to the intensive care unit (ICU). This score has now been refined and simplified. The independent variables associated with mortality are: age ≥65 years, serum albumin ≤27g/l and an international normalised ratio (INR) ≥1.3. The simplified MISSED score ranges from 0 to 3 depending on the number of variables present.

We aim to validate the simplified MISSED score in the ED population admitted with sepsis. The primary end point was in-hospital all-cause mortality. The secondary endpoint was the validation of the risk stratification for mortality and ICU admission.

Methods

ED patients admitted with a primary diagnosis of presumed infection in the year 2012 were studied. Patients missing data on any of the variables and those on warfarin were excluded. The simplified MISSED score was calculated for each patient. The test characteristics for mortality of the simplified MISSED score and the odds ratios of the high risk groups for the secondary end-points were calculated.

Results

674 patients including 65 deaths were studied. The area under the curve (AUC) for the simplified MISSED score was 0.74 [95% confidence interval (CI) 0.70–0.77]; p<0.0001. The test characteristics for mortality were: sensitivity 93.9% [85–98.3], specificity 37.9% [34.1–41.9], positive predictive value 13.9% [10.8–17.5] and negative predictive value 98.3% [95.7–99.5]. The addition of the septic shock criteria improves the sensitivity to 70.8% [55.9–83]. The odds ratio for mortality for a score≥2 was: 5.01 [2.93–8.57], p<0.0001 and that for ICU admission was 3.00 [1.70–5.28], p=0.0001. The specificity of a score of 3 for mortality is 97.7% (96.2–98.7).

Conclusion

The simplified MISSED score could be used in addition to the septic shock criteria to risk stratify septic patients in the ED.
EARLY WHOLE BODY VERSUS FOCUSED COMPUTED TOMOGRAPHY IMAGING FOLLOWING MAJOR TRAUMA: EXISTING EVIDENCE AND ANALYSIS OF 10 YEARS OF TARN DATA
Authors: Hunt P , Bouamra O , Jenks T , Lecky FE , Edwards A , Woodford M , Yates D , Han K
Published: November 2015

Objectives & Background

Whole Body Computed Tomography (WBCT) scanning is considered to be the chief imaging modality for patients with major trauma. There is growing evidence that the rate of survival is higher for patients undergoing early WBCT by facilitating rapid and accurate anatomical characterisation of potentially life-threatening injuries. There remains ongoing controversy whether this outweighs the potential risks from high-dose ionising radiation.

Methods

Data from the Trauma Audit and Research Network (TARN) trauma registry was analysed for all patients presenting from January 2005 to July 2014 inclusive aged 16 years or more admitted directly to hospital Emergency Departments (ED) with suspected severe blunt polytrauma. Survival was compared between two groups: (1) patients who underwent WBCT scans, and (2) those who underwent a focused CT (“non-WBCT”) scanning approach within the first four hours of arrival at the ED.

Results

14,598 (23·2%) of 62,942 eligible cases underwent WBCT directly from the ED within four hours of arrival. The calculated crude survival rate for the WBCT group was 89·2%, compared to 88·9% in the non-WBCT group (p=0·260). The results of multivariate regression analysis, taking account of all possible confounders, demonstrated a trend towards improved survival in the WBCT scan group, with an OR=1·080 (95% CI 0·986–1·183) compared to the non-WBCT group (p=0·098).

Conclusion

The results of our investigation demonstrate a trend towards improved survival for adult patients with suspected severe blunt polytrauma undergoing WBCT scanning early in their management in the ED. Our analysis of the largest series of trauma cases investigating WBCT so far is the first to take account of all possible confounding factors including centre effect – often a major limitation for generalisability in previous studies of this kind. The existing evidence for the use of WBCT during the management of major trauma is also discussed in the context of these new results.

Figure 1Figure 2
COLD, CRAMP & CANNOT CONTINUE IN SNOWDONIA MOUNTAIN CASUALTIES
Authors: Brazel N , Dykes L
Published: November 2015

Objectives & Background

Each year, about 120 casualties from Snowdonia attend our ED following assistance from Search & Rescue (SAR) services. We have noticed an increase in uninjured mountain users requiring evacuation due to “cold, cramp & cannot continue” (CCCC). We offered to investigate further, in order to help target injury prevention education.

Methods

We interrogated our database of mountain casualties brought to our hospital following contact with Mountain Rescue Teams and/or RAF SAR helicopter 01/01/2004–16/11/2014. Age, sex & home postcode of CCCC casualties was noted. Surnames were used as a proxy estimate of ethnic origin.

www.surmanedb.com was used to ascertain origin of surnames (Anglo-Saxon, W/E European – “European”; SE Asian, Middle East/Indian Subcontinent & African – “Black & Ethnic Minority/BME”).

Results

Of 1159 patients on the database, 56/1159 (4.8%) were CCCC. In 2004, the number of CCCC cases was one, remaining <5/yr until 2009, since when the number has been consistently >8/yr.

Of 1115 casualties with a European surname, 43 (4%) were CCCC cf. 13/43 (29%) with a BME surname (p<0.0000001, Fishers Exact test) with an OR of 10.12 (95% CI 4.96–20.64).

European surnames: 25/43 (58%) male, median age 32 (range 6–79, mean 36.7). BME surnames: 10/13 (77%) male, median age 26 (range 16–67, mean 29.7). 77% lived in the Birmingham or London conurbations.

Conclusion

National Parks across the UK have been working since 2009 to increase the diversity of park users, so an increase in mountain casualties of BME origin is to be expected.

We acknowledge that surname analysis provides only a crude estimate of likely ethnicity, and our database is smaller than the populations for which this technique is generally used. Nevertheless, there is a stark difference in the proportion of mountain casualties requiring rescue for CCCC whose surnames are of BME vs. European origin. This confirms anecdotal reports by SAR personnel.

The most likely explanation is cultural. Few urban BME mountain users are taken hill-walking as children and may be unfamiliar with the misery of being wet, cold & weary with 2 hours walk to the car. There are also well-documented cultural differences in response to pain/discomfort.

Alongside encouraging people of BME origin to utilize the fantastic leisure opportunities of Britain's National Parks, we must step up efforts to alert them to the challenges of outdoor activities in what can be a lethal environment for the unprepared.
IMPROVING THEIR EXPERIENCE—HOW CAN WE ENHANCE THE LEARNING ENVIRONMENT FOR MEDICAL STUDENTS IN THE ED?
Authors: Burton J , Turner C
Published: November 2015

Objectives & Background

EDs and AMUs are potentially a rich source of learning for medical students. Spending time in emergency departments has been shown to be a great motivator for student learning, however these areas can be difficult environments for students to learn. Students are regularly asked to provide feedback on teaching. Little is known, however, about the factors students find important in providing high quality teaching. We aimed to complete a pilot study to ascertain which factors students consider to be important in delivering high and low quality teaching in busy clinical environments.

Methods

We decided on a sample size of 70, as it was felt this would represent a reasonable cross section of opinion.

This is a 2 centre, multi department study of final year medical students in Warwickshire.

A voluntary, anonymous questionnaire was given to each of the students undertaking the block.

Demographics and free text responses around both the positive and negative experiences of the students were collected.

Three clinical teaching fellows conducted a qualitative thematic analysis of the responses. Comments were coded through iterative discussion and consensus among the panel.

Results

The ED was cited most frequently as the most valuable learning experience (84%) with majors the most popular area (38%).

Being involved in patient care and friendly enthusiastic staff were most commonly cited as reasons for these being good learning experiences.

Reasons for poor clinical experiences included a perceived lack of learning opportunities, being too busy and not feeling involved.

Positive experiences included history taking, patient assessment and management/knowledge of specific conditions.

Where students had a negative learning experience 13% stated that they did not learn anything, although others noted they learned of the life of a junior Dr.

Conclusion

Through this pilot study a number of themes have emerged. Students wish to feel involved in patient care and friendly, enthusiastic staff have been identified as facilitators to student learning. The most frequently cited barrier to learning appears to be staff not helping identify the opportunities. This could be overcome by encouraging a culture where staff actively identify opportunities for the medical students, promoting interactive, inductive training in the acute setting.
WHAT MAKES A GOOD MEDICAL SHOP FLOOR LEADER?
Authors: Pell M , Khan R , Turner C , ilyas H , Rehman SR , gill S
Published: November 2015

Objectives & Background

High quality leadership is associated with improved outcomes for patients and increased staff satisfaction. A combined team of clinicians from UHCW and HEFT felt that during this time of particular pressure, shop floor leadership qualities, as stated by other staff, would be of use to guide behaviours.

Aims

We aimed to identify the qualities staff valued in shop floor medical leadership. We also aimed to identify behaviours that were felt to be unhelpful as well as identifying Senior tier doctors (Consultant/Middle Grade) who were most felt to run a good floor.

Methods

We conducted a qualitative survey across 3 departments in the West Midlands over one month in early 2015.

We used an anonymous questionnaire which first collected demographics then responses to the following questions

1) What characteristics do you associate with effective shop floor leadership?

2) What characteristics do you associate with ineffective shop floor leadership

3) Are any staff particularly good? Please tell us why.

The responses were assessed to spot themes and agreed upon by the authors. Answers were codified by a group of 4 of the authors with disputes settled by discussion.

Results

A total of 101 responses were received with a broad spectrum of staff answering. All codified results were assessed and it was deemed the best way to represent the data was in the form of word clouds. Each word present in the cloud has a larger presence in relation to the frequency of it being mentioned as a response. Interestingly the attributes most highly regarded by staff were that the senior shop floor doctor was approachable and supportive. With less of a need for good communication skills or their enthusiasm at work. This would imply that staff see the senior doctor as being somebody to be able to turn to in need without fear of rebuke. This is reinforced by a high number of the negative attributes being aspects of interpersonal interactions and areas that would represent a barrier to being a supportive and approachable member of staff. The ability to aid decision making when turned to for advice is clearly relied upon as a key with both a lack of availability and then being unable to make decisions seen as negatives. Communication is not seen as positive attribute to be good at as much as it is seen to be a negative if its done poorly.

Conclusion

Being approachable is viewed as a good characteristic in a leader with unavialability and bad interpersonal skills as a negative attribute.

Figure 1

Positive Attributes.

Figure 2

Negative Attributes.
PRE-HOSPITAL EMERGENCY SKILLS FOR MEDICAL STUDENTS
Authors: Wheeler C
Published: November 2015

Objectives & Background

There is an expectation amongst Doctors and the public that Doctors should be able to assist in medical and traumatic emergencies in the community. It is also a requirement of the General Medical Council that Doctors offer assistance. Pre-hospital care receives little attention in the majority of medical courses in the UK. At Manchester Medical School there is opportunity to study and gain experience in basic pre-hospital care for only a few students pursuing student selected modules. The aim of this study is to assess competence and confidence of medical students when dealing with pre-hospital emergencies.

Methods

All of the 115 students from the 3rd year medical students based at Manchester Royal Infirmary were asked to complete a questionnaire. Confidence with pre-hospital scenarios was assessed with Likert scale questions and competence was assessed using multiple choice questions.

Results

Confidence

67% of participants reported they would be willing to try to approach the scene of an accident. Airway and cervical spine control, and motorcycle helmet removal received low confidence with 45% and 74% respectively reporting feeling really anxious or not very confident. Assessment of breathing had high levels of confidence with 61% reporting quite or very confident in this skill. Control of haemorrhage received average confidence (50%).

Competence

The majority of students answered “Get help” for the scene approach question but only 33% assessed danger of the scene first. The immobilisation question was answered well with 82% of participants correct. There were relatively poor results for the questions regarding catastrophic haemorrhage and airway control with only 48% and 57% respectively answering correctly.

Over 90% would be interested in attending a session focussed on pre-hospital care but relatively few have actually come across an incident where they were required to offer assistance.

Conclusion

These results show that there is some anxiety amongst students about being able to manage pre-hospital emergencies in which the public might expect them to cope or in which they feel obliged to help. The results show that although students would be willing to help they may not posess the necessary knowledge to do so. They show that there is a demand for teaching focussed on these skills but that there is not necessarily a need for it taking into account the frequency of incidents encountered. A trial teaching programme will take place in July.
SYSTEMATIC REVIEW: INTRAVENOUS PARACETAMOL VERSUS INTRAVENOUS MORPHINE IN THE MANAGEMENT OF ACUTE RENAL COLIC
Authors: Navaratnam R , Parker S
Published: November 2015

Objectives & Background

Renal colic is commonly managed in emergency departments worldwide. Initial treatment requires prompt and effective analgesia. The mainstay of analgesia revolves around non-steroidal analgesics and opiates. Though effective they are associated with a number of significant side effects.

Paracetamol is available in a number of preparations. The intravenous route has been shown to be effective within 10 minutes of administration and is associated with few adverse side effects.

The aim of this review is to assess the available evidence comparing the analgesic effect of intravenous paracetamol versus intravenous morphine in renal colic.

Methods

A systematic review of medical databases was undertaken (June 2015). Databases searched included Embase (1946 to May 2015 Week 1), Medline (1946 to June 2015) Google Scholar and the Cochrane Database of Systematic Reviews.

The terms searched were:

1. (Renal colic OR ureteric colic OR nephrolithasis)

2. (Acetaminophen OR paracetamol) AND morphine

After the searches were combined, the following limits were imposed: English language, human subjects, aged 18–60, presenting acutely, use of intravenous forms of the drugs, the diagnosis of renal colic radiologically confirmed.

Results

A total of 66 papers were returned after the initial search. 3 further papers were identified following analysis of the references of search results. Abstracts were reviewed for inclusion, resulting in the exclusion of 66 studies.

A total of 348 patients were analysed over 3 studies. Patient demographics, doses of paracetamol and morphine used and the measure of effect was similar across the studies.

Mean baseline visual analogue pain scores were similar across studies (Mean: Paracetamol 8.05, Morphine 8.40). All 3 studies showed paracetamol reduced visual analogue pain scores at both 15 minutes (Mean: Paracetamol=4.32 vs Morphine=5.26) and 30 minutes (Mean: Paracetamol=2.55 vs Morphine=3.67) following administration. The need for ‘rescue’ analgesia was reduced in patients receiving paracetamol. The number of adverse events experienced by patients recieving paracetamol was less versus those receiving morphine.

Conclusion

Review of the literature suggests intravenous paracetamol is as effective as intravenous morphine in providing analgesia in acute renal colic. This effect was associated with a reduced incidence of adverse events and need for supplemental analgesia.
THE EFFECT OF TRIAGE ON PAEDIATRIC WAITING TIMES IN A PAEDIATRIC ASSESSMENT UNIT
Authors: Brittain C , Forster A
Published: November 2015

Objectives & Background

Our hospital is in the process of increasing the number of hours its paediatric assessment unit (PAU) remains open in order to help patient flow within the emergency department. Previously we have used our ward based Paediatric Early Warning Score (PEWS) charts to triage these patients. However, in view of the increased demand on the department, a more PAU focussed triage tool was deemed necessary to primarily improve patient safety, but also patient experience through reducing waiting times.

Whilst various paediatric triage tools have been developed for use within paediatric emergency departments, we could not find a tool for use within the PAU, which primarily sees the unwell rather than the injured child.

Our aim was to assess whether we could construct a triage tool to identify the unwell child in order to result in them being seen sooner by a member of the medical team. We also hoped it would improve waiting times compared with the currently used PEWS method.

Methods

We devised a triage tool that was suitable for our PAU. This was based on The Emergency Severity Index, Leicester's Paediatric Observation Priority Score, the Modified Manchester Triage system, and the PEWS and Paediatric Acute Warning Score (PAWS) charts that are already in use within our hospital. We then compared waiting times for children to be seen who were assessed by the previously used PEWS, with those assessed with the triage tool. We also compared our breaches for waiting within the department for more than 6 hours.

Results

For the week of the PEWS scoring, 89% had a PEWS 0–1, 5% had a score of 2–3, and 6% of 4+. The mean length of time to be seen was 39 min, 29 min and 0 min respectively. For the week using our triage tool, 69% scored green, 22% amber and 9% red. Average time to be seen was 44 min, 22 min and 32 min respectively.

Using the PEWS method, senior review was outside the target time of two hours in 16%, compared with 3.7% with the triage tool. Patients were staying more than the recommended 6 hours in 5.8% of cases with PEWS and 2.96% with the triage tool.

Conclusion

Our triage tool appears to have improved breaches for time to senior review and as such has resulted in a reduction in length of stay within the department; thus improving patient turnover and flow between the emergency department and PAU. It has not however, improved the speed at which the unwell child is reviewed, this may be due to poor specificity of the tool.
Lymphocytic panniculitis: an algorithmic approach to lymphocytes in subcutaneous tissue
Authors: Shiau Carolyn J , Abi Daoud Marie S , Wong Se Mang , Crawford Richard I
Published: November 2015

The diagnosis of panniculitis is a relatively rare occurrence for many practising pathologists. The smaller subset of lymphocyte-predominant panniculitis is further complicated by the diagnostic consideration of T cell lymphoma involving the subcutaneous tissue, mimicking inflammatory causes of panniculitis. Accurate classification of the panniculitis is crucial to direct clinical management as treatment options may vary from non-medical therapy to immunosuppressive agents to aggressive chemotherapy. Many diseases show significant overlap in clinical and histological features, making the process of determining a specific diagnosis very challenging. However, with an adequate biopsy including skin and deep subcutaneous tissue, a collaborative effort between clinician and pathologist can often lead to a specific diagnosis. This review provides an algorithmic approach to the diagnosis of lymphocyte-predominant panniculitis, including entities of septal-predominant pattern panniculitis (erythema nodosum, deep necrobiosis lipoidica, morphea profunda and sclerosing panniculitis) and lobular-predominant pattern panniculitis (lupus erythematous panniculitis/lupus profundus, subcutaneous panniculitis-like T cell lymphoma, cutaneous γ-δ T cell lymphoma,Borreliainfection and cold panniculitis).