bluuebunny/crossref_metadata_2025 huggingface dataset:
The improvement mechanism of mechanical properties of B4C ceramics by constructing core–shell powders
Authors: Yao Wankai , Yan Junbing , Chen Pingan , Li Xiangcheng , Zhu Yingli , Zhu Boquan
Published: December 2022

B4C ceramics have been widely used in armor plate and cutting tools due to their high hardness. However, their poor sintering performance and low fracture toughness have limited their extended applications. In order to solve these problems, B4C@TiB2 composite powders with core–shell structure were prepared by a sol–gel method using B4C and TiCl4 as raw materials and then sintered by spark plasma sintering. The composite powders were characterized by X‐ray diffraction, X‐ray photoelectron spectroscopy, and scanning electron microscopy. The mechanical properties of B4C ceramics were tested by indentation and three‐point bending methods. The results showed that the B4C@TiB2 composite powders exhibited a tight core–shell structure, and the chemical bonds on the surface were mainly B–C and B–Ti bonds. When the molar ratio of B4C:TiCl4 was 2:1, the relative density and bulk density of B4C ceramics reached 96.2% and 2.92 g/cm3, respectively. Because of the good sintering performance of the B4C@TiB2 composite powders, the Vickers hardness and fracture toughness reached 26.6 GPa and 5.22 MPa m1/2, respectively. The bending strength reached a maximum of 570 MPa. The excellent fracture toughness can be attributed to crack deflection, crack branching, and the residual thermal stress of the core–shell structure.
Enhanced piezoelectric strain response in 〈100〉 grain‐oriented lead‐free bismuth ferrite–based piezoelectric ceramics
Authors: Khanal Gopal Prasad , Fujii Ichiro , Ueno Shintaro , Wada Satoshi
Published: December 2022

The 〈100〉 grain‐oriented 0.11(Bi0.5K0.5)TiO3–0.23BaTiO3–0.02Bi(Mg0.5Ti0.5)O3–0.64BiFeO3 piezoelectric ceramics were prepared by a reactive templated grain growth method using a platelike H1.08Ti1.73O4·nH2O (HTO) template and Bi2O3–KHCO3–MgO–Fe2O3–BaCO3 matrix particles. The high degree of texturing (a Lotgering orientation factor of 80%) and high density (95%) were achieved by employing weight‐pressing treatment during the binder‐removal and sintering treatment along with optimizing the sintering temperature. The water‐quenching treatment has a significant impact on the enhancement of dielectric, ferroelectric, and piezoelectric properties with the increase of dielectric constant, remanent polarization, and piezoelectric strain constant from 764, 13.6 μC/cm2, and 384 pm/V for the as‐sintered ceramics to 812, 29.9 μC/cm2, and 526 pm/V after the water‐quenching treatment at 850°C, respectively. The obtained piezoelectric strain constant with a 1.8 times enhancement compared to that of the ceramics with randomly oriented grains is significantly higher than those reported for other lead‐free piezoelectric ceramics with Curie temperature >300°C. This study suggested the strong potentiality of this material system for high‐temperature actuator application.
Children and adolescents' mental health during the COVID‐19 pandemic: A qualitative study of their experiences
Authors: Montreuil Marjorie , Gendron‐Cloutier Lauranne , Laberge‐Perrault Emilie , Piché Geneviève , Genest Christine , Rassy Jessica , Malboeuf‐Hurtubise Catherine , Gilbert Elsa , Bogossian Aline , Camden Chantal , Mastine Trinity , Barbo Geneveave
Published: December 2022

Topic

Public health measures implemented in response to the COVID‐19 pandemic severely disrupted children and adolescents' (C&A) lives, affecting their sense of structure, predictability, and security.

Purpose

To examine C&A' experiences during the COVID‐19 pandemic to better understand how this context and its associated public health measures affected them and their mental health, and to identify helpful coping strategies.

Sources used

The study was guided by a participatory hermeneutic framework. Semistructured interviews were conducted with 25 C&A aged 6–17 years during the first and second pandemic waves. Participants' interviews were analyzed following a narrative synthesis approach, through which C&A' experiences were contrasted and contextualized to highlight relevant themes.

Conclusions

Participants described a distinct pattern related to their mental health as the pandemic unfolded, which followed the severity of the pandemic in the province. Negative repercussions on their mental health were linked to the loss of social activities, imposed public health measures, transition to online learning, and challenges with family relationships. Certain youth shared positive societal and moral reflections triggered by the pandemic context. Coping strategies reported include: having a variety of hobbies; expressing their emotions; and accessing financial and material resources.

This study highlights the importance of supporting C&A' mental health during crisis situations such as a pandemic. Their perspectives are vital for clinical practice and policy improvement, particularly to find means for social engagement while maintaining safety.
Diagnostic ability using fatty liver and metabolic markers for metabolic‐associated fatty liver disease stratified by metabolic/glycemic abnormalities
Authors: Okada Akira , Yamada Gen , Kimura Takeshi , Hagiwara Yasuhiro , Yamaguchi Satoko , Kurakawa Kayo Ikeda , Nangaku Masaomi , Yamauchi Toshimasa , Matsuyama Yutaka , Kadowaki Takashi
Published: December 2022

Aims/Introduction

Although several noninvasive predictive markers for fatty liver and metabolic markers have been used for fatty liver prediction, whether such markers can also predict metabolic‐associated fatty liver disease (MAFLD) remains unclear. We aimed to examine the ability of existing fatty liver or metabolic markers to predict MAFLD.

Materials and Methods

Participants in a high‐volume center in Tokyo were classified into groups with and without MAFLD, based on the presence of metabolic abnormalities and fatty liver diagnosed through abdominal ultrasonography, between 2008 and 2018. The diagnostic abilities of three fatty liver markers: fatty liver index (FLI), hepatic steatosis index (HSI), and lipid accumulation product (LAP), and three common metabolic markers: waist‐to‐height ratio (WHR), body mass index (BMI), and waist circumference (WC), for predicting MAFLD, were evaluated. Analyses stratified by MAFLD subtypes were performed.

Results

Of 92,374 individuals, 19,392 (36.1%) had MAFLD. The diagnostic performances for MAFLD prediction, measured as c‐statistics, for FLI, HSI, LAP, WHR, BMI, and WC were 0.906, 0.892, 0.878, 0.844, 0.877, and 0.878, respectively. Optimal cutoff values for diagnosing MAFLD for FLI, HSI, LAP, WHR, BMI, and WC were 20.3, 32.7, 20.0, 0.49, 22.9, and 82.1, respectively. Analyses stratified by MAFLD subtypes, based on BMI and metabolic/glycemic abnormalities, suggested that FLI and HSI had acceptable (c‐statistics >0.700) diagnostic abilities throughout all the analyses.

Conclusions

All six markers were excellent predictors of MAFLD in diagnosing among the general population, with FLI and HSI particularly useful among all sub‐populations.
Efficacy and safety of topical agents in the treatment of melasma: What's evidence? A systematic review and meta‐analysis
Authors: Chang Yu‐Feng , Lee Tai Lin , Oyerinde Oyetewa , Desai Seemal R. , Aljabban Ali , Bay Camden P. , Bain Paul A. , Chung Hye Jin
Published: December 2022

Background

Various topical agents have been used to treat melasma; however, a large‐scale evaluation among the currently available treatment is lacking.

Objectives

The aim of this study was to evaluate the efficacy and safety of topical agents for melasma.

Methods

The MEDLINE, Embase, Web of Science, Cochrane, and Alt‐Healthwatch databases were searched in November 2021. Original studies that reported pre‐ and post‐treatment Melasma Area Severity Index (MASI)/modified Melasma Area Severity Index (mMASI) scores and/or adverse effects (AEs) were eligible for inclusion. The main outcome was the efficacy analyzed by the changes in the pre‐ and post‐treatment with standardized mean difference (SMD) of MASI/mMASI scores; the AEs were calculated with incidence proportion by the reported percentage of skin irritations.

Results

A total of 45 studies (2359 patients) and 55 studies (4539 patients) met the inclusion criteria for efficacy and AEs, respectively. Hydroquinone (HQ) monotherapy (SMD ‐1.3, 95% CI [−1.6 to −1.0]), HQ‐containing combination therapy (−1.4, [−1.7 to −1.1]), cysteamine (−1.6, [−2.0 to −1.2]), tranexamic acid (−1.5, [−2.0 to −1.1]), azelaic acid (−1.3, [−1.7 to −1.0]), and kojic acid (−0.9, [−1.3 to −0.5]) demonstrated comparable efficacy, while zinc sulfate did not exhibit statistically significant improvement (−1.2, [−2.7 to 0.4]). HQ‐containing combination therapy (50.9%) and cysteamine (42.2%) demonstrated the highest incidence of irritation, while azelaic acid (18.7%), kojic acid (5.3%), and tranexamic acid (0.8%) revealed a lower risk.

Conclusions

In this meta‐analysis, non‐HQ agents except zinc sulfate may be considered as an alternative to HQ‐containing agents. However, treatment should be guided by patient's tolerance, availability, and physicians' experience.
Novel management of granuloma formation secondary to dermal filler: A multi‐modality approach
Authors: Bowles Alexandra , Ghalili Sabrina , Ojong Oben B. , Vasile Gabriella F. , Li Yumeng M. , Aguilera Shino Bay
Published: December 2022

Background

Dermal fillers for soft tissue augmentation have become increasingly popular among patients of all ages and ethnicities. With more widespread use, there has been an increased incidence of adverse reactions, one of which is the granulomatous foreign body reaction (GFBR).

Materials & Methods

We present a three patient case series in which GFBR secondary to dermal filler was successfully treated with a multi‐leveled approach. The first modality involves intralesional injection of a mixture containing 1 cc of 5‐fluorouracil (5‐FU), 0.5 cc of dexamethasone sodium phosphate, and 0.1 cc of triamcinolone 10. The lesion is injected intradermally in small aliquots, similar to scar treatment. The patient then takes colchicine 1.2 mg loading dose on day 1, then 0.6 mg twice per day for 4 days concurrently with naproxen 500 mg orally once daily for 5–7 days. This process may be repeated in 6 weeks if the lesions have not resolved and PDL laser may be employed for residual post‐inflammatory erythema.

Results

All three patients presented in this case series had significant aesthetic improvement in their dermal filler‐derived foreign body granulomatous reactions.

Conclusion

GFBR provides both a medical and aesthetic issue for these patients including mental distress, pain, and dysfunction, therefore having an effective treatment for GFBR will affect medical management of these patients, improving patient outcomes and satisfaction. Our proposed regimen for GFBR has been shown to be highly efficacious and safe for these patients, providing a significant improvement in both function and cosmesis of the area.
Craft(wo)manship, female sisterhood and myth‐(un)making in Anna Solomon's The Book of V
Authors: Gasztold Brygida , Rabinovich Irina
Published: December 2022

Taking on the lenses of historical fiction and literary feminism, the article explores the lives of five women in an attempt to demonstrate that craft and art, female friendship and metaphoric “sisterhood,” have been the unifying force that helped women cope with patriarchal domination and dire societal pressures. Bringing together three different periods and realities: the Old Testament, the 1960s, and 2016 allows for the examination of female roles across time, with special attention paid to the problems of identity, motherhood, and gender power relations. The Jewish traditional Purim celebration (Shpil) is discussed as a major feminist event where female craft, storytelling, and sisterhood merge as a culminating and unifying element, creating a magical aura and promising consolation.
Healthy, Wealthy, and Happy: The Joint Role of Health and Income in Explaining Global Life Satisfaction
Authors: Selini Katsaiti Marina , Kopinska Joanna , Atella Vincenzo
Published: December 2022

Based on Gallup World Poll data, we explore the heterogeneous evolution of income, health, and well‐being within world population subgroups identified according to country, gender, age, and education, offering an integrated approach with wide geographical coverage. We provide novel evidence on the global “winners” and “losers” in life satisfaction between 2009 and 2018, showing that individuals located at the bottom of the global income distribution and those with poor health saw pronounced reductions in life satisfaction as opposed to populations with incomes falling between the 60th and the 80th centile and the healthy ones, who experienced significant improvements. Our results highlight that health is at least on a par with income in explaining life satisfaction, although there are considerable differences across world regions. In particular, health supersedes income in its relevance to life satisfaction, mostly in more affluent world regions, while the opposite holds in destitute parts of the world.
Algebra and geometry of link homology: Lecture notes from the IHES 2021 Summer School
Authors: Gorsky Eugene , Kivinen Oscar , Simental José
Published: December 2022

These notes cover the lectures of the first named author at 2021 IHES Summer School on “Enumerative Geometry, Physics and Representation Theory” with additional details and references. They cover the definition of Khovanov‐Rozansky triply graded homology, its basic properties and recent advances, as well as three algebro‐geometric models for link homology: braid varieties, Hilbert schemes of singular curves and affine Springer fibers, and Hilbert schemes of points on the plane.
Abstracts from international emergency medicine journals
Authors: Production EMJ
Published: December 2022

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.
1658 Improvement in the quality of care delivered to head injury (HI) patients presenting to the emergency department of a district general hospital
Authors: Aslam Mohammed Jamil , Malik Shahid Pervez
Published: December 2022

Aims, Objectives and Background

A significant mortality and morbidity rate has been observed in patients presenting with head injuries. Delays in assessment, imaging, time critical diagnosis and management has compromised patient safety and quality of care at Walsall Manor Hospital.

To roll out an effective HI pathway with the aim to ensure:-

> 90% of high risk HI patients are assessed within 15 minutes

Greater efficiency within the process of obtaining CT (computed tomography) imaging

Final decision making < 4 hours.

Method and Design

Quality improvement methodology was employed in the form of process mapping to understand the current patient journey. SWOT (Strengths, weaknesses, opportunities and threats) analysis and driver diagrams were used to analyse the problem. Gantt chart was used to plan proposed timelines and PDSA (Plan-Do-Study-Act) cycles used to implement small changes with continued analysis. A new HI pathway was introduced which involved; a succinct thorough assessment, earlier identification of need for CT head, modifications to the requesting and transfer processes to imaging and review of the decision making processes.

Abstract 1658 Figure 1

Results and Conclusion

Data retrieval and analysis post interventions showed a reduction in time to initial ED clinician assessment from 63 minutes to 29 minutes. Percentage of CT scans performed within the hour increased from 67% to 89%. Time to CT scans being performed improved from 82 minutes to 55 minutes. These changes in turn had a significant impact on the decision to admit/discharge time which reduced from an average of 9 hours and 5 minutes to 3 hours and 40 minutes.

The introduction of a HI pathway alongside other adjuvant interventions had a marked impact on the safety and quality of care, provided to head injury patients at Walsall Manor Hospital. These measures will be re-evaluated at 6–12 monthly intervals to ensure continued enhanced performance.
1739 Improving the management of paediatric angulated upper limb fractures in the emergency department
Authors: Shah Roshni , Garcia Francesca , Deylamipour Yashar , Edwards Matthew
Published: December 2022

Background

Upper limb fractures are common to the Paediatric Emergency Department (PED). Most angulated and/or displaced fractures are traditionally referred to the orthopaedic team to admit for manipulation under anaesthesia (MUA). The Emergency Department (ED) believes that their manipulations and associated analgaesia are sub-optimal to those performed/given in theatre. This means a higher number of avoidable overnight paediatric admissions, long waiting times while fasting, and the theoretical risks of general anaesthesia and surgery.

Aims

Reduce the number of hospital admissions for MUA from the PED by managing suitable upper limb fractures safely and appropriately. Encourage long-term changes in clinician readiness to manipulate suitable paediatric injuries.

Objectives

Increase number of patients identified with upper limb fractures suitable for manipulation in PED

Reduce number of patients in this cohort requiring admission to hospital for MUA

Method and Design

A Plan-Do-Study-Act methodology was implemented. Adherence to our local policy was measured, specifically: inclusion/exclusion criteria, modes of analgesia and presence of a senior Orthopaedic doctor.

From October 2020 -June 2021, interventions were undertaken: a teaching package for Emergency Nurse Practitioners and doctors, posters placed in the PED, meetings with key stakeholders including the orthopaedic team and the introduction of a new departmental guideline. Data was collected between June 2021–September 2021 to see if results were maintained.

Results and Conclusion

ResultsRate of manipulations in PED increased from 41% to 78% in the 3rd cycle; improving to 86.36% after interventions stopped. Of those manipulated in PED, 73.68% were discharged from the department. Admissions for MUA decreased from 85% to 70% in the 3rd cycle; decreasing to 36.36% after interventions stopped.

The project showed success in improving management of paediatric angulated upper limb fractures. By identifying appropriate fractures, involving the senior orthopaedic team and providing adequate analgesia, admission for general anaesthesia can be avoided.
1480 The application of an age adjusted D-dimer threshold to rule out suspected venousthromboembolism (VTE) in an emergency department setting: A retrospective diagnostic cohort study
Authors: Barrett Liam , Jones Tom , Horner Daniel
Published: December 2022

Aims, Objectives and Background

Venous Thromboembolic disease (VTE) poses a diagnostic challenge for clinicians in acute care. Over reliance on reference standard investigations can lead to over treatment and potential harm.

We sought to evaluate the pragmatic performance and implications of using an age adjusted d-dimer (AADD) strategy to rule out VTE in patients with suspected disease attending an emergency department setting.

We aimed to determine diagnostic test characteristics and assess whether this strategy would result in proportional imaging reduction and potential cost savings.

Method and Design

Design

Single centre retrospective diagnostic cohort study.

All patients >50 years old evaluated for possible VTE who presented to the ED over a consecutive 12-month period between January and December 2016 with a positive D-dimer result.

Clinical assessment records and reference standard imaging results were followed up by multiple independent adjudicators and coded as VTE positive or negative.

Results

During the study period, there were 2132 positive D-dimer results. 1236 patients received reference standard investigations. A total increase of 314/1236 (25.1%) results would have been coded as true negatives as opposed to false positive if the AADD cut off point had been applied, with 314 reference standard tests subsequently avoided.

The AADD cut off had comparable sensitivity to the current cut off despite this increase in specificity; sensitivities for the diagnosis of DVT were 99.28% (95% CI 96.06–99.98%) and 97.72% for PE (95% CI 91.94% to 97.72). There were 3 potential false negative results using the AADD strategy.

Conclusion

In patients with suspected VTE with a low or moderate pre-test probability, the application of AADD appears to increase the proportion of patients in which VTE can be excluded without the need for reference standard imaging. This management strategy is likely to be associated with substantial reduction in anticoagulation treatment, investigations and cost/time savings.
1522 The composite outcome fallacy in the PRIEST COVID-19 clinical prediction score
Authors: Dash Kieran , Goodacre Steve , Sutton Laura
Published: December 2022

Aims, Objectives and Background

Clinical prediction models are often developed using composite outcomes, based on the implicit assumption that the predictors have similar associations with each component outcome. Using an example of a clinical prediction tool for adverse outcome in suspected COVID-19, we aimed to test this assumption and determine whether using a composite outcome led to suboptimal prediction of individual elements of the composite outcome.

Method and Design

We reanalysed data from the Pandemic Respiratory Infection Emergency System Triage (PRIEST) study; data was collected from 20,891 patients attending 73 emergency departments with suspected COVID-19 and was used to develop a clinical score predicting a composite outcome of mortality or receipt of major organ support up to 30 days following attendance. In this reanalysis we created Least Absolute Shrinkage and Selection Operator (LASSO) multiple regression models to produce unrestricted prediction models for (1) the composite outcome, (2) mortality, and (3) receipt of major organ support.

Results and Conclusion

Unrestricted regression models had c-statistics of 0.86 (95% Confidence Interval (CI) 0.85–0.86) for mortality, 0.78 (95% CI 0.77–0.80) for receipt of major organ support, and 0.82 (95% CI 0.82–0.83) for the composite outcome. Key variables in the clinical score (increased age, reduced performance status and reduced consciousness) predicted increased risk for mortality and the composite outcome but decreased or no significant risk for receipt of major organ support. The assumption that predictors have similar associations with individual elements of a composite outcome may not hold. Clinical prediction models may incur a ‘composite outcome fallacy’ if they are driven by predicting one element of the composite outcome but used to predict another. Further research into other clinical prediction score with composite outcomes is required.
1726 Integrating established clinical scores with a novel transcriptomic severity classifier augments early risk assessment in the ED
Authors: Diehl-Wiesenecker Eva , Galtung Noa , Liesenfeld Oliver , Uhle Florian , Sweeney Timothy E , Bauer Wolfgang
Published: December 2022

Aims, Objectives and Background

Reliable risk assessment in patients presenting to emergency departments (ED) with suspected infection is of utmost importance to support clinical decisions. Vital sign-based scoring systems such as NEWS2 or qSOFA enable a rapid first assessment of patient urgency at triage. However, their inherent high sensitivity might drive over-utilization of healthcare resources. Our aim was to evaluate if adding the result of a transcriptomic severity classifier can synergistically improve current score-based risk assessment in the ED.

Method and Design

We performed a secondary analysis of a patient cohort (n=312) enrolled in the Charité University hospital ED (Berlin, Germany) with suspected infection and at least one vital sign alteration. The expression of 29-host mRNAs in PAXgene-stabilized whole blood was quantified using NanoString nCounter® SPRINT. The proprietary machine learning classifier IMX-SEV-3 was applied to calculate a score that falls into pre-defined interpretation bands: low/moderate/high severity. NEWS2 and qSOFA were documented on admission and combined with the classifier results to analyze the incidence of two clinical endpoints: ‘need for critical care’ (composite of need for ventilation, dialysis, and/or vasopressors) within 7d and ‘28d mortality’.

Results and Conclusion

Among enrolled patients, 22 (7.1%) died and 66 (21.1%) required ICU-level care. Of patients with a high NEWS2 (≥5 points; n=184), there was a stepwise increase in mortality among the low (0%; n=0/47), medium (10.1%; n=12/119) and high (44.4% n=8/18) IMX-SEV-3 severity subgroups. A similar stratification was achieved across the low (17%), moderate (31%), and high (61%) IMX-SEV-3 subgroups for prediction of critical care. More granular risk stratification could also be confirmed when using IMX-SEV-3 in combination with high qSOFA (≥2 points; n=76): 0/10.6/50% mortality and 23.5/40.4/66% need for critical care in the low/moderate/high subgroups, respectively.

In summary, the combined use of immune-based IMX-SEV-3 results for ED patients with high clinical scores allows improved prediction of mortality and the need for critical care.
1473 In patients with chest pain suspicious for ACS, is arrival by emergency ambulance associated with increased likelihood of myocardial infarction?
Authors: Murray James , Raja Edwin Amalraj , Cooper Jamie
Published: December 2022

Aims, Objectives and Background

Patients commonly present to the Emergency Department (ED) with chest pain suspicious of an acute coronary syndrome (ACS). Clinical features and historical risk factors for ACS are assimilated with electrocardiographic (ECG) findings and cardiac biomarkers to assess risk, determine diagnosis and decide subsequent disposition. Many such patients arrive by ambulance but whether the mode of arrival is associated with an increased likelihood of myocardial infarction is unknown.

Method and Design

Adult patients (≥16 years) presenting to Aberdeen Royal Infirmary ED with chest pain suspicious of ACS and non-diagnostic ECGs were identified from two prospectively collected cohorts. Patient demographics, known ACS risk factors at presentation, cardiac biomarker results and clinical outcomes up to 30 days were recorded. Data sets were retrospectively interrogated electronically to identify the mode of ED arrival: by ambulance, or other. The independently adjudicated primary outcome was the development of type 1 or 4 myocardial infarction or cardiac death at 30 days.

Logistic regression was used to determine the association between mode of arrival and the primary outcome after adjusting for other confounds. The strength of association was reported as odds ratio (OR) and adjusted odds ratio (aOR) and its 95% confidence interval (CI).

Statistical analysis was performed using SPSS v27. A p-value <0.05 was considered to be statistically significant.

Results and Conclusion

Of 1606 patients [mean age 62 (SD 16) years, 45% women], 1246 (78%) arrived via ambulance and 188 (12%) reached the primary outcome.

After adjusting for known confounders, a statistically significant association (aOR 1.72; 95% CI 1.11 to 2.66) between ED arrival by ambulance and the development of type 1 or type 4 myocardial infarction or cardiac death at 30 days was demonstrated (table 1).

Abstract 1473 Table 1

Relationship of risk factors to the development of the primary outcome expressed using a Chi-square test and calculation of crude and adjusted Odds Ratios (OR) with 95% confidence intervals (CI). A P-value of <0.05 was considered statistically significant. The primary outcome was the development of a Type 1 or Type 4 myocardial infarction or cardiac death at 30 days

In our cohort of patients with chest pain suspicious of ACS, ED arrival by ambulance correlates strongly with the development of myocardial infarction at 30 days.
1795 Beyond the default male: exploring sex differences in the acute physiological response to trauma and associated clinical outcomes
Authors: Ross Jennifer , Bocchetta Natasha , Hickey Hayden , Lindsay Charlotte , Cole Elaine
Published: December 2022

Aims, Objectives and Background

Female patients are consistently outnumbered by males in trauma studies. This introduces bias towards male physiology when developing treatments and protocols and may result in females receiving less efficacious care. Recent studies have looked at sex based differences in injury patterns and outcomes following motor vehicle collisions1 as well as TXA administration following severe injury2. In this study we aimed to describe differences between male and female patients with equivalent injury severities (as assessed by ISS), specifically looking at acute physiological responses to injury and subsequent clinical outcomes.

Method and Design

We have sex disaggregated data from over 2000 patients enrolled in the Activation of Coagulation and Inflammation in Trauma (ACIT-II) prospective cohort study (REC: 07/Q0603/29) at the Royal London Hospital. Patients are eligible for inclusion into ACIT-II if they arrive in the Emergency Department within 2 hours of injury and meet the local criteria for a trauma team activation. Blood samples are taken on admission, and physiological parameters and outcome data are collected daily for up to 28 days or until death or discharge. Injury Severity Scores (ISS) were grouped into ‘control’ (ISS 0-3), ‘mild’ (ISS 4-8), ‘moderate’ (ISS 9-15), ‘severe’ (ISS 16-25), ‘critical’ (ISS 25-35) and ‘super critical’ (ISS ≥36).

Abstract 1795 Figure 1

Results and Conclusion

Our data showed a number of variations in physiological response between females and males of the same injury severity categories, notably in terms of depth of shock and coagulation. We also demonstrated worse 28-day survival for females compared to males in the higher injury severity groups (severe p = 0.006, critical p = <0.001). This work shows a definite requirement for further study into how sex based differences can affect presentations and outcomes in trauma.
1497 Methods to diagnose carbon monoxide exposure: A scoping review
Authors: Babu Ashik , Jarman Heather , Moss Phil , Reid Stephen
Published: December 2022

Aims, Objectives and Background

Carbon-monoxide (CO) is a colourless, odourless gas produced from incomplete combustion of carbon-containing fuels. Measurement of CO levels to diagnose exposure is difficult due to its short half-life. The effects of exposure to CO range from mild symptoms, such as headache, to neurotoxicity and death.

In this scoping review we aimed to establish the existing methods used in clinical practice and research to determine CO exposure and map the diagnostic cut-off values used.

Method and design

We undertook a scoping review to establish methods used in clinical practice and research to measure CO exposure and to determine diagnostic thresholds in each. EMBASE, Medline and CINAHL databases were searched for published articles in English from 2002 onwards using keywords ‘carbon monoxide’, ‘poisoning’ and ‘diagnosis’. Two reviewers independently screened published abstracts for inclusion, with a third arbiter where there was lack of agreement between reviewers. Full text papers were then reviewed, and data extracted on methods used to measure CO level, diagnostic cut-off values, and whether CO exposure was from a known or unknown source.

Results and Conclusion

A total of 85 papers were identified meeting the inclusion and exclusion criteria. The most common methods identified for diagnosing CO exposure were measurement of carboxyhaemoglobin (COHb) in whole blood (50.5%) and CO-oximeter spectrophotometrics (20%). Diagnostic values were poorly reported and varied in non-smokers and smokers. Exhaled CO levels using breath analysers (8.2%) and ambient CO measurement (11.7%) were also documented. Diagnostic threshold values varied between 2–5% in non-smokers and 10–15% in smokers. Several methods are used in clinical practice and research to diagnose CO exposure. There is variation in the cut-off values used to make this diagnosis which is challenging for clinicians and makes comparison of research findings difficult.
1347 Systematic review of the effectiveness of advocacy interventions for adult victims of domestic violence within an emergency department setting
Authors: Basheer Mohamed Bushry , Bell Rachel , Boyle Adrian
Published: December 2022

Aims, Objectives and Background

Advocacy interventions for survivors of domestic violence is well established and supported by evidence in some community and healthcare settings. Survivors of domestic violence identified in emergency departments have important differences and it is not clear whether evidence can be applied to this population. Therefore, we conducted an inclusive systematic review of controlled studies evaluating the effectiveness of advocacy workers for adult survivors identified in emergency departments.

Method and Design

We included studies that reported primary research studies evaluating the effectiveness of advocacy workers in supporting survivors of domestic abuse conducted in emergency departments. We excluded studies that reported screening trials, interventions to increase identification of abuse by healthcare staff, studies conducted on children and studies that weren’t reported in English. The search for studies was done via the following online databases from their start dates till February 2022: PubMed/MEDLINE, Cochrane Library, CINAHL/Ebsco, EMBASE and PsycINFO. We anticipated that there would be few high quality double-blinded RCTs and aimed to include before and after studies.

Abstract 1347 Table 1

Results and Conclusion

We only found one randomised control trial that met our inclusion criteria, and several observational studies which were judged as too weak for inclusion. We found a non-peer reviewed study done as part of a dissertation by a UK emergency consultant, as well as an unpublished randomised controlled trial carried out as part of a PhD thesis. None of the studies we found reported harm from advocacy interventions. The cost effectiveness is uncertain, but likely to be beneficial. We are able to make a weak recommendation that advocacy interventions are likely to helpful, unlikely to be harmful but are of uncertain cost effectiveness. Future research should define meaning outcomes and controlled trials evaluating referral to advocacy are justified. Survivors of domestic violence who present to emergency departments are likely to benefit from referral to advocacy workers.
1467 Hair Tourniquet syndrome, an audit on the efficacy of depilatory creams. An analysis of 3 years of Data, showed a positive rationale for supporting the usage of depilatory cream to remove the hair
Authors: Bragg Julia , Davies Ffion
Published: December 2022

Aims, Objectives and Background

Purpose of the study was to provide supporting evidence for the application of depilatory cream on a child presenting with hair tourniquet syndrome, and measure it’s efficacy and any side effects.

Hair tourniquet syndrome is a rare phenonium and there are minimal evidenced based studies to support best practice on how to remove them safely.

Our department has been using depilatory cream to dissolve the hair, and have audited 3 years worth of data in order to achieve a sample size large enough to show efficacy for this procedure. Sample size was still low at 22 patients, but this is representative of the rareity of the complaint.

Method and Design

With patients attending with a hair tourniquet where the skin was intact, Depilatory cream was applied to the site for 6–8 minutes according to the products instructions, then washed off thoroughly with an aim to dissolve the hair.

The audit was a retrospective study of 3 years of attendances to a busy children’s Emergency department. It looked at the age of the child, site of the hair tourniquet, method used to remove the hair and any iatrogenic side effects from the method chosen. It also looked at any further care needed if removal was unsuccessful.

Results and Conclusion

95% of patients had the hair removed effectively within 1 hour of arrival in ED

x 3 children had the hair removed manually, of which one received a small wound from a scalpel.

x 18 children had depilatory cream applied, and of those 18 children it was effective in 83% 1st time. Two children required a second application and it was then successful and One went on to require removal by plastics, under a general anesthetic. It therefore 94% effective as a method of removal. Iatrogenic side effects included mild skin break down in 3 patients (16.6%).
1750 Prediction of 6 month Trauma PROMS using in-hospital data
Authors: Coats Timothy , Bouamra Omar , Edwards Antoniette , Lecky Fiona , Mirkes Evgeny , Sergeant Jamie , Ivan Tyukin
Published: December 2022

Aims, Objectives and Background

Trauma audit has used lived/died as an outcome for 30 years, but Patient Reported Outcome Measures (PROMS) have also been collected by the Trauma Audit and Research Network (TARN) for the past 5 years across major trauma centres. These are measured at 6 months after injury and include two measures of health-related quality of life, EQ5D-5 and GOSE, employment status and three patient experience questions. It is not known if 6-month PROMS can be predicted after major trauma.

Method and Design

The TARN PROMS data was extracted and randomly divided into a model development (training) and a model testing (test) dataset. There is no standard way of using this type of complex data, so three different modelling approaches were used: (1) conventional logistic regression, (2) artificial intelligence (AI) selection of ‘nearest neighbours’, and (3) AI decision trees. The performance of each model was evaluated using the test dataset.

Results and Conclusion

There were 5791 patients in the training set and 1447 patients in the test set. All three of the methods achieved an ROC AUC between 0.69 and 0.77 – implying that this might be the limit of prediction based on this type of data. When tested against the binary Glasgow Outcome Score the results are shown in the table 1. The AI method of ‘k Nearest Neighbours’ achieved a balance between sensitivity (72%) and specificity (71%).

Abstract 1750 Table 1GOSE Groupk Nearest NeighboursLogistic RegressionDecision treesSensitivity72%91%79%Specificity71%26%65%PPV90%82%39%NPV42%45%91%ROC0.7640.6850.77ROC 95% CI0.733 – 0.7950.648 – 0.723

Conclusion

patient reported outcomes at 6 months after injury can be predicted from in-hospital data. This potentially gives a new method for clinical audit and comparison of trauma outcomes using a measure that is more relevant to survivors of major trauma than the current ‘lived/died’.
1375 An analysis of the certified cause of death within one year of serious injury in the Scottish population
Authors: Craig Hannah , Gordon Malcolm WG , Khan Angela
Published: December 2022

Aims, Objectives and Background

To date, few studies effectively quantify the long-term incidence of death directly related to injury.

The absence of detailed mortality data and underlying cause of death information following trauma results in an inadequate understanding and a potential underestimation of the true consequences of injury on an individual and population level.

This study takes a nationwide approach to identify the true one-year mortality in patients due to serious injury in Scotland, evaluating survivorship in relation to other pre-existing co-morbidities and incidental causes of death.

Method and Design

This retrospective cohort study assessed the one-year mortality of adult trauma patients with an Injury Severity Score > 9 during 2020 using the Scottish Trauma Audit Group (STAG) registry linked to inpatient hospital data and death certificate records. Patients were divided into three distinct subgroups: death due to injury, death due to another cause, but injury was a contributory factor, and death due to a separate cause. These were subsequently analysed to determine risk factors linked to death. Kaplan-Meier curves and Cox regression were used for survival analysis to evaluate mortality.

Abstract 1375 Figure 1

Kaplan-Meier survival curve of the 2020 STAG cohort of traumatically injured adult patients who died within 365 days post-trauma hospitalisation stratified by underlying cause of death subgroup: trauma, trauma-contributed and non-trauma

Results and Conclusion

4056 patients were analysed with a median age 63 years and male predominance (55.2%). 782 patients died within 365 days (19.3%), with 55% occurring post-discharge. 47.7% of all deaths were attributable to trauma, and 35.3% were a direct consequence of injury. Non-traumatic deaths accounted for 20.3% and 79.4% in-hospital and post-discharge deaths respectively, most frequently due to circulatory, neoplastic and respiratory disease (37.7%, 12.3%, 9.1%, respectively). GCS < 8, modified Charlson Comorbidity score > 5, Injury Severity Score >25, Head AIS >3, Sex, and Age were independent risk factors for mortality at one year. Approximately 20% of patients died within 365 days due to trauma. Although early deaths reflect the bulk of trauma-related mortality, our sample demonstrated a significantly higher post-discharge one-year mortality than previously appreciated.
1404 Patients attending the emergency department for blunt thoracic trauma: a validation study of the STUMBL score
Authors: Giamello Jacopo Davide , Martini Gianpiero , Santoro Marco , Prato Davide , Arese Ylenia , Battle Ceri Elisabeth , Driscoll Timothy , Artana Nicoletta , Barutta Letizia , Sciolla Andrea , Lauria Giuseppe
Published: December 2022

Aims, Objectives and Background

Blunt thoracic trauma (BTT) is a leading cause of emergency department (ED) trauma-related attendance. The STUMBL score is a prognostic model for BTT, derived and validated in the United Kingdom; this study’s aim was to validate the STUMBL score in an Italian ED.

Method and Design

This single-centre retrospective validation study was conducted in the ED of Cuneo hospital, north-western Italy. All patients with an ED attendance for isolated BTT from 2018 to 2021 were included. Exclusion criteria were: age of under eighteen and the presence of any immediately life-threatening lesion. The primary outcome was the development of trauma-related complications, defined by the occurrence of one or more of the following: in-hospital mortality, pulmonary complications (infection, pleural effusion, haemothorax, pneumothorax, pleural empyema), need for intensive care unit admission, hospital length of stay equal to or greater than seven days. The performance of the STUMBL score was analysed in terms of discrimination with the evaluation of the receiver operating characteristiccurve and calibration with the Hosmer-Lemeshow test and with the calibration belt.

Abstract 1404 Figure 1

Results and Conclusion

745 patients were enrolled (median age 64 [50;78], male/female ratio 1:4, median Charlson comorbidity index 2 [1;4], median STUMBL score 11 [6;17]). 65.2% of patients were discharged home after ED evaluation. 203 patients (27.2%) developed the primary outcome. The STUMBL score was significantly different in patients with complications compared to those without complications (9 [5;13] vs 21 [17;25], p<0.001). The C index of the score for the primary outcome was 0.9 (95% CI 0.88 – 0.93) (figure 1), and the result of the Hosmer-Lemeshow test was 9.01 (p=0.34). STUMBL score = 16 had a negative predictive value of 0.92. In conclusion, this validation study demonstrated that the STUMBL score had excellent discrimination and calibration in predicting the outcome of patients attending the ED with a BTT.
1755 The differential determinants of delivering prehospital emergency anaesthesia within 45-minutes of the 999-call – a multi-centre, retrospective observational study
Authors: Kratz Maria , Price James , Lachowycz Kate , Major Rob , Moncur Lyle , McLachlan Sarah , Keeliher Chris , Steele Alistair , Barnard Ed
Published: December 2022

Aims, Objectives and Background

Prehospital emergency anaesthesia (PHEA) is a necessary intervention for a significant proportion of severely injured trauma patients. The National Institute for Health and Care Excellence (NICE) trauma quality standards include delivery of prehospital emergency anaesthesia (PHEA), where indicated, ≤45-minutes of the 999-call. The aim of this study was to report the differential determinants of meeting this standard in a large regional cohort of trauma patients.

Method and Design

A consecutive sample of adult trauma patients undergoing PHEA (2015–2020) at three Helicopter Emergency Medical Services (HEMS) in the East of England. The primary outcome was PHEA ≤45-minutes of 999-call; defined as duration between call ‘pick-up’ and administration of anaesthetic drugs. Data were extracted from all three HEMS electronic medical records (HEMSbase, MedicOne Systems), and combined. Variables included: dispatch type (immediate, interrogate, crew-request), demographics, time of day (day/night), PHEA indication, pre-PHEA physiology.

A purposeful selection logistic regression model was used in R (a language and environment for statistical computing). Each variable was first tested in turn to explore the unadjusted association with the outcome. Significant variables were then included in the multivariable analysis. Variables were successively eliminated until only statistically significant variables remained. This was a service evaluation study (EAAA 2021/025).

Results and Conclusion

1,155 adult trauma patients were included in the analysis. The primary outcome, PHEA ≤45-minute of 999-call, was achieved in n=196 (17.0%) of cases. The data model is under construction. However, there is signal that non-immediate dispatch type, older age, and night-time operations are all associated with a reduced likelihood of delivering PHEA ≤45-minutes of the 999-call.

Less than one in five trauma patients receive PHEA ≤45-minutes of the 999-call in the East of England. Results from this project may positively influence dispatch systems in order to increase the timely delivery of prehospital anaesthesia where indicated (pending the complete data model).