bluuebunny/crossref_metadata_2025 huggingface dataset:
PILOTING A RAPID ASSESSMENT TOOL IN CHILDREN'S ED
Authors: Issa S , Cole R , Alcock A , Sajjanhar T , Selby N
Published: November 2016

Objectives & Background

The Children's Emergency Department at University Hospital Lewisham sees up to 130 attendances daily. This can result in delays to triage and sick children being missed.

In our department, 50–84% of children are triaged within 15 minutes (monthly variation). Peak median time to triage is 41 mins and can depend on skill mix.

Our objective was to create a safe Rapid Triage Tool to assess patients rapidly and identify the most unwell patients early. Recent RCEM work on Vital Signs in Children Clinical Audit 2015–16 indicated the need for improvement. Our project supports standards 1 and 3. It can also help to meet the KPI for initial assessment of ambulance patients and the RCEM pain targets.

Methods

Rapid Assessment Tools were designed by extrapolating from the Manchester Triage System. One for trauma/injury and a second for medical illness figures 1 and 2.

▸ Pilot of 40 patients triaged- weekdays, evenings, weekends and night shifts

▸ Rapid Assessment was employed when the wait for triage was greater than 30 minutes and there were more than 3 patients waiting. It was done in one minute by a senior nurse with relevant training

▸ The nurse assesses the patient using the proforma, assigns a priority and indicates what actions are required

▸ Secondary nurse then acts on these and completes the triage- Figure 3.

Results

40 patients were assessed using the Rapid Assessment Tool.

▸ Qualitative correlation to the traditional triage was made and the patients were shown to be given the same priority ranking in all cases

▸ It takes less than a minute to perform the Rapid Assessment compared to 5–20 minutes for the traditional triage.

▸ Flow through the initial stages in the department was quicker

▸ There was better use of the nursing skill mix

▸ The sickest patients were identified faster

▸ Figure 4

Conclusion

This Rapid Triage Tool may be a safe tool to use in replacement of the traditional triage method. The perception from staff was that this felt safer and reduced the workload when there was large volume of patients.

Further work

▸ Training is required to standardise the implementation of the Rapid Triage Tool

▸ A larger pilot will be conducted to make quantitative conclusions about the effects this has on overall triage time, time to treatment and the on meeting the RCEM Vital Signs and Pain Standards and the KPI

▸ This project has identified a number of areas for improvement such as an extra HCA at triage to facilitate the observations and providing all staff with mobile saturation probes

Figure 1

Rapid Assessment Proforma for Illness.

Figure 2

Rapid Assessment Proforma for Injury.

Figure 3

Results (Outcomes).
ANAESTHETIC CHARTS IN ACUTE ICU ADMISSIONS: DEVELOPMENT FOR USE IN THE EMERGENCY DEPARTMENT
Authors: Castell SA , Noble B , Leyden K
Published: November 2016

Objectives & Background

Anaesthetic charts are an invaluable source of concurrent and retrospective information. They provide relevant history and events during surgical and/or anaesthetic procedures. Admission notes to the intensive care unit showed poor record keeping of events outside the theatre environment. In accordance with standards set by the Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI), we developed an 'Emergency Anaesthetic Chart', to be used in the Emergency Department by both emergency physicians and anaesthetists. The aim was to improve the quality and quantity of information recorded during an emergency requiring critical care input, in a recognisable and easy to use format.

Methods

A retrospective notes based review of admissions to the intensive care unit from the Emergency Department provided comparison against standards set by RCoA and AAGBI. The results were presented at a departmental meeting and the development of an ‘Emergency Anaesthetic Chart’ was undertaken to drive improvement. This was based on the current trust ‘Day/23 hour Anaesthetic Record’ used in the theatre environment. A further review looked at admission data since the implementation of the new chart, with the final data collection ongoing.

Results

In the initial audit 9 sets of notes were examined over 6 week period, in the re-audit 11 sets of notes over a 6 week period were examined, 7 using the new chart. All were patients admitted from the emergency department.

Re-audit data (before, after) showed that demographic data remained well recorded at 100%. Improvement was seen in recording of medical history (56%, 100%) initial observations, (56%, 86%) and airway assessment (11%, 29%). Most importantly recording of procedural events (44%, 71%), repeat observations (33%, 100%) and subsequent drug administrations (22%, 86%) all showed significant improvement.

Conclusion

We revealed poor record keeping during critical care involvement in the emergency department and identified the need for a more reproducible and standardised method of data recording. An adapted version of a current anaesthetic chart has been found to be effective in increasing the quality and quantity of information recorded for emergency admissions. This improves adherence to the required standards, and is also recognisable and user friendly for staff conditioned to use the Trust's anaesthetic charts.
PILOTING IN ED–EXTRA DIFFICULT OR EASILY DONE
Authors: Zee T , Thomas D , Jannaway N , Bassey S
Published: November 2016

Objectives & Background

Patient Identification is fundamental to the success of safe transfusion. ABO incompatible blood transfusion has been classed as a Never Event by the Department of Health.

In 2014, 680 Wrong Blood in Tubes (WBIT's) were reported nationally to SHOT (Serious Hazards of Transfusion). National Guidelines have changed (2013) to improve accuracy in sample labeling (two sample rule) but SHOT reports prove on going noncompliance with this procedure.

Blood samples are rejected if ANY aspect of the labeling is incorrect. This can generate rejection rates for transfusion specimens >10%. Over 3000 samples were rejected in 2014 at RCHT. This results in loss of patient confidence due to repeated clinical procedures, delay to treatment, loss of staff time, and increased cost of equipment and reagents.

Llama Safe is a unique application that enables healthcare professionals to guarantee positive patient identification and accurate transfusion sample labeling at the bedside. The decision to pilot the application in the Emergency Department (ED), beginning Jan 2015, was due to:

▸

Above average Tx samples rejected;

▸

Large multidisciplinary teams with high staff rotation;

▸

Unpredictable workload and stressful environment;

▸

60–70 thousand patients per year;

▸

Poor adherence to labelling at the patient's bedside, including Wrong Blood in tube events annually;

Methods

Prior to the pilot, two months were spent shadowing a multitude of clinical staff in the ED to fully understand the sampling processes and the problems that arise.

A simple system was designed in collaboration with ED staff, containing minimal steps, ensuring all safety measures had been considered and satisfied.

Llama posters and stickers were placed throughout the department to remind staff to use the new labelling system.

Results

Staff were extremely invested and supportive in the Llama implementation allowing the pilot to be smooth and successful.

ED very quickly took it upon themselves to cascade training and encourage the implementation on other wards.

No WBITs have been identified in ED since the introduction of Llama (18 months).

Rejections in ED have reduced 10 fold with Llama labelled samples, consequently improving patient care and proving concept for full roll out.

Conclusion

With appropriate planning and collaboration, introducing new technology into an acute environment can be easily achieved.

Staff pressure has been relieved from a tense clinical environment.

Llama was very positively received in the ED.
RESUS ESTIMATED TIMES OF ARRIVAL – JUST HOW ACCURATE ARE THEY?
Authors: Turner C , Patten H , Williams M
Published: November 2016

Objectives & Background

Effective use of staff and facilities is one of the cornerstones of good Emergency Departments (EDs). An accurate estimated time of arrival (ETA) at the point of the alert call to the ED allows us to prepare efficiently prior to patients arriving.

If the patient arrives too early the receiving team may not be fully assembled and specialist equipment not readily available; too late and team members are inadvertently wasting time that could have been allocated to other tasks, or leave the Resuscitation Area (Resus).

We aimed to compare estimated versus actual time of arrival (ATA) of patients to Resus at UHCW ED in order to determine and quantify any difference.

Methods

We analysed records of patients alerted into resus over a 17 day period between 22/10/15 and 07/11/15.

We obtained call time and ETA from alert logbook and also noted presentation subtype: cardiac arrest, trauma, medical, FAST +ve, paediatric trauma or paediatric medical.

We used individual patient Resus records for the ATA and then calculated the time difference. Ambulance PRFs were also used to identify which crew had transferred the patient.

Ethical approval was waived as this was regarded as service evaluation.

Results

104 cases were analysed representing patients alerted by crews from both East and West Ambulances Services and the HeliMed Team. Across all cases the mean difference between ETA and ATA was 4.7±17.5 minutes (calculated to two standard deviations). This ranged from arriving 11 minutes early to 62 minutes late.

The data demonstrates a normal distribution and as such we can calculate that the probability of a patient arriving at or before the ETA is 30%. The probability of a patient arriving within ten minutes of the ETA is 73% and by 20 minutes after the ETA we would expect 96% of patients to have arrived.

Conclusion

(1) There is significant variance between ETA and ATAs

(2) Most patients arrive within ten minutes of their ETA

(3) If we can develop more accurate mechanisms for predicting what time alerts arrive we would potentially improve care and reduce wasted time.
ATTENDANCE AVOIDANCE THROUGH APP BASED MEDICATION REVIEW
Authors: Muller JJ , Mcnamara R
Published: November 2016

Objectives & Background

Adverse drug reactions represent a major burden on healthcare, causing between 3–5% of all hospital admissions.1 This impact is magnified in older patients; studies have shown that up to 51.3% of older patients were prescribed potentially inappropriate medications.1

These findings are highly relevant to Emergency Medicine with ever increasing emphasis being placed on attendance avoidance, and increasing numbers of older patients.

Methods

We utilised the STOPP/START criteria2 and Anticholinergic burden scoring3 to assess the drug histories of all patients over the age of 65 who presented over the course of a year to a major London A+E department with three common presentations: bleeding, confusion and falls.

Results

We found consistently high levels of potentially inappropriate prescribing with 64% of patients presenting post a fall, 92% with new confusion and 23% with bleeding, having drug histories that warranted a medications review. 22% of patients presenting after a fall also had clinically relevant anticholinergic scores and higher re-attendance rates than those with low anticholinergic scores.

Conclusion

We designed a pilot study using a digital app designed by a Geriatrician to analyse and prompt potential medication changes for patients admitted to our Clinical Decision Unit with the aim of future attendance avoidance.
A DESCRIPTIVE PARADIGM OF ESCALATING ENDOVASCULAR INTERVENTION FOR THE MANAGEMENT OF 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

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) aims to improve trauma survival by controlling torso haemorrhage. Selective Aortic Arch Perfusion (SAAP) is an experimental resuscitative technique that, in addition to controlling torso haemorrhage, allows infusion of oxygenated blood into the proximal aorta - theoretically providing coronary perfusion pressures adequate for return of spontaneous circulation (ROSC) in cardiac arrest (figure 1). Prolonged cardiac support can subsequently be achieved by converting the SAAP blood supply from exogenous to autologous via a central venous catheter–an extra-corporeal life support circuit (SAAP-ECLS).

Hypotheses–1. Swine in haemorrhage-induced traumatic cardiac arrest that do not achieve a ROSC with initial therapy (REBOA), will have ROSC with more advanced therapy (SAAP). 2. Animals that do not achieve ROSC with REBOA and subsequent SAAP will achieve ROSC with SAAP-ECLS.

Methods

70–90 kg swine underwent a combination of non-compressible torso and arterial haemorrhage. Arrest was defined as a systolic blood pressure (SBP) <10 mm Hg, together with an inappropriate bradycardia. All animals initially received REBOA (inflation of zone 1 REBOA and four units of intravenous blood). Those that did not achieve ROSC (defined as SBP >50 mm Hg) subsequently received SAAP (800 ml/minute of intra-aortic oxygenated blood, up to 4000 ml). Animals that did not have a ROSC after SAAP received continuous SAAP-ECLS (at 800 ml/minute). The protocol end-point was 60 minutes from the start of the REBOA intervention. Data are descriptive, and presented as mean (+/−standard deviation) and number (percent).

Results

Eight animals were included; weight 75.0 kg (+/−3.6); time from the start of the injury to onset of arrest was 9.9 minutes (+/−1.4). Two (25.0%) animals had a ROSC with REBOA, and out of the remaining six a further two (25.0%) had a ROSC with SAAP. The four remaining animals, that had not achieved ROSC with REBOA and subsequent SAAP, all had a ROSC with SAAP-ECLS (figure 2).

Conclusion

A step-wise approach of more complex endovascular intervention in haemorrhage-induced traumatic cardiac arrest may be an effective clinical paradigm – in this swine model all animals had short-term survival following escalating intervention: REBOA, followed by SAAP, followed SAAP-ECLS as required.

Figure 1Figure 2
EXIT INTERVIEWS FOR JUNIOR DRS- WHAT CAN WE LEARN? THE POPE-I PROJECT
Authors: Turner C , Lee-Shrewsbury V , Hill N
Published: November 2016

Objectives & Background

Organisations which conduct exit interviews are known to create more promoters in people who leave than organisations that do not. Despite this and the valuable feedback gained, exit interviews are uncommon in medicine.

Our objectives were to develop an exit interview programme which was brief, gave the opportunity to say positives and negatives and guaranteed anonymity. Further to this we wished to evaluate the information that we received and how useful it was felt to be by those taking part.

Methods

Following a pilot study we developed a peer on peer, time restricted, anonymous, semi structured interview process which was delivered by our junior medical tier to each other.

Specific questions related to good experiences, bad experiences, the overall educational experience, ease of the interview process and any members of staff that the interviewees might wish to thank. Staff were given the questions in advance to allow them some time to consider their answers.

At the end of the interview the responses were reflected back to the interviewee to check for accuracy.

Completed interviews were thematically analysed and coded by the research team.

Results

At the time of submission we have >30 interviews completed.

All respondents found having an exit interview useful or very useful.

The paperwork was regarded as being user friendly by the staff delivering and receiving the interviews.

The most appreciated part of the job was consistently felt to be the consultant contact and patient diversity.

Areas of frustration differed to the information we had received from junior Drs forum, which would seem to imply this process adds value.

Amongst other issues, the junior medical staff wish more exposure to resus (trauma in particular) and more teaching in minors.

On direct questioning there was an exact 50:50 split between those who were more and those who were less likely to follow a career in EM after doing the job.

Conclusion

The process was appreciated by those who took part.

If the evidence from the business community is replicated in healthcare then we should create more positivity about the EM job by using this process. Even if we do not create more promoters of the department, we have received much very useful feedback (both positive and negative) that we can work on.

We feel we can recommend this method of feedback as safe, personalised, anonymous and valuable.
IDENTIFYING TRAUMA CENTRE NEED (TCN) IN ADULTS SUSTAINING INJURY: A NARRATIVE REVIEW
Authors: Follows A , Phillips R , Vassallo J
Published: November 2016

Objectives & Background

Field triage is the process of identifying patients who, sustaining trauma, are in need of treatment at a trauma centre (TCN – trauma centre need). This is acheived by Emergency Medical Service (EMS) personnel employing a field-triage algorithm to enable them to make this decision; within the UK there is considerable variation between algorithms, dependent on the region. In common, is a four tier approach looking at a patient's physiological derangement, their likely anatomical injury, mechanism of injury and other special considerations in turn to determine whether TCN is indicated. Optimum triage is desired as both under and over triage have been proven to have a negative impact on patient morbidity and mortality. Guidelines within the USA suggest that the performance of field triage algorithms be sufficient to limit under and over triage to <10% and <50% respectively. The objective of this study was to review the literature to determine the evidence base and the ability of mechanism of injury, anatomical injury and/or physiological derangement at predicting TCN in the adult patient sustaining injury.

Methods

Using NHS Evidence a literature search of MEDLINE (1946) and EMBASE (1974) was conducted to week 3 May 2016. Only articles published in English were included.

Results

The search produced 241 articles, following a review of title and abstract 26 written English papers were identified to review in full. 5 papers were removed as inaccessible as full-text. Following full text review 9 were removed as non relevant. The remaining 12 relevant papers were included in the review.

Conclusion

There is a paucity of high quality evidence (RCTs) surrounding pre-hospital triage of traumatically injury adult patients, with a number of studies contradicting one-another. The majority of the literature is reliant on the retrospective analysis of trauma registries with their associated limitations such as incomplete data capture and selection bias. There is currently no consensus as to what constitutes TCN, with both the output measured differing between identified studies and also the statistics employed to assess performance.

Although there is some evidence to support physiological, anatomical injury and mechanism of injury as a predictor of TCN, it is not of high quality & is contradictory. Targeted research is required to determine the optimum method of pre-hospital identification of the adult trauma patient.
EMERGENCY CRICOTHYROTOMY: REVISED ANATOMY AND ITS IMPLICATIONS FOR CLINICAL PRACTICE
Authors: Nutbeam T , Enki D , Clarke R , Luff T , Gay D
Published: November 2016

Objectives & Background

Emergency cricothyrotomy is a common feature in all difficult airway algorithms. It is the final step following failed attempts to oxygenate a patient. It is rarely performed and has a significant failure rate. The size of the cricothyroid membrane (CTM) has been previously reported in the literature. There is variation in the reported size of this membrane, especially across population groups. Procedure failure may result from a discrepancy between the size of the equipment used and the size of the CTM.

Methods

An initial sample of 61 trauma CT scans were reviewed by two radiologists independently. Electronic calipers were used to measure the maximum height of the CTM. This sample was used to power further data collection by assuming a 5% level of significance with 95% confidence interval and precision of 0.2 mm–further scans were reviewed until a sample size of 478 patients was achieved.

Results

The median height reported was 5.85 mm (female) and 7.65 mm (male). These dimensions are much smaller than previously reported in the literature for Western patients. The external diameters of commonly used tubes used to pass through the CTM were compared with these measurements.

Conclusion

The CTM in this population is smaller than previously reported. Practitioners encountering patients who may require a surgical airway should be aware of this. Rescue airway equipment of a smaller external diameter should be immediately available if required.

Figure 1

Table 1

Comparison of surgical airway devices, their external diameter and the percentage of population in which CTM height>external diameter of device

Tube TypeExternal Diameter% of population in which CTM height>external diameter of device6 mm836.25 mm6.760.54 mm5.677.63 mm4.293.2Shilley10.87.7Melker8.234.6TracheoQuick586.5
CAN THE INTRODUCTION OF A “VIRTUAL” CLINIC IN A PAEDIATRIC TERTIARY CENTRE HELP TO REDUCE THE BURDEN OF FOLLOWUP FOR MINOR PAEDIATRIC FRACTURES?
Authors: Roy SK , McDonald N , Back D
Published: November 2016

Objectives & Background

Fractures account for 25% of all injuries during childhood in the UK. Of those the radius/ulna are common (30%) −80% of those are torus fractures. Despite their innocuous nature, they are often managed incorrectly. There is evidence showing that optimal treatment entails the use of a Futuro splint for 3 weeks, with minimal followup and adequate safety netting. Many emergency departments (ED) are adopting this approach successfully.

The aim of this quality improvement project was to introduce a new pathway for the management of torus fractures, including a “virtual” fracture clinic in collaboration with our orthopaedic colleagues. We reviewed our current management and compared its costs against the new protocol, including attendance, plasters and splints.

Methods

A list of children aged 0–16 years with wrist xrays between June–November 2015 was obtained. Those with a torus fracture were reviewed for method of immobilization and outcome of fracture clinic followup.

Results

24 children fulfilled the inclusion criteria; 14 were treated with a Futuro splint; 10 with a plaster of Paris (POP). All were reviewed in fracture clinic. 7 children switched from a Futuro to a POP, 3 switched from a POP to a Futuro, leaving 9 in total with a splint. 1 child was discharged from fracture clinic on first attendance; 23 required ongoing followup with at least one additional visit to clinic. This equates to at least 57 hospital appointments in this group for inclusion to the virtual clinic over 5 months. In this clinic, the Orthopaedic Consultant reviews the case notes and images; contacts the family by phone and decides whether a followup hospital attendance is required. The costs of running this would be approximately 20% cheaper on our current overheads.

Conclusion

The majority of children were managed correctly within the ED. Some discrepancies were identified with preferential use of a POP in Fracture Clinic. Therefore, we educated staff on gold standard treatment through a new clinical guideline. The number of unnecessary followup attendances in this patient cohort has prompted the introduction of a virtual fracture clinic. This should generate significant cost savings as well as providing families with continuity of care, reassurance and convenience. In the future, we will reaudit whether this happens in view of expanding it to include other minor fractures.

Figure 1

Figure 2

Patient Cohort and inclusion criteria

Figure 3

New Torus Fracture Management Guideline

Figure 4

Patient and Parent Discharge Information
THE 'SQUEEZED SAMPLE': IS THERE A RELATIONSHIP BETWEEN FALSELY ELEVATED LACTATE AND POTASSIUM IN BLOOD GAS SAMPLES IN CHILDREN?
Authors: Sinton D , Hall J , Roland D
Published: November 2016

Objectives & Background

Gaining intervenous access in children, especially those who are unwell, can be difficult. Blood samples are often taken from the cannula hub to avoid repeated venepuncture but leads to concerns about whether it is “free-flowing' and what effect it has on the accuracy of results. We postulated that this process should equally impact on all electrolytes and metabolites. In particular we wondered if there was a relationship between potassium and lactate which are both felt to be affected by procedures in which blood was difficult to obtain.

Methods

A retrospective convenience sample of 101 children and young people (<16) who had had a blood gas performed were collated and analysed via microsoft excel.

Results

4 patients were excluded due to insufficient or inadequate data leaving 97 data sets available for analysis. A scatter graph of potassium and lactate results was plotted (figure 1). The correlation coeffecient was very weak (r=0.11). Mean potassium samples when lactates were seperated into values above and below 2.0 was not significantly different (4.4 vs 4.1)

Conclusion

There appears to be no obvious relationship between lactate and potassium values. A procedure which results in a perceived haemolysed sample may therefore not affect all electrolytes or metabolites. Further data is needed to confirm the abence or precence of any relationship.

Figure 1

Scatter graph of potassium versus lactate in a convenience sample of 97 patients
INCIDENCE AND SEVERITY OF ACUTE MOUNTAIN SICKNESS AND ASSOCIATED SYMPTOMS IN TAIWANESE CHILDREN ON XUE MOUNTAIN (3,886 M)
Authors: Cheng F
Published: November 2016

Objectives & Background

Acute mountain sickness (AMS) is common among people who trek at high altitudes. Headache, the cardinal symptom of AMS, is often accompanied by dizziness, fatigue, nausea and vomiting, and sleep disturbances. The incidence of AMS in children varies, and large group population studies in children are rare. We examined the incidence of AMS and prevalence of AMS-associated symptoms in older children trekking Xue Mountain in Taiwan.

Methods

This prospective cohort study included 197 healthy, non-acclimatized 11 and 12-year-old children who participated in a round-trip trek from the trailhead to the summit of Xue Mountain (2,179 m to 3,886 m) over 3 days. We used the Lake Louise AMS scoring criteria to record daily AMS-associated symptoms (headache, dizziness, fatigue, anorexia, vomiting, and sleep disturbances) and to diagnose AMS. Medication was prescribed at the onset of AMS symptoms. Written informed consent was obtained from all of the subjects and their parents.

Results

The overall incidence of AMS was 40.6%. The incidence was higher in males and in children with a higher body mass index (p<0.05). Previous high altitude experience, AMS history, and menstruation were not associated with the development of AMS. The mean overall AMS score of was 1.77±2.08. The mean AMS score of subjects developed AMS (3.02±2.46) was significantly higher than that of those in the non-AMS group (0.92±1.16,p<0.001). The most common symptom was sleep disturbance followed by dizziness, and headache. The prevalence of headache was 46.2% on Day 2 at 3,100 m, and 31.3% on Day 3 at the same altitude. Males experienced significantly more headache and fatigue during the trip (p<0.05). The AMS scores and prevalence of all the AMS symptoms were significantly higher in the AMS than in the non-AMS group (p<0.05).

Conclusion

Although AMS was common among the participants in our study, the symptoms were mild in most cases. Sleep disturbance was the most common symptom. The effects of medication or acclimatization may explain the lower incidence of headache on Day 3 compared to Day 2. The incidence of AMS in our study was higher than that previously reported in adults, and lower than that of a previous study on Jade Mountain (3,952 m) in Taiwan.

Figure 1

Overall and daily incidence of AMS in children trekking on Xue Mountain (3,886 m).

Figure 2

Daily AMS scores.

Figure 3

Prevalence of AMS-associated symptoms in males and females.
DESCRIPTIVE STUDY OF PAEDIATRIC OBSERVATION PRIORITY SCORE (POPS) TRIAGE TOOL IN BRONCHIOLITIS
Authors: Roland D , Arshad F
Published: November 2016

Objectives & Background

Bronchiolitis is a common diagnosis in patients presenting over the winter months. Predicting early in the patient journey the need for continued observation may improve patient flow and reduce crowding. In this study we aimed to assess the correlation between guideline derived severity of illness and initial acuity with outcome.

Methods

Data on 100 patients who presented to our Children's Emergency Department with a diagnosis of bronchiolitis between September 2012 and June 2013 was analysed (data was also being used for an international study on outcomes of bronchiolitis). Severity of illness (via local guidance), initial POPS (Paediatric Observation Priority Score) and patient disposition was analysed.

Results

4 patients were excluded due to insufficient data, 14/96 had severity documented by the clinician and 96/96 had severity derived based on local guidelines. Figure 1 demonstrates POPS scores at the three levels of severity. Excluding patients who represented, Pearson's correlation between POPS and percentage discharged/admitted was significant (p=0.002) with r2value of 0.72.

Conclusion

In this small sample initial acuity (via POPS) demonstrates an association with patient disposition and bronchiolitis severity grading. It is noted the confidence intervals are large, potentially due to an insufficient sample size or large heterogeneity presenting features of bronchiolitis. We also note generally good agreement between a clinician's subjective opinion of severity and guideline derived severity. There is the potential for POPS to reduce cognitive error when there is a discrepancy between these assessments.

Figure 1
PAEDIATRIC OUT-OF-HOSPITAL TRAUMATIC CARDIAC ARREST: A REVIEW OF THE PS14 SURVIVAL PREDICTION MODEL
Authors: Mynors-Wallis D , Lecky F , Bouamra O , Burke D
Published: November 2016

Objectives & Background

Trauma is a leading cause of death in children. Paediatric out-of-hospital traumatic cardiac arrest (POOHTCA) is a subsection of this. The Ps14 survival prediction model is used to predict survival in trauma patients on the Trauma Audit and Research Network (TARN) database. TARN collects and audits data from all trauma receiving hospitals in the UK and many others internationally. It has been hypothesised that there is a difference between the Ps14 survival prediction for POOHTCA and actual survival for POOHTCA patients on the TARN database.

Methods

Data from the TARN database between 1989–2015 was analysed. A comparison between the Ps14 and actual survival was made. Univariate and logistic regression analyses were conducted on the data using SPSS. A new model to predict survival after POOHTCA was constructed and a comparison between the Ps14 and the new model was made.

Results

There was a significant difference between the Ps14 prediction model and actual survival. For Known outcomes, predicted survival was 44.9% (95% CI 40.2–49.5%) compared with actual survival of 5.0% (95% CI 3.0%–7.0%). On univariate analysis, age, drowning, year of presentation and time from scene to Emergency Department were found to be significantly different between survivors and non-survivors. Further logistic regression showed only year of presentation and those who received care in the most recent time cohort, remained significant with the remaining variables losing significance. Three models of varying care and patient factors were constructed. The new models were not significantly different to the Ps14 model, C-statistic: 0.709 (95% CI 0.614–0804), 0.709 (0.614–0804) 0.798 (0.672–0.920) and 0.715 (0.603–0.827) for models 1,2,3 and Ps14 respectively.

Conclusion

The current Ps14 model is not a good predictor of survival for POOHTCA patients. This is most likely due to the small number of POOHTCA patients that survive to discharge. Although the model could be improved with a larger data set, it has been suggested that a traumatic arrest variable could be inserted into the Ps14 model which would reduce predicted survival to between 3% and 7% for this patient population. This would be much closer to actual survival rates and could improve the audit of paediatric trauma care.

Figure 1Figure 2
Carotid stenosis in women: time for a reappraisal
Authors: Marulanda-Londoño Erika , Chaturvedi Seemant
Published: November 2016

The treatment approach for patients with internal carotid artery stenosis is receiving increased scrutiny. Major advances in optimal medical therapy have been associated with a declining stroke rate for symptomatic and asymptomatic patients with carotid stenosis. Customising treatment according to gender is worthy of consideration, since earlier clinical trials showed reduced benefit with carotid endarterectomy in women compared to men. In this review, clinical trial results in women are summarised, studies pertaining to carotid plaque imaging in men and women are discussed and new clinical trials are identified. Finally, the rationale for a women's carotid trial is provided.
Canine parvovirus (CPV‐2) variants circulating in Nigerian dogs
Authors: Apaa T. T. , Daly J. M. , Tarlinton R. E.
Published: November 2016

Canine parvovirus type 2 (CPV‐2) is a highly contagious viral disease with three variants (CPV‐2a, CPV‐2b and CPV‐2c) currently circulating in dogs worldwide. The main aim of this study was to determine the prevalent CPV‐2 variant in faecal samples from 53 dogs presenting with acute gastroenteritis suspected to be and consistent with CPV‐2 to Nigerian Veterinary Clinics in 2013–2014. Seventy‐five per cent of these dogs tested positive for CPV‐2 in a commercial antigen test and/or by PCR. Partial sequencing of the VP2 gene of six of these demonstrated them to be CPV‐2a. Most of the dogs (60 per cent) were vaccinated, with 74 per cent of them puppies less than six months old.
Inhibition of the gut enzyme intestinal alkaline phosphatase may explain how aspartame promotes glucose intolerance and obesity in mice
Authors: Gul Sarah S. , Hamilton A. Rebecca L. , Munoz Alexander R. , Phupitakphol Tanit , Liu Wei , Hyoju Sanjiv K. , Economopoulos Konstantinos P. , Morrison Sara , Hu Dong , Zhang Weifeng , Gharedaghi Mohammad Hadi , Huo Haizhong , Hamarneh Sulaiman R. , Hodin Richard A.
Published: November 2016

Diet soda consumption has not been associated with tangible weight loss. Aspartame (ASP) commonly substitutes sugar and one of its breakdown products is phenylalanine (PHE), a known inhibitor of intestinal alkaline phosphatase (IAP), a gut enzyme shown to prevent metabolic syndrome in mice. We hypothesized that ASP consumption might contribute to the development of metabolic syndrome based on PHE’s inhibition of endogenous IAP. The design of the study was such that for the in vitro model, IAP was added to diet and regular soda, and IAP activity was measured. For the acute model, a closed bowel loop was created in mice. ASP or water was instilled into it and IAP activity was measured. For the chronic model, mice were fed chow or high-fat diet (HFD) with/without ASP in the drinking water for 18 weeks. The results were that for the in vitro study, IAP activity was lower (p < 0.05) in solutions containing ASP compared with controls. For the acute model, endogenous IAP activity was reduced by 50% in the ASP group compared with controls (0.2 ± 0.03 vs 0.4 ± 0.24) (p = 0.02). For the chronic model, mice in the HFD + ASP group gained more weight compared with the HFD + water group (48.1 ± 1.6 vs 42.4 ± 3.1, p = 0.0001). Significant difference in glucose intolerance between the HFD ± ASP groups (53 913 ± 4000.58 (mg·min)/dL vs 42 003.75 ± 5331.61 (mg·min)/dL, respectively, p = 0.02). Fasting glucose and serum tumor necrosis factor-alpha levels were significantly higher in the HFD + ASP group (1.23- and 0.87-fold increases, respectively, p = 0.006 and p = 0.01). In conclusion, endogenous IAP’s protective effects in regard to the metabolic syndrome may be inhibited by PHE, a metabolite of ASP, perhaps explaining the lack of expected weight loss and metabolic improvements associated with diet drinks.
Gravity and magnetic modelling of layered mafic–ultramafic intrusions in large igneous province plume centre regions: case studies from the 1.27 Ga Mackenzie, 1.38 Ga Kunene–Kibaran, 0.06 Ga Deccan, and 0.13–0.08 Ga High Arctic events
Authors: Blanchard J.A. , Ernst R.E. , Samson C.
Published: November 2016

Gravity and magnetic data from the global EGM2008 and EMAG2 datasets are used to identify geophysical anomalies in large igneous province (LIP) plume centre regions with the goal of characterizing mafic–ultramafic intrusions linked to those LIPs. Geophysical anomalies within 18 LIPs distributed globally are investigated. Four of these LIPs are selected for detailed modelling: the 1.27 Ga Mackenzie, 1.38 Ga Kunene–Kibaran, 0.06 Ga Deccan, and 0.13–0.08 Ga High Arctic LIPs. We recognize three spatial distribution types for intrusions in plume centre regions. These are (1) intrusions emplaced along a circular fault system that circumscribes the plume centre, (2) intrusions emplaced along linear rifts that, in some cases, converge towards the plume centre, and (3) single or unclassified intrusions. Modelling supports that the geophysical anomalies associated with these LIPs tend to be produced by large (radius >30 km) and deep-seated crustal intrusions, with densities consistent with mafic–ultramafic rock and magnetic susceptibilities consistent with serpentinized ultramafic rock, except within the Deccan where intrusions are smaller, mainly mafic in composition, and positioned at shallower depths in the crust.
Age and origin of the Cannon Point syenite, Essex County, New York: southernmost expression of Monteregian Hills magmatism?
Authors: Bailey David G. , Lupulescu Marian , Chiarenzelli Jeffrey , Traylor Jonathan P.
Published: November 2016

Two syenite sills intrude the local Paleozoic strata of eastern New York State and are exposed along the western shore of Lake Champlain. The sills are fine-grained, alkali feldspar syenites and quartz syenites, with phenocrysts of sanidine and albite. The two sills are compositionally distinct, with crossing rare earth element profiles and different incompatible element ratios, which eliminates the possibility of a simple petrogenetic relationship. Zircon extracted from the upper sill yields a U–Pb age of 131.1 ± 1.7 Ma, making the sills the youngest known igneous rocks in New York State. This age is similar to that of the earliest intrusions in the Monteregian Hills of Quebec, >100 km to the north. Sr and Nd radiogenic isotope ratios are also similar to those observed in some of the syenitic rocks of the eastern Monteregian Hills. The Cannon Point syenites have compositions typical of A-type, within-plate granitoids. They exhibit unusually high Ta and Nb concentrations, resulting in distinct trace element signatures that are similar to those of the silicic rocks of the Valles Caldera, a large, rift-related magmatic system. We suggest that the Cannon Point syenites were melts derived primarily by anatexis of old, primitive, lower crustal material in response to Mesozoic rifting and to the intrusion of mantle-derived magmas. The sills indicate that the effects of continental rifting were spatially and temporally extensive, resulting in the reactivation of basement faults in the Lake Champlain Valley hundreds of kilometers west of the active rift boundary, and crustal melting >50 Ma after the initiation of rifting.
Exploiting Social Capabilities in the Minority Game
Authors: Cicirelli Franco , Nigro Libero
Published: November 2016

The minority game (MG) is an inductive binary-decision model that is able to study emergent behaviors in a population of agents who compete, through adaptation, for scarce resources. The original formulation of the game was inspired by the W.B. Arthur’s El Farol Bar problem: a fixed number of people have to independently decide, each week, whether to go to a bar having a limited capacity. People’s choices are only affected by the information about the number of visitors who attended the bar in the past weeks. Basic MG assumes that the information about the past game outcomes is publicly available, and it does not contemplate any communication among players. This article proposes the Dynamic Sociality Minority Game (DSMG). DSMG is an original variant of the classic MG where (1) information about the outcome of the previously played game step is only known to agents that really attended the bar the previous week, and (2) a dynamically established acquaintance network is introduced to propagate such information to nonattendant players. Specific settings of the game are identified in which DSMG is able to show a better coordination level among players with respect to the standard MG. Emergent properties of the DSMG along with players’ wellness are thoroughly analyzed through agent-based simulation of a simple road-traffic model.
Campylobacter-Associated Diseases in Animals
Authors: Sahin Orhan , Yaeger Michael , Wu Zuowei , Zhang Qijing
Published: November 2016

Campylobacter includes a group of genetically diverse species causing a range of diseases in animals and humans. The bacterium is frequently associated with two economically important and epidemiologically distinct reproductive diseases in ruminants: enzootic infectious infertility in cattle owing to Campylobacter fetus subsp. venerealis and abortions in sheep, goats, and cattle. Septic abortion, usually epizootic in sheep, has been historically associated with C. fetus subsp. fetus and to a lesser extent with Campylobacter jejuni. However, there has been a dramatic species shift in the etiology of Campylobacter abortions in recent years: C. jejuni has now replaced C. fetus subsp. fetus as the predominant cause of sheep abortion in the United States, which appears to be driven primarily by clonal expansion of a hypervirulent tetracycline-resistant C. jejuni clone. Here we provide a review on the recent advances in understanding the pathobiology of Campylobacter infections in animals, with an emphasis on the diseases in ruminants, covering epidemiology, pathogenesis, genomics, and control measures.
Salmonellain Swine: Microbiota Interactions
Authors: Kim Hyeun Bum , Isaacson Richard E.
Published: November 2016

For the important foodborne pathogen Salmonella enterica to cause disease or persist in pigs, it has evolved an intricate set of interactions between itself, the host, and the indigenous microflora of the host. S. enterica must evade the host's immune system and must also overcome colonization resistance mediated by the pig's indigenous microflora. The inflammatory response against S. enterica provides the bacteria with unique metabolites and is thus exploited by S. enterica for competitive advantage. During infection, changes in the composition of the indigenous microflora occur that have been associated with a breakdown in colonization resistance. Healthy pigs that are low-level shedders of S. enterica also exhibit alterations in their indigenous microflora similar to those in ill animals. Here we review the literature on the interactions that occur between swine, S. enterica, and the indigenous microflora and discuss methods to reduce or prevent colonization of pigs with S. enterica.
Veterinary Replicon Vaccines
Authors: Hikke Mia C. , Pijlman Gorben P.
Published: November 2016

Vaccination is essential in livestock farming and in companion animal ownership. Nucleic acid vaccines based on DNA or RNA provide an elegant alternative to those classical veterinary vaccines that have performed suboptimally. Recent advances in terms of rational design, safety, and efficacy have strengthened the position of nucleic acid vaccines in veterinary vaccinology. The present review focuses on replicon vaccines designed for veterinary use. Replicon vaccines are self-amplifying viral RNA sequences that, in addition to the sequence encoding the antigen of interest, contain all elements necessary for RNA replication. Vaccination results in high levels of in situ antigen expression and induction of potent immune responses. Both positive- and negative-stranded viruses have been used to construct replicons, and they can be delivered as RNA, DNA, or viral replicon particles. An introduction to the biology and the construction of different viral replicon vectors is given, and examples of veterinary replicon vaccine applications are discussed.
Extracellular Matrix Remodeling and Stiffening Modulate Tumor Phenotype and Treatment Response
Authors: Leight Jennifer L. , Drain Allison P. , Weaver Valerie M.
Published: November 2016

Solid tumors are characterized by a remodeled and stiffened extracellular matrix. The extracellular matrix is not a passive by-product of the tumor, but actively compromises tissue-specific differentiation, enhances tumor cell proliferation and survival, and fosters tumor cell invasion and migration. The tumor extracellular matrix also influences the behavior of the stromal cells, which through vicious, feedforward-reinforcing pathways promote tumor progression and compromise treatment efficacy. To investigate how the tumor extracellular matrix alters cancer phenotype and treatment, a number of three-dimensional, organotypic culture models have been developed that employ a variety of materials, including natural matrices, collagen, fibrin, and reconstituted basement membrane gels, as well as synthetic hydrogel materials such as polyacrylamide and polyethylene glycol. These models have been used to interrogate how specific microenvironmental features modify tumor and stromal cell function and to identify the molecular mechanisms that regulate tumorigenesis and therapeutic efficacy. To translate these findings into more effective treatment strategies for patients, clinically informed studies are needed that incorporate computational modeling and in vivo validation.
Chemical Carcinogenesis Models of Cancer: Back to the Future
Authors: McCreery Melissa Q. , Balmain Allan
Published: November 2016

Over a century has elapsed since the first demonstration that exposure to chemicals in coal tar can cause cancer in animals. These observations provided an essential causal mechanistic link between environmental chemicals and increased risk of cancer in human populations. Mouse models of chemical carcinogenesis have since led to the concept of multistage tumor development through distinct stages of initiation, promotion, and progression and identified many of the genetic and biological events involved in these processes. Recent breakthroughs in DNA sequencing have now given us tools to dissect complete tumor genome architectures and revealed that chemically induced cancers in the mouse carry a high point mutation load and mutation signatures that reflect the causative agent used for tumor induction. Chemical carcinogenesis models may therefore provide a route to identify the causes of mutation signatures found in human cancers and further inform studies of therapeutic drug resistance and responses to immunotherapy, which are dependent on mutation load and genetic heterogeneity.