bluuebunny/crossref_metadata_2025 huggingface dataset:
The magnetic field and turbulence of the cosmic web measured using a brilliant fast radio burst
Authors: Ravi V. , Shannon R. M. , Bailes M. , Bannister K. , Bhandari S. , Bhat N. D. R. , Burke-Spolaor S. , Caleb M. , Flynn C. , Jameson A. , Johnston S. , Keane E. F. , Kerr M. , Tiburzi C. , Tuntsov A. V. , Vedantham H. K.
Published: November 2016

Probing the intergalactic magnetic field

Fast radio bursts (FRBs) are powerful flashes of astronomical radio waves that last just milliseconds and whose origins are a matter of debate. Raviet al.discovered a FRB that is exceptionally bright (see the Perspective by Kaspi). This allowed them to measure how the polarization of the signal varies with wavelength (Faraday rotation). Combining this with the time delay of the flash at different wavelengths revealed the mean magnetic field along the line of sight. Assuming that the FRB originates from a colocated galaxy, the results constrain the intergalactic magnetic field and will inform models of galaxy formation and cosmology.

Science, this issue p.1249; see also p.1230
Gleaning Insights from Fecal Microbiota Transplantation and Probiotic Studies for the Rational Design of Combination Microbial Therapies
Authors: Hudson Lauren E. , Anderson Sarah E. , Corbett Anita H. , Lamb Tracey J.
Published: November 2016

Beneficial microorganisms hold promise for the treatment of numerous gastrointestinal diseases. The transfer of whole microbiota via fecal transplantation has already been shown to ameliorate the severity of diseases such as
Clostridium difficile
infection, inflammatory bowel disease, and others. However, the exact mechanisms of fecal microbiota transplant efficacy and the particular strains conferring this benefit are still unclear. Rationally designed combinations of microbial preparations may enable more efficient and effective treatment approaches tailored to particular diseases. Here we use an infectious disease,
C. difficile
infection, and an inflammatory disorder, the inflammatory bowel disease ulcerative colitis, as examples to facilitate the discussion of how microbial therapy might be rationally designed for specific gastrointestinal diseases. Fecal microbiota transplantation has already shown some efficacy in the treatment of both these disorders; detailed comparisons of studies evaluating commensal and probiotic organisms in the context of these disparate gastrointestinal diseases may shed light on potential protective mechanisms and elucidate how future microbial therapies can be tailored to particular diseases.
Complete Genome Sequences of Three
Siphoviridae
Bacteriophages Infecting Salmonella enterica Serovar Enteritidis
Authors: Paradiso Rubina , Lombardi Serena , Iodice Maria Grazia , Riccardi Marita Georgia , Orsini Massimiliano , Bolletti Censi Sergio , Galiero Giorgio , Borriello Giorgia
Published: November 2016

Three bacteriophages, 118970_sal1, 118970_sal2, and 64795_sal3, were isolated from water buffalo feces in southern Italy, exhibiting lytic activity against
Salmonella enterica
serovar Enteritidis. These bacteriophages belong to the
Siphoviridae
family and have a 60,113-bp, 123,930-bp, and 48,094-bp double-stranded DNA (dsDNA) genome containing 72, 173, and 80 coding sequences (CDSs), respectively.
Complete Genome Sequence of an African Swine Fever Virus Isolate from Sardinia, Italy
Authors: Granberg Fredrik , Torresi Claudia , Oggiano Annalisa , Malmberg Maja , Iscaro Carmen , De Mia Gian Mario , Belák Sándor
Published: November 2016

Previous genetic characterization of African swine fever virus isolates from the Italian island of Sardinia, where the virus has been present since 1978, has largely been limited to a few selected genomic regions. Here, we report the complete genome sequence of the isolate 47/Ss/08 collected during an outbreak in 2008.
Genome Sequence of Lactobacillus fermentum Strain NCC2970 (CNCM I-5068)
Authors: Barretto Caroline , Ngom-Bru Catherine , Genevaz Alienor , Fournier Coralie , Moine Deborah , Kassam Mohamed , Iltis Agnes , Sagory-Zalkind Pierre , Ciron Pierre-Emmanuel , Faucherand Gilles , Descombes Patrick , Duboux Stephane
Published: November 2016

Lactobacillus fermentum
NCC2970 (CNCM I-5068) is a lactic acid bacterium originating from the Nestle Culture Collection. Here, we disclose its full 1.9-Gb genome sequence comprising one chromosome with no plasmid.
Draft Genome Sequence of
Curtobacterium
sp. Strain ER1/6, an Endophytic Strain Isolated from
Citrus sinensis
with Potential To Be Used as a Biocontrol Agent
Authors: Garrido Leandro Maza , Alves João Marcelo Pereira , Oliveira Liliane Santana , Gruber Arthur , Padilla Gabriel , Araújo Welington Luiz
Published: November 2016

Herein, we report a draft genome sequence of the endophytic
Curtobacterium
sp. strain ER1/6, isolated from a surface-sterilized
Citrus sinensis
branch, and it presented the capability to control phytopathogens. Functional annotation of the ~3.4-Mb genome revealed 3,100 protein-coding genes, with many products related to known ecological and biotechnological aspects of this bacterium.
Draft Genome Sequence of Microcystis aeruginosa CACIAM 03, a Cyanobacterium Isolated from an Amazonian Freshwater Environment
Authors: Castro Wendel Oliveira , Lima Alex Ranieri Jerônimo , Moraes Pablo Henrique Gonçalves , Siqueira Andrei Santos , Aguiar Délia Cristina Figueira , Baraúna Anna Rafaella Ferreira , Martins Luisa Carício , Fuzii Hellen Thais , de Lima Clayton Pereira Silva , Vianez-Júnior João Lídio Silva Gonçalves , Nunes Márcio Roberto Teixeira , Dall'Agnol Leonardo Teixeira , Gonçalves Evonnildo Costa
Published: November 2016

Given its toxigenic potential,
Microcystis aeruginosa
is an important bloom-forming cyanobacterium. Here, we present a draft genome and annotation of the strain CACIAM 03, which was isolated from an Amazonian freshwater environment.
Oral and gastrointestinal symptomatic metastases as initial presentation of lung cancer
Authors: Jeba Jenifer , Backianathan Selvamani , Ishitha Gunadala , Singh Ashish
Published: November 2016

Metastasis to the tongue, duodenum or pancreas from primary lung cancer is uncommon. Primary lung cancer presenting with symptoms related to metastases at these sites, at initial presentation is extremely rare. We report a 45-year-old man with disseminated lung malignancy who presented with dyspepsia, melena, symptoms due to anaemia and swelling in the tongue. Oral examination revealed a hard submucosal anterior tongue lesion. Biopsies from the tongue lesion and the duodenal ulcer seen on upper gastrointestinal endoscopy were suggestive of metastasis from lung primary. CT revealed lung primary with disseminated metastasis to lung, liver, adrenals, kidneys, head and body of pancreas, duodenum and intra-abdominal lymph nodes. The patient was treated with palliative chemotherapy. The unusual presentation and diagnostic details are discussed.
Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature
Authors: Goodman Daisy , Ogrinc Greg , Davies Louise , Baker G Ross , Barnsteiner Jane , Foster Tina C , Gali Kari , Hilden Joanne , Horwitz Leora , Kaplan Heather C , Leis Jerome , Matulis John C , Michie Susan , Miltner Rebecca , Neily Julia , Nelson William A , Niedner Matthew , Oliver Brant , Rutman Lori , Thomson Richard , Thor Johan
Published: November 2016

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail athttp://www.squire-statement.org.
SELECTIVE AORTIC ARCH PERFUSION FOR THE REVERSAL OF HAEMORRHAGE-INDUCED TRAUMATIC CARDIAC ARREST IN A SWINE MODEL OF NON-COMPRESSIBLE TORSO HAEMORRHAGE
Authors: Barnard EB , Smith JE , Manning JE , Rall JM , Cox JM , Bebarta VS , Ross JD
Published: November 2016

Objectives & Background

Haemorrhage is the leading cause of potentially survivable trauma death. Selective Aortic Arch Perfusion (SAAP) is an experimental resuscitative intervention that has the potential to improve trauma survival: a trans-femoral intra-aortic balloon controls torso haemorrhage, while the catheter's large central lumen allows oxygenated blood to be delivered to the proximal aorta–theoretically providing coronary perfusion pressures adequate for return of spontaneous circulation in cardiac arrest (figure 1).

Hypothesis–In haemorrhage-induced traumatic cardiac arrest, SAAP with oxygenated blood will infer a short-term survival advantage over both closed chest compressions (CPR) with intravenous blood, and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with intravenous blood.

Methods

70–90 kg swine underwent a non-compressible torso haemorrhage (NCTH) and controlled arterial haemorrhage. Arrest was defined as a systolic blood pressure (SBP) <10 mm Hg, together with an inappropriate bradycardia. Animals were allocated to one of three groups: CPR with four units of intravenous blood, REBOA with four units of intravenous blood, and fresh whole blood SAAP (FWB-SAAP) with 1600 ml of oxygenated intra-aortic blood. Primary outcome was 60-minute ‘pre-hospital’ survival. Data are described as mean (+/− standard devation). Multi-group analyses were by ANOVA, and survival was analysed by Log-rank (Mantel-Cox) test.

Results

There were ten animals per group, a total of 30 swine. Mean weight of 79.9 kg (+/−5.5) p=0.3. Mean time from the start of the injury to onset of arrest was 11.2 minutes (+/−1.9) p=0.2. Prior to intervention the mean SBP was 2.9 mm Hg (+/−3.2) p=0.7, and the mean heart rate was 41 bpm (+/−32) p=0.5.

Primary outcome – FWB-SAAP demonstrated an 80% 60-minute ‘pre-hospital’ survival, compared to 10% with CPR, and 0% with REBOA, p<0.001 (figure 2).

Conclusion

In this swine model of haemorrhage-induced traumatic cardiac arrest with NCTH, SAAP infers a short-term survival advantage over both conventional therapy (CPR), and over evolving therapy (REBOA). Of note, SAAP induced return of spontaneous circulation from cardiac electrical asystole.

Figure 1Figure 2
VALIDATION OF THE SHORT FORM OF THE INTERNATIONAL CROWDING MEASURE IN EMERGENCY DEPARTMENTS (ICMED): INTERNATIONAL STUDY
Authors: Boyle A , Richter S , Atkinson P , Clouston R , Stoica G , Basaure Verdejo C , Wakai A , Chan E , Grewal K , Gilligan P , Higginson I , Liston P , Newcombe V , Norton V
Published: November 2016

Objectives & Background

There is little consensus on the best way to measure emergency department crowding. We have previously developed a consensus based measure, the International Crowding Measure in Emergency Departments (ICMED). This measure has both flow and non-flow items, and also contains items which measure Input, Throughput and Output. We aimed to externally validate a short form of the ICMED against emergency physician's perceptions of crowding and danger across a wide variety of Emergency Departments. Face validity is important to support implementation of any measure

Methods

We performed an observational validation study in seven emergency departments in five different countries. We recorded sICMED observations and the most senior available emergency physician's perceptions of crowding and danger at the same time. We performed a times series regression model to account for clustering and correlation.

Results

397 data points were analysed. The sICMED showed moderate positive correlations with emergency physician's perceptions of crowding r=0.4110, p<0.05) and danger (r=0.4566, p<0.05.) There was considerable variation in the performance of the sICMED between different emergency departments. The sICMED was only slightly better than measuring occupancy or emergency department boarding time.

Conclusion

The short form of the ICMED has moderate face validity in measuring crowding. This is an important first step in validating this measure. The measure performs less well in Emergency Departments that are constantly crowded.

Figure 1
THE IMPACT OF PERIPHERAL INTRAVENOUS (IV) CANNULATION IN THE AMBULANCE AND EMERGENCY DEPARTMENT
Authors: Steel M , Goodacre S
Published: November 2016

Objectives & Background

Intravenous cannulation in an emergency setting has significant potential benefits and harms to patients. Patients need to understand these in order to make an informed decision about cannulation. This research aims to improve knowledge and understanding of the benefits and harms of cannulation to patients, in addition to understanding the patient perspective of cannulation.

Methods

Eighty patients were recruited from a convenience sample in a large urban academic emergency department (ED). Patients were included if they attended the department by ambulance and had a peripheral intravenous catheter inserted. Participants were asked to complete a questionnaire whilst they were attending the department. A follow up questionnaire was sent to the patients assessing the frequency of complications from cannulation. The number of attempts, proportion of catheters that go unused, rate of complications, symptoms associated with siting a cannula, patient understanding of cannulation and the patient perception of potential benefits and harms of cannulation were assessed.

Results

The study population was 50% (40/80) male, with a mean age of 65 years and 72.5% (58/80) had their cannula inserted in the ED; the remainder were inserted in the ambulance (22/80). Cannulae were used 60% (CI 51.4%–68.6%) of the time, cannulae inserted in the ambulance were much more likely to be used than those inserted in the ED, 92% vs 48%, p<0.001.

Some 21.3% (CI 13.8%–28.8%) of patients did not know why they had a cannula inserted. Not knowing why the cannula was inserted was not associated with anxiety levels (p=0.415).

Mean pain score (Likert 0–10 scale) was 1.66 (CI 1.21–2.12). Patients who underwent multiple attempts reported higher pain score, 3.45 vs 1.38 (p=0.020). Only 26.6% (CI 19%–35.4%) of patients were told the risks of cannulation but 88.8% (CI 82.5%–93.8%) of patients believed insertion of the cannula was important.

Conclusion

The majority of patients have an understanding of the purpose of cannulation, with the majority of patients believing cannulation is important in emergency care. However patients are not frequently told the potential risks of cannulation and would like to be told these. Cannulae inserted in the emergency department are not frequently used and efforts should be made to reduce the number of cannulae inserted but then not used.
EVALUATING THE SAFETY AND COST EFFECTIVENESS OF MANAGING FAT PAD POSITIVE ELBOW INJURIES WITHIN THE EMERGENCY DEPARTMENT
Authors: Tricks R , Ilavala LN , Cumberland J
Published: November 2016

Objectives & Background

Elbow injuries associated with fat pads on X-ray are traditionally treated as fractures. Studies show fracture rates vary from 23%1to 90.2%2with follow up imaging. In 2006 Sheffield Children's Hospital (SCH) Emergency Department (ED) created a guideline advising isolated fat pad injuries do not need automatic referral to fracture clinic. Review is in ED Clinic at 7 days, unless x-ray is reported as a fracture. If concerns persist referral to fracture clinic should occur. This service evaluation assesses if the guideline is being followed, its safety, cost effectiveness and variation in diagnosis and management between professionals.

Methods

We retrospectively reviewed all elbow X-rays, with their ED and radiological reports, taken in the ED at SCH from June 2014 to May 2015. Those with an initial interpretation of fat pad only by the ED clinician were included. ED and hospital notes were reviewed for management and diagnoses.

Results

99 isolated fat pad injuries were identified– 5 discharged immediately. 64 were referred to ED clinic as per protocol and 30 referred directly to fracture clinic. Radiology identified 11/94 as fractures of which 4 had ED clinic follow up. 3/4 were flagged by radiology, 2 were redirected to fracture clinic. 1 went from ED clinic to fracture clinic; diagnosed as a soft tissue injury (STI). 1 was not flagged and reattended with a diagnosis of STI.

Of the remaining 62, 43 attended. 7 were referred to fracture clinic. 2/7 were diagnosed as fractures.

Of the 30 referred to fracture clinic directly, 7 had a fracture reported by radiology. 5/7 were diagnosed as a fracture. Of those reported as no fracture, 5 fractures were diagnosed clinically. 33% of all fracture clinic reviews were diagnosed as fractures compared to 1.6% of all those seen in ED clinic.

Radiologists and Orthopods agreed in 71% of fractures.

There were 5 unplanned re-attenders; 1(originally referred to fracture clinic directly) was diagnosed as a fracture.

Taking into account clinic costs alone a saving of £9,965 was estimated in this population of 94 patients.

Conclusion

Our evaluation shows it is both safe and cost effective to treat simple, fat pad positive elbow injuries with collar and cuff and ED review at 7 days. There are significant cost benefits and with an appropriate safety net and radiology reporting system, no fractures requiring significant intervention were missed.
THE COST-EFFECTIVENESS OF PATIENT CONTROLLED ANALGESIA VERSUS ROUTINE CARE IN PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT IN PAIN, WHO ARE SUBSEQUENTLY ADMITTED TO HOSPITAL
Authors: Smith JE , Squire R , Pritchard C , Ewings P , Barton A , Rockett M , Creanor S , Hayward C , Eyre V , Cocking L , Benger J
Published: November 2016

Objectives & Background

The clinical effectiveness of patient controlled analgesia (PCA) has been demonstrated in a variety of settings. However, PCA is rarely utilized in the emergency department (ED). The aim of this study was to compare the cost effectiveness of PCA versus treatment as usual (TAU) in patients admitted to the ward from the ED with pain due to traumatic injury or non-traumatic abdominal pain. This is the cost-effectiveness analysis of the previously reported PAin SoluTions In the Emergency Setting (PASTIES) study.

Methods

Pain scores were measured hourly for 12 hours using a visual analogue scale from 0–100 mm. Scores of 45 mm or above reflected moderate or severe pain. Cost-effectiveness is reported as the additional cost per hour in moderate to severe pain avoided by using PCA rather than TAU, the incremental cost-effectiveness ratio (ICER). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis.

Results

For patients suffering pain from traumatic injuries, the cost per hour in moderate or severe pain averted (ICER) was estimated as £24.77 (bootstrap estimate 95% CI=£8.72 to £89.17). The ICER for patients with abdominal pain was estimated as £15.17 (bootstrap estimate 95% CI=£9.03 to £46.00). Overall costs were higher with PCA than TAU in both groups: for pain from traumatic injuries an additional £18.58 (95% CI 15.81 to 21.35) per 12 hours; for abdominal pain £20.18 (95% CI 19.45 to 20.84).

Conclusion

The cost of PCA use in ED varies with the clinical scenario, but is in the region of £15–£25 per hour of moderate or severe pain averted. Overall additional costs are around £20 per 12-hour patient episode.

Figure 1

Sampling variation for traumatic pain trial: ICER estimates from 1,000 bootstrap samples shown on the cost-effectiveness plane

Figure 2

Sampling variation for abdominal pain trial: ICER estimates from 1,000 bootstrap samples shown on the cost-effectiveness plane
COMPARING THE ABILITIES OF TWO NOVEL TRIAGE TOOLS TO PREDICT HOSPITAL ADMISSION – THE GLASGOW ADMISSION PREDICTION SCORE AND THE AMBULATORY CARE SCORE
Authors: Jones D , Mason S , OKeeffe C
Published: November 2016

Objectives & Background

Patient waiting times in Emergency Departments (ED) have risen in recent years, leading to increasing pressure on EDs to meet targets. As increased funding for EDs is an unlikely solution, better utilisation of current ED resources is required. An accurate method of predicting hospital admission at the point of triage could reduce wait times by facilitating patient streaming, bed planning and aiding staff decision making. Two tools that predict admission at triage have been created. They are the Glasgow admission prediction score (GAPS) and the ambulatory care score (AMBS). The primary aim of this study is to compare the the two tools' abilities to predict admission.

Methods

Sampling was performed over ten days at the Sheffield Teaching Hospitals NHS Trust ED. Data was collected prospectively at triage for all consecutive patients who presented to the ED during sampling periods. GAPS and AMBS were calculated independent of patient clinical management and their disposition recorded. The accuracy of each tool was assessed using receiver operating characteristic curve (ROC) analysis.

Results

Data was collected for 645 patients. GAPS had a higher area under ROC (AUC) of 0.815 (95%CI 0.781 to 0.849), compared to AMBS at 0.763 (95%CI 0.727 to 0.800). The difference in AUC was 0.0518 (95%CI 0.0135 to 0.0900) P=0.0080. GAPS had a sensitivity and specificity of 81.4% (95%CI 75.8% to 86.1%) and 67.5% (95%CI 62.7% to 72.0%) respectively, a PPV of 59.1% (95%CI 53.5% to 64.5%) and a NPV of 86.2% (95%CI 82.0% to 89.8%). Finally, GAPS correctly predicted the outcome of 72.6% of patients. AMBS had a sensitivity of 49.2% (95%CI 42.6% to 55.72%), a specificity of 81.4% (95%CI 77.3% to 85.1%), a PPV of 60.4% (95%CI 53.1% to 67.4%) and a NPV of 73.5% (95%CI 69.2% to 77.5%). Lastly, AMBS correctly predicted the outcome of 69.6% of patients.

Conclusion

GAPS outperformed AMBS at predicting patient disposition. GAPS had a statistically significantly larger AUC than AMBS and as a result, better discriminative power. Additionally, GAPS had a more clinically favourable sensitivity, specificity, PPV, NPV and accuracy overall, when compared to AMBS. However, the results show that GAPS alone should not be used to determine patient outcomes, as it does not have sufficient accuracy, and may be best utilised alongside clinical judgment.
WE ALL LOVE A GOOD MEDICAL DRAMA – BUT ARE THEIR DEPICTIONS OF CPR BAD FOR THE PUBLIC?
Authors: Welman T , Welman T , Williams C , Bryan J , Colwill M , Lindberg E , Somerville C
Published: November 2016

Objectives & Background

Out of hospital cardiac arrests (OHCS) are frequent worldwide but have disappointingly poor outcomes. Non medically trained individuals have been identified to perform substandard CPR by exerting less force than required to achieve adequate cardiac output. We have noticed that televised medical dramas often portray poor quality CPR. We set out to identify how well televised medical dramas depict cardiopulmonary resuscitation (CPR) and whether public knowledge of CPR technique is influenced by these programmes.

Methods

We performed a prospective observational study of three popular medical dramas: Grey's Anatomy, Casualty and Holby City. A short survey was distributed amongst non-medically trained personnel to investigate public knowledge of CPR technique. Rate and depth of chest compressions depicted on screen and selected as correct by survey participants were evaluated.

Results

90 episodes were reviewed over the study period with 39 resuscitation attempts shown. Rate of chest compressions varied from 60 to 204 compressions per minute with a median of 122 (95% confidence interval 113 to 132). Depth varied from one to six centimetres with a median of two (2.1 to 2.87). Both the rate and depth observed were found to be significantly different from the UK Resuscitation Council Guidelines (2010) (p<0.05, t-test). Survey participants (n=160, response rate of 80%) documented what they thought was the correct rate and depth of chest compressions and were scored accordingly. Those who documented watching medical dramas regularly, scored significantly worse than those who only tune in occasionally (p<0.05, Mann Whitney test).

Conclusion

Televised medical dramas often depict an inaccurate portrayal of CPR and members of the public are significantly less well-informed about the technique the more they tune into these popular programmes. The authors recommend that television producers improve the depiction of CPR on television to mimic the national guidelines.
USE OF AN ANAPHYLAXIS CARE BUNDLE TO IMPROVE MANAGEMENT IN THE EMERGENCY DEPARTMENT
Authors: Adam E , Turnbull K
Published: November 2016

Objectives & Background

NICE guidance on anaphylaxis (Dec 2011) focuses on initial emergency management and onward referral. The guideline emphasises 5 main domains; documentation, tryptase sampling, observation, safe discharge and speciality follow up. Poor guidance compliance was highlighted during a departmental audit in 2012. An anaphylaxis care bundle was developed and implemented in response. We aimed to evaluate the impact of this bundle on departmental management of anaphylaxis.

Methods

A retrospective case note review of all adult patients diagnosed with anaphylactic shock, identified from electronic records between 8/7/15–13/12/15 (cycle 1) and 30/3/16–17/5/16 (cycle 2) was conducted. A departmental anaphylaxis care bundle was introduced on 14/12/15. The bundle included a diagnostic checklist, clinical pathway, patient information leaflet and covering fax letter for the newly arranged allergy clinic direct referral. Implementation was supported by posters, educational sessions and staff emails. Performance was evaluated against the 5 main domains of the NICE guidance with the required standard of 100% compliance.

Results

Cycles 1 and 2 identified 29 and 10 patients respectively. Performance improved across all 5 domains following the care bundle implementation. Documentation of time of onset improved from 17/29 to 10/10. Tryptase sampling at presentation and after 1–2 hours improved 4/29 and 2/29 respectively during cycle 1 to 9/10 and 9/10 during cycle 2. None of the patients in cycle 1 received advice regarding baseline tryptase compared to 9/10 in cycle 2. All 10 patients in cycle 2 were observed for at least 6 hours compared to 24/29 in cycle 1. In cycle 2 safe discharge was achieved in 9/10 patients compared to cycle 1 where 20/29 received epipens and 12/29 received information leaflets. Referral to specialist allergy services improved from 3/29 to 9/10.

Conclusion

Following the introduction of the departmental anaphylaxis care bundle, more adult patients presenting with anaphylaxis are being managed, discharged and followed up in accordance with NICE guidelines. The concise algorithm could be an invaluable resource in other busy and high pressure departments. The importance of education, awareness, reinforcement and accessibility was important in achieving the improvements seen. Due to the rotational nature of junior staff on-going education is needed to ensure sustainability of the improved performance.

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5
DO ALL HEART SCORES BEAT THE SAME: EVALUATING THE INTER-OPERATOR VARIABILITY OF A CHEST PAIN RISK STRATIFICATION TOOL IN A UK EMERGENCY DEPARTMENT
Authors: Niven WG , Wilson D , Green S , Robertson A , Goodacre S
Published: November 2016

Objectives & Background

Patients presenting with chest pain represent a significant proportion of attendances to the emergency department (ED). The HEART score derived by Backus et al is a validated tool for the risk stratification of suspected ischaemic chest pain within the ED – image 1 below.

Little is known about whether HEART scores can be reproduced with reliable agreement irrespective of the grade of nurse or doctor. The goal of this research was to establish the inter-operator reliability of the HEART score as performed in the ED by different grades of doctor and nurse.

Methods

This was a prospective, cross-sectional study that was carried out at the Homerton Hospital – a district general hospital (DGH) with approximately 120 000 A+E attendances per year. Consented patients were interviewed separately by 4 clinicians of different grades. These were Senior doctor (ST4 and above), Junior doctor (FY2–ST3), Senior nurse (Band 6+), Junior nurse (band 5). Each clinician calculated the patient's HEART score independently. Data was entered electronically at the time of assessment. The intraclass correlation coefficient (ICC) was calculated using R statistical package as the primary measure of agreement. We calculated 86 comparisons would be needed to achieve a desired power of 80%.

Results

104 patients were consented for recruitment of which 88 complete comparisons were obtained. The mean HEART score was 3.7 with no significant difference between mean scores for each clinician group. The overall ICC was 0.9 (0.87, 0.93).

The ICC was also calculated between each group of clinicians; junior nurse and senior nurse 0.88 (0.83, 0.92), junior nurse and junior doctor 0.92 (0.88, 0.94), junior nurse and senior doctor 0.91 (0.86, 0.94), senior doctor and senior nurse 0.9 (0.85, 0.93), junior doctor and senior doctor 0.89 (0.85,0.93) and senior nurse and junior doctor 0.93 (0.9,0.95).

On analysis of subjective components of the HEART score, for history the ICC was 0.39 (0.27, 0.52), ECG interpretation 0.64 ( 0.54, 0.73), risk factor assessment 0.84 (0.79, 0.89).

Conclusion

This study has demonstrated very strong overall inter-operator agreement between the 4 groups of clinicians studied. This suggests the HEART Score can be used reliably regardless of grade or role by both nurses and doctors as part of an early risk stratification process within the ED.

Figure 1
IMPROVING QUALITY OF CARE IN THE MANAGEMENT OF PATIENTS WITH URINARY CATHETERS THAT ATTEND THE EMERGENCY DEPARTMENT
Authors: Yeung C , Krishnathasan K , Chan C , Blows S , Cheah K , Whitwell K
Published: November 2016

Objectives & Background

Patients presenting with catheter problems are a significant burden on the Emergency Department (ED). An initial audit was performed in 2014/15 which showed that the majority of these patients were elderly, arrived in working hours, did not need to see a specialist and were discharged after simple interventions. A number were also repeat attenders.

Following this audit, a number of interventions were introduced. The equipment was reviewed to ensure that the correct catheters were used. Troubleshooting protocols for common catheter problems were placed on the catheter trolleys. Education regarding catheter problems was incorporated into the induction program for junior doctors. Three urology ED nurse champions were appointed. A multidisciplinary team was formed comprising geriatric, urology & ED consultants, with the aim of formulating solutions to tackle the rising burden of catheter patients. The audit was then repeated in 2015/16.

Methods

This was a retrospective case note review of patients with a ‘catheter problem'. They were identified through a manual search on our ED coding database. Data (e.g. age, time of arrival, admission rate, etc.) was first collected from Nov 14 to Feb 15. This was repeated from Nov 15 to Feb 16 after our interventions listed above. 24 ‘catheter problem’ patients that presented in Oct 15 were also telephoned to evaluate patient satisfaction using a standardised questionnaire.

Results

There were 5% fewer attendances and 28% fewer repeat attenders in 2015/16 despite a rise of 7% in the total no. of all ED attendances over the same time period. Again, majority of the patients were elderly, arrived in working hours (60%), and were discharged home from ED (83%). Only 13% needed a urological opinion.

There were 18 phone responses out of 24 (75%). A going home catheter pack was given to all patients that needed them. The process of catherisation was explained to all patients. 100% of patients were satisfied with the ED service, with 67% awarding us a 6 (on a scale of 1 to 6, with 1 being not at all satisfied and 6 being very satisfied).

Conclusion

We have improved the quality of care of patients with urinary catheters by ensuring correct initial management and good patient education. That has led to a subsequent reduction in patient attendances and re-attendances to the ED, as well as a high standard of care provided to those that did present in ED.

Figure 1

Attendances of 'catheter problem' patients in 2014/15 and 2015/16

Figure 2

Age distribution of 'catheter problem' patients in 2014/15 and 2015/16

Figure 3

Patient satisfaction survey scores
PELVIC FRACTURES IN TRAUMA PATIENTS ATTENDED TO BY THE EMERGENCY MEDICAL RETRIEVAL SERVICE
Authors: Browne H , Corfield AR
Published: November 2016

Objectives & Background

Pre-hospital application of pelvic binders is recommended by the 2016 NICE guidelines for Major Trauma in any patient with blunt high-energy trauma and suspected active bleeding from a pelvic fracture. The Emergency Medical Retrieval Service (EMRS) provide a pre-hospital critical care team by road and air to for the West of Scotland to a mixed rural and urban catchment area. The EMRS SOP mandates pelvic binder application to patients with suspected pelvic fractures including all polytrauma with significant mechanism of injury. We aimed to ascertain the incidence of pelvic fractures in this group of patients and whether this mechanism predicted significant pelvic injury.

Methods

Retrospective analysis of all trauma patients attended by EMRS between 2011 and 2015 who had a pelvic binder applied and were not declared dead at scene. 140 patients were identified – of these, 11 were excluded due to lack of access to imaging. Data was obtained from the EMRS database and in-hospital systems including TrakCare, Portal and PACS. Information was collected and analysed using Microsoft Excel. Parametric data was analysed using Students T-test and non parametric data was analysed using Mann-Whitney test on Stata v12.

Results

Of the 129 trauma patients who had pelvic binders applied, 32 (25%) had evidence of active bleeding and 28 (22%) had a pelvic fracture identified on imaging. The ‘fracture present’ versus ‘fracture not present’ populations were compared. This data is summarised in Table 1. Most common mechanisms to cause pelvic fracture were being either the car occupant in an RTC (29% of fractures) or a pedestrian in an RTC (29%). Motorcyclists made up 19% of patients to whom a pelvic binder was applied, but they only represented 7% of the pelvic fracture population.

Conclusion

Application of a pelvic binder to this group of patients seems an appropriate action as a significant proportion subsequently have a pelvic fracture identified on imaging. The population of pelvic fracture patients seen by EMRS are more commonly patients involved in road traffic collisions (as opposed to ‘falls from height’ seen more commonly in purely rural populations) with an ISS of more than 15 to constitute ‘major trauma’.

Table 1

Epidemiology of all trauma patients with a pelvic binder applied pre-hospitally by EMRS

Pelvic fracture presentPelvic fracture not presentp valueAge, years (mean)43440.760Gender (% male)46%72%0.010*Median ISS17130.211Suspicion of bleeding (%)39%21%0.0517 day mortality (%)4%10%0.317X-ray AND CT imaging of pelvis in hospital89%53%<0.001*Mechanism of InjuryLow Fall (<10 ft)4%3% High Fall (>10 ft)14%15% RTC – vehicle occupant32%40% RTC – pedestrian29%12% RTC – motorcyclist7%19% RTC – cyclist4%8% Other11%4%
THE IMPACT OF BYPASS OF NON-SPECIALIST ACUTE HOSPITALS IN FAVOUR OF SPECIALIST NEUROSCIENCE CENTRES AS THE PRIMARY HOSPITAL DESTINATION FOR TRAUMATIC BRAIN INJURY PATIENTS
Authors: Edwards DT , Lecky F , Fragoso-Iniguez M
Published: November 2016

Objectives & Background

Since the introduction of the regional trauma networks in the UK, the practice of transporting traumatic brain injury (TBI) patients past the nearest non-specialist acute hospital (NSAH) in order to reach the closest specialist neuroscience centre (SNC) has been implemented. However, it has not yet been established whether this practice of ‘bypass’ improves survival in TBI patients, and there are concerns that it may cause delays in the stabilisation of the airway, breathing and circulation (ABC) leading to worse survival. This study sought to address this uncertainty in survival benefit.

Methods

A comparative cohort study method was used to observe the differences in risk-adjusted survival in TBI patients who either bypassed the nearest NSAH to attend a SNC, or underwent selective secondary transfer from a NSAH to a SNC. The data of 400 patients with significant TBI (abbreviated injury scale score ≥3 in the head region) from two Trauma Networks in the North of England was retrospectively extracted from the Trauma Audit and Research Network (TARN) database, and cases of bypass (n=112) or secondary transfer (n=96) were identified. Using direct standardisation to adjust for casemix variation, and logistic regression to control prognostic variables, the differences between the expected and observed rates of survival in each group were compared.

Results

Bypass of TBI patients did not significantly increase the observed minus expected survival rate (+4.4, 95% CI –1.6 to 10.5). However, selective secondary transfer of TBI patients was associated with more survivors than expected (+11.3, 95% CI 3.4 to 19.3), although the difference between groups was not statistically significant.

Conclusion

Bypass of NSAHs in favour of SNCs, does not appear to significantly improve survival in TBI patients; and selective secondary transfer to a SNC, following stabilisation of ABCs at a nearer NSAH, may be a more appropriate strategy.

Figure 1
A COMPARISON OF THE HEART, TIMI AND GRACE SCORES IN THE PREDICTION OF A MAJOR ADVERSE CARDIAC EVENT (MACE) IN PATIENTS PRESENTING WITH UNDIFFERENTIATED CARDIAC CHEST PAIN: A PROSPECTIVE COHORT STUDY IN A UK POPULATION.
Authors: Reaney PD , Elliott H , Cooper J
Published: November 2016

Objectives & Background

Cardiac sounding chest pain is one of the commonest reasons for presentation to the Emergency Department (ED) or acute medical receiving. An electrocardiogram (ECG) can rapidly identify those patients suffering from an ST elevation acute coronary syndrome (ACS) but the differentiation of patients with non ST elevation ACS from those with non cardiac chest pain or stable cardiac disease is often not straightforward and encompasses historical, clinical and biochemical factors. Effective early risk stratification of this group of non ST elevated ACS patients may streamline care pathways for those at high risk and lead to effective use of resources and early discharge in those in whom ACS is unlikely.

Methods

A prospective cohort study of adult patients presenting to the ED or acute medical receiving unit of Aberdeen Royal Infirmary with cardiac sounding chest pain and an a non-diagnostic ECG. A necessary sample size of 1000 patients was calculated and recruitment began in December 2014. HEART, GRACE and TIMI scores were calculated from data obtained on patient attendance, with subjective aspects entered by the attending medical practitioner in real time. Patients were followed up to 30 days for the development of a MACE. Receiver Operated Characteristic (ROC) curves were plotted to determine discriminative power of each of the three scores to detect MACE. Sensitivities and specificities (with 95% CIs) for each score (at different cut-offs) were calculated.

Results

Preliminary results are available on 605 patients. Ages ranged from 20–95 years (mean 61.8 years), 360 (59.5%) were male and 108 patients (17.9%) patients suffered a MACE at 30 days.

Area under the ROC curves demonstrated that HEART (0.86) had a greater ability to discriminate patients going on to develop a MACE than TIMI (0.71) and GRACE (0.76) scores.

Within the HEART low risk group 1.2% of patients developed a MACE and within the high risk group over 60% developed a MACE.

Conclusion

The HEART score out performs GRACE and TIMI in predicting MACE in patients presenting to the ED with cardiac sounding chest pain. It rapidly identifies a low-risk population that may be suitable for early discharge or ambulatory management from the ED and higher risk patients may be promptly prioritised for invasive management.

Figure 1

Table 1

Preliminary HEART Score Data

Risk GroupHEART ScorePatients30 Day MACE (%)Low0–31672 (1.2)Intermediate4–632538 (11.7)High7–1011368 (60.2)
COMPARISON OF STANDARD CPR AND CPR FEEDBACK METHODS IN TERMS OF THE EFFECTIVENESS OF CHEST COMPRESSIONS DURING CARDIOPULMONARY RESUSCITATION: A RANDOMIZED CONTROLLED STUDY
Authors: Akbuga Ozel B , Ozel G , Mamak Ekinci EB , Goger B , Delikanli C , Ersoy EC , Karademir LN , Gursoy M , Kocalar UG
Published: November 2016

Objectives & Background

The primary purpose of the study was to compare the metrics on the effectiveness of chest compressions obtained through an advanced CPR (cardiopulmonary resuscitation) manikin and a real-time CPR feedback device during simulated CPR.

Methods

This was a prospective, randomized controlled study. The study group consisted of 21 medical school and 62 paramedic students who were already trained in BLS skills. A five-question pretest on high-quality CPR was administered to all participants and they all performed a two-minute chest compression on an advanced CPR manikin. No statistically significant relationship was found in terms of pretest results, basal compression rates and depths between the two groups (p>0.05). The population was then randomly divided into two groups. The control group, consisting of 43 students, performed two-minute CPR on an advanced CPR manikin, followed by a two-minute CPR session with a simple metronome feedback. The study group performed two-minute CPR on an advanced CPR manikin, followed by a two-minute CPR using a TrueCPR real-time feedback device. We analyzed the compression rate and depth of both techniques.

Results

The compression rate during CPR with a simple metronome feedback was significantly higher compared to that obtained during standard CPR (108±6.2 vs 119.0±18.2/min;p<0.05). However there was no significant difference in compression depth between the techniques (p>0.05). Use of the TrueCPR feedback device resulted in significant improvement in both the compression rate (106.2±4.8 vs 121.6±13.1/min;p<0.05) and the compression depth (56.5±5.8 mm vs 53.6±7.0 mm; p<0.05) compared to standard CPR without feedback. When CPR performance obtained by using both feedback methods was compared, there was no statistical difference between compression rates (p>0.05), whereas the TrueCPR device yielded significantly deeper compression depth compared to the simple metronome (56.5±5.8 vs 53.3±6.5 mm; p<0.05).

Conclusion

Feedback with a device during CPR is an effective method to achieve adequate compression rate and depth. The real-time feedback device can be particularly effective and offer advantages during the actual CPR procedure based on the more effective CPR metric achieved by its use. However, further studies to show the clinical effectiveness of the real-time CPR feedback devices are needed.
PALLIATIVE CARE IN THE EMERGENCY DEPARTMENT: A SYSTEMATIC REVIEW
Authors: Cooper E , Sheikh Z , Townend W , Johnson M , Hutchinson A
Published: November 2016

Objectives & Background

Emergency departments (EDs) receive a variety of patients: those with unexpected injuries or trauma, chronic disease exacerbation or progression and existing advanced disease or terminal illness. Thus expectations of attendees can vary greatly. However the primary focus of EDs is acute management.The provision of tailored palliative care (PC), that meets the unique needs of people with advanced disease, is often difficult in the ED. The main objective of this qualitative synthesis was to increase understanding of the ED experience of people with advanced disease, their relatives and healthcare professionals.

Methods

Medline, Embase, CINAHL and PsychInfo were searched for articles published prior to 2016. All titles and abstracts were reviewed by two independent reviewers according to predefined eligibility criteria. Differences were resolved by discussion and recourse to a third independent reviewer. The subsequently identified full texts then underwent the same process. Included papers were appraised for quality. A thematic synthesis of these qualitative data was then conducted using the techniques described by Thomas and Harden.

Results

The search identified 19 studies which fulfilled the inclusion criteria. All passed the quality appraisal stage. Coding of the articles revealed 31 free text codes which were divided into nine key themes: environmental factors, provision of care, communication, interdisciplinary working, decision making, accessing care, education, legal concerns and preparation for death. These were condensed further into three analytical themes that described the most prominent aspects of the experience of PC patients, relatives and healthcare providers in the ED: environment and purpose; systems of care and interdisciplinary working; education and training.

Conclusion

This synthesis has provided a greater breadth of insight to enable recurring themes regarding the potential conflicts between emergency care and PC to be identified with a view to overcoming the challenges faced. Significantly recognising the need for educating ED physicians in the scope and components of PC, improving interdisciplinary working and enabling better understanding of patients and carers about their likely disease progression and the opportunities open to them. Further research should focus on the best ways to provide such education, the specific reasons for shortfalls in communication and how these could be overcome.