bluuebunny/crossref_metadata_2025 huggingface dataset:
001 Can we make the emergency department handover safer?
Authors: Tan Yok , Mansell Holly , Evans Josie , Kanani Anand , Stanhope Benjamin
Published: April 2023

Background

Handover of care is one of the most perilous procedures in medicine.1The unique shift-based work in the ED, where there is a high degree of patient turnover, unpredictability and patient volume can create challenges to good quality clinician and nursing handover.

The above highlights a need for an improved and standardised patient bedside handover tool for both clinicians and nurses involving and empowering patients and families. Both handover tools will cement safe continuity of information between shift changes and improved communication with patients and families.

Method and results

A standard operating procedure, flowchart and clinician’s handover tool was designed to maximise safe handover as illustrated in figure 1. The tool has been introduced into the department since June 2017. After the introduction of the tool, an evaluation survey of 30 participants across various grades of clinicians was performed.

Abstract 001 Figure 1

Clinicians handover tool

Building on the success of the clinician’s handover tool; a standard operating procedure, flowchart and the first standardised nurse’s handover tool was designed as illustrated in figure 2.

Abstract 001 Figure 2

Nurses handover tool

Conclusions

For the month of September 2017, 30 completed surveys evaluating the clinician’s handover tool was collected. 100% positive responses were received stating they found it useful. The handing over clinicians commented feeling more satisfied that ‘their patient was appropriately and safely handed over at the bed side in front of the family’.

The nurse’s handover over tool was praised as nurses felt ‘happier’ with handover and more satisfied to leave shift ‘without forgetting significant patient information’.

Both tools have become routine practice within the ED and are very useful adjuncts to improve patient safety within the department.

Multidisciplinary handover post-shift work at the bedside has become standardised practice and improved patient safety with continuity of care with these tools. Regular ongoing audit have demonstrated that the tools are routinely used by both clinicians and nurses.

Reference

British Medical Association. Safe handover: safe patients. Guidance on clinical handover for clinicans and managers. London: BMA, 2004.
013 Paramedic HEART scores in the prediction of MACE and AMI. The ambulance cardiac chest pain evaluation in scotland (ACCESS) study
Authors: Cooper Jamie , Ferguson James , Donaldson Lorna , Black Kim , Davidson Elaine , Horrill Judith , Livock Kate , Lee Kuan Ken , Anand Atul , Mills Nicholas , Scott Neil
Published: April 2023

Background

Cardiac sounding chest pain represents about 5% of all Emergency Department (ED) attendances in the United Kingdom (UK), often via 999 ambulance.

Much work has focused on the rapid distinction of the 1 in 5 patients without ST elevation on ECG, who are suffering from a non ST elevation myocardial infarction (NSTEMI). Pre-hospital translation of such work may allow improved access to specialist treatment for patients with NSTEMI and also identify a low risk population suitable for management without immediate ambulance transfer to hospital.

The objective was to determine the accuracy of a wholly paramedic calculated pre-hospital HEART score to predict a 30-day Major Adverse Cardiac Event (MACE). The potential implications of pre-specified low-risk and high-risk cut offs were also to be determined.

Method and results

Prospective diagnostic accuracy study in Northeast Scotland (UK) on adult (>18 yr) patients with cardiac sounding chest pain, attended by a paramedic ambulance and who had no ST elevation on initial ECG.

A real time paramedic HEAR score was calculated and blood drawn for analysis with a POC cTn assay and later with both laboratory based contemporary and high-sensitivity cTn assays. Normal care then ensued and patients were followed up to 30 days for development of MACE.

Conclusions

Between Nov 2014 and April 2018, 1275 patients agreed to participate in the ambulance and 1056 later gave informed consent with 1054 completing 30 day follow up.

358 patients had complete Paramedic HEART scores with all 3 assays and 969 patients with the 2 lab based assays (figure 1)

Abstract 013 Figure 1

Patient flow diagram

Sensitivities and specificities (95% CI) for the HEART scores vs MACE will be calculated and ROC curves generated. Diagnostic properties at different score cut-offs will be presented and analysis of the impact of the different cTnI assays presented.

Apologies: Independent AMI adjudication due to complete next week, so no full results yet.
015 ‘I actually only come to work for the banter’: a qualitative study into contributors to emergency department care providers’ transitory emotional state
Authors: Roy Susie , Jaap Alan , Skinner Janet
Published: April 2023

Background

Our affective (emotional) state has far reaching and well recognised implications relating to well-being, team-work and patient safety. The aim of this novel study was to gain an in depth understanding of factors that influence the transitory emotions of Emergency Department (ED) care providers whilst at work.

Method and results

Using a pragmatist theoretical lens, a qualitative methodology was selected to explore staff members’ experiences of factors generating positive and negative emotions. Focus groups were facilitated with ED staff from a major acute teaching hospital in Scotland. Purposive sampling was used to recruit participants, with each group containing members of the same or similar grade and occupation. Consultant, higher specialty trainee, junior doctor and nursing focus groups were undertaken. Following transcription, data were coded and thematically analysed to arrive at key concepts.

Abstract 015 Table 1

Themes and representative quotes

Abstract 015 Figure 1

Where care provider emotion can impact

Conclusions

Six main themes were identified: ‘ ED team rapport’ referring to the personalities and attitudes of those working that day; ‘achievement’ with successful task completion, skill use, being thanked and constructive educational opportunities generating positive emotions and lack of this feeling generating the converse; ‘interpersonal interactions’ where the negative impact of incivility from staff or patients was highlighted; ‘equipment/infrastructure’ showcasing how frustration manifests when either fails; ‘the open and the close’ representing the impact of how the tone set in handover influences affect and finally, the self-explanatory ‘a bad day outside work can influence that inside.’

This study illustrates the importance of recognising personal ‘wins’ whether that be a well-managed patient or successfully recognised teaching opportunity. It adds impetus to the campaign against incivility - reaffirming the negative effect rudeness has on affect. On a personal level, it highlights that we can take responsibility to ‘choose our own weather’ as a team member or leader in being a colleague that others enjoy working with. This may improve outcomes for all.
019 Club 18–40: why do young adults attend the emergency department? M
Authors: Muz Ahmad S , Davidson Craig
Published: April 2023

Background

Crowding in the Emergency Department (ED) continues to be a challenge across the country. Recent focus has been on the increasingly complex elderly patients. However, data from the Royal Infirmary of Edinburgh (RIE) shows that over the last 10 years, attendances in young adults have doubled, whereas those in over-65s have increased by just 16%. Studies show that patients aged 18–40 are least likely to attend their GP; perhaps they see the ED as a convenient one-stop shop for 24-hour access to care. Until now, literature exploring their motivations to attend the ED has been sparse, often limited to establishing characteristics of a frequent user.

Method and results

This project investigated the reasons for attendance to the ED in young adults aged 18–40 and their opinions of the emergency services at the RIE. A survey was conducted for three weeks where 131 patients were recruited at check-in, the waiting room and within department cubicles.

Questions were based around recurrent themes of previous literature, which discussed the ideas of the ED being a convenient system to acquire medical attention at any time of day. Patients were asked about their reasons for attendance and to rate on a Likert scale a series of statements about the ED.

Conclusions

Our findings show that patients aged 18–40 in fact, did not consider the ED more convenient in terms of time or location than their GP, nor did they think the ED provides better care.

However once they considered their problem as urgent they did not perceive primary care as being able to accommodate this urgency. Patients therefore present to the ED as the only other option. Understanding this perspective provides potential targets for intervention, allowing patients to be seen by the right person, in the right setting, the first time.
025 Hospital interventions to improve patient flow: emergency department outcomes of an action research study
Authors: Sethi Simon , Boulind Caroline , Bruijns Stevan
Published: April 2023

Background

The Royal College of Emergency Medicine has highlighted reduced patient flow through the hospital system as a major challenge to improving emergency department flow. We describe the impact of a hospital-wide flow intervention on Yeovil District Hospital emergency department’s clinical quality indicators, in order to demonstrate the value of a whole-system approach to curb access block.

Method and results

We followed up on an action research study that identified and intervened on several areas within the hospital that were disproportionally contributing to access block during 2016. Using a retrospective, cross-sectional design, we described the effect of the interventions on the Royal College of Emergency Medicine’s clinical quality indicators (four-hour standard, time to decision maker, seven-day unplanned re-attendance, left without being seen, ambulatory patient care and patient experience) between January 2014 and October 2018. Pearson correlation coefficient (r) was used to compare variables and linear regression was used to describe the contribution of interventions to the change in four-hour standard.

Abstract 025 Figure 1

ED attendance YDH vs national

Abstract 025 Figure 2

Four hour performance YDH vs national

Abstract 025 Figure 3

Time to doctor and triage

Conclusions

Yeovil District Hospital emergency department was attended by 233,378 patients over the study period. Mean monthly attendance was 4,029 (±341) patients), mean age was 43 (±28) years and there was an equal male/female split (49/51%). The four-hour standard makes a gradual and consistent recovery from under 95% to over 95% that is not reflected in national data (r=0.09). This is despite a rising trend in emergency department attendances both for Yeovil and nationally (r=0.75). Other clinical quality indicators (except seven-day unplanned re-attendance) improved significantly. The overall regression model fit was R2=0.81; three interventions contributed significantly and a further two contributed non-significantly).

The impact on clinical quality indicators reveals the significant effect of a hospital-wide flow intervention that targeted multiple causes of access block. Further research should include qualitative research to understand the facilitators and barriers to flow improvement work in emergency departments.
030 Are staff recorded pain scores a ‘gold standard’ for ED pain research?
Authors: Connor Putnam R , Thornton Hilary , Coats Timothy
Published: April 2023

Background

Relief of pain is a key activity of emergency medicine, however pain is often poorly monitored. As part of the evaluation of an electronic patient pain score recording device we needed to smooth a time series of pain scores in order to minimise ‘noise’ and false readings. In order to evaluate different methods we used the staff recorded pain score as a reference standard.

Patients used an electronic pain recording device containing buttons set out in the same way as a pain visual analog scale. The button corresponding to the currently level of pain was pressed in response to an audible prompt every 15 minutes. Pain scoring by ED staff continued in the normal way, recorded in the electronic health record.

Smoothing was undertaken using 20 and 30 minute bins, with either the median or the maximum patient recorded score being calculated for each bin. The staff recorded pain score nearest to 2 hours was paired with the patient recorded score in the same time window.

For each smoothing method a Bland-Altman plot was made of the paired results and Spearman’s correlation coefficient calculated.

There was little difference between the smoothing methods (table 1). However the most striking finding was that ED staff overall record a lower pain score (by 1 to 2 points) than is self-reported by patients. There were also very wide limits of agreement - implying variation between patient recorded and staff recorded pain scores (figure 1).

Abstract 030 Figure 1Abstract 030 Table 1

Better understanding of the dynamic of the interaction between patient and ED staff, including staff perceptions, is important in managing pain in emergency care. Our (perhaps naive) initial presumption that a staff recorded score forms a ‘reference standard’ may not be valid.
033 Diagnostic investigation and prediction of shock (DiPS), in the emergency department: a prospective observational study
Authors: Sorayya Sorayya Kakhi , Nadeem Afaque , Seymour Jamie , Ngua Nicholas , Yousef Zaheer , Rainer Timothy
Published: April 2023

Background

Currently there exists no widely accepted, objective tool for determining the probability of shock in the emergency department (ED). Associated mortality outcomes remain unacceptably high. Using variables that are associated with shock and available in the ED we aimed to derive an objective tool for estimating the probability of shock

Methods

In a prospective, longitudinal study conducted in the ED, Cardiff, adult patients aged ≥18 years, presenting with NEWS ≥3 were recruited. We derived a model consisting of 8 variables, and validated it using bootstrap (1000 iterations; random number seed: 978). The primary outcome was combined 30-day mortality or ICU admission.

Results

361 patients were recruited (mean age 69.4 ±15.9 years; male 62.7%; 80 positive outcome) to the study. The multivariate model variables were: Glasgow Coma Scale 3–8 (Odds ratio (OR) 9.1 (95% CI 1.2–69.4) p=0.0324), 9–12 (OR 1.3 (95% CI 0.4–4.2) p=0.6561); capillary return >4 (OR 8.7, (95% CI 2.9–26.1) p=0.0001), 3–4 (OR 3.7 (95% CI 1.3–10.4); p=0.0113); temperature ≤35°C (OR 5.4, (95% CI 1.8–16.3); p=0.0045); bilirubin >34 (OR 4.9, (95% CI 1.6–14.5); p=0.0045); oxygen supplement (OR 1.9, (95% CI 1.0–3.7); p=0.06); respiratory rate >24 (OR 2.6, (95% CI 1.3–5.1); p=0.0069); and albumin <35 (OR 1.9, (95% CI 0.9–3.8); p=0.09).

The model was a 100-point scale where 0 was low probability and 100 was maximal probability of shock. The AUC was 0.801 (95% CI 0.756–0.841), accuracy 82%, p<0.0001, Hosmer & Lemeshow test 9.19 (p=0.326). At a cut off >35, and Youden Index 0.4557 the sensitivity and specificity were 56.2% (95% CI 44.7–67.3) and 89.32% (95% CI 85.1–92.7) respectively. At a fixed specificity of 80%, the estimated sensitivity was 60.5% (95% CI 49.4–71.3). At a fixed sensitivity of 80%, the estimated specificity was 62.3% (95% CI 45.9–71.2).

Conclusions

An accurate 7-point ED tool for shock has been derived and internally validated.
036 Feasibility of collecting real-time emergency department patient safety and experience feedback
Authors: Wilson Sally-Anne , Marsh Claire
Published: April 2023

Background

The NHS Long Term Plan aims to make care more Patient-Centred through listening to patients. The acute nature of ED care presents barriers to collecting patient feedback. We have explored two interventions (PRASE and Y-PET), as mechanisms for collecting and reporting safety feedback (PRASE) and experience feedback (Y-PET) in EDs.

An iterative approach was used to develop PMOS10 (PRASE questionnaire) for the ED which was tested in 5 departments with over 100 patients. The Y-PET was used alongside these tools in 2 departments with 40 patients.

A mixture of patient volunteers and staff collected the feedback.

Two questions from the PMOS10 proved to be unsuitable for the ED setting, and were substituted. Through further iterative tests, we now have a PMOS10(ED).

Hospital volunteers and staff not associated with the department are best placed to collect unbiased results. Patients (or their relatives) who are awaiting transport home or a hospital bed are best placed to give feedback. The traffic light display of patient safety feedback provided in PRASE is useful for assurance but staff need more qualitative data to inspire change. PRASE patient comments go someway to providing this but are strongly enhanced by the open answers of the Y-PET. The Y-PET format for presenting qualitative data as headline areas to celebrate or improve was effective in engaging staff in feedback from both tools.

ED patients can give valuable insight into how safe their care is and areas to celebrate and improve. Staff can engage with feedback themes and key quotes to initiate improvement.
037 Improving the adult patient experience by introducing a paediatric wound closure method – the hair apposition technique
Authors: Waydia Shree-eesh , Rehnberg Lucas
Published: April 2023

Background

Scalp lacerations are a common presentation to the Emergency Department (ED). The Hair Apposition Technique (HAT) is a safe, effective, efficient and patient-centred alternative to sutures and commonly used in paediatrics. This Quality Improvement Project (QIP) was inspired by a patient with dementia who could not tolerate sutures for her scalp laceration therefore HAT was used with excellent results and patient satisfaction. This project aimed to introduce the technique to 50% of all eligible adult patients within 6 months.

Method and results

A retrospective, case-note baseline review demonstrated no use of HAT in adults during a period of three months. Barrier analysis using staff surveys explored why HAT was not standard practice. We introduced HAT using the Institute of Healthcare Improvement (IHI)’s Model for improvement methodology and conducted four Plan, Do, See, Act (PDSA) cycles to implement changes. Our process measure was the number of patients having HAT compared with sutures. Outcome measures were via a qualitative phone survey evaluating pain, satisfaction and inconvenience score on a scale of 0–10. Balancing measures included wound complication and re-attendance.

Conclusions

During the 6 months following the introduction of HAT 71% patients who were eligible to have HAT had the technique instead of sutures or staples, with improvement in all patient outcome measures compared with those who had sutures. HAT was popular with staff and patients. Our sustainability review at one year showed ongoing use of the technique and we have achieved a significant culture change by establishing the technique as standard practice for adults.

Abstract 037 Table 1

Breakdown of head lacerations and their closure by month comparing a 3-month period, one year apart

Abstract 037 Figure 1

Graph to show impact of PDSA Cycles on the No. of Patients Having Either Sutures/Staples vs. HAT Over Time

Abstract 037 Figure 2

Run chart comparing the Baseline results with HAT for Pain scores

Conclusion

HAT should be considered in eligible adult patients with scalp lacerations presenting to the ED. Applying quality improvement methodology resulted in a sustained culture change; the ED involved now offers an effective suture free paediatric technique to adults which has improved patient outcomes and satisfaction.
040 Prehospital national early warning score predicts patient disposition also in japan
Authors: Endo Takuro , Fujitani Shigeki , Taira Yasuhiko
Published: April 2023

The National early warning score (NEWS) was originally developed in the UK for hospitalized patients. We examined if NEWS can be applied for emergency transported patients in Japan.

We assessed the patients transported to one hospital between April 2017 to March 2018. We calculated NEWS from the vitals recorded by ambulance staff. Emergency department (ED) disposition data were categorized into the following groups depending on their outcome: discharged from ED, admitted to a ward, admitted to the intensive care unit or died in ED. We assessed the predictive performance of the NEWS for combined patient dispositions using receiver operating characteristics curves, from which possible cut-off values for risk categorizations were derived. Patient dispositions were compared between NEWS-based three categories adjusting for age, gender and presence of traumatic injury.

Results

Of 2,847 patients, mean (±standard deviation) NEWS of patients who discharged from ED (n=1330), admitted to a ward (n=1263), admitted to the ICU (n=232), and died in ED (n=22) were 3.7±2.9, 6.3±3.8, 9.4±4.0, 11.7±2.9, respectively. Prehospital NEWS’s C-statistics (95% confidence interval) for admission to a ward/the ICU or death in ED was 0.733(0.715–0.751), admission to the ICU or death in ED was 0.807 (0.780–0.833), and death in ED was 0.900 (0.868–0.933). After adjusting for age, gender and trauma, odds ratio (95% confidence interval) for admission to the ICU or death in ED of high-risk NEWS category (≥7) was 13.8 (8.9–21.6) and middle category (5 or 6) was 4.2 (2.5–7.1), each compared to low-risk category (≤4).

Conclusion

Our study shows prehospital NEWS can identify patients at risk of adverse outcomes also in Japan.
043 Should adults with mild head injury taking direct oral anticoagulants undergo CT scanning? A systematic review
Authors: Fuller Gordon , Evans Rachel , Preston Louise , Woods Helen Buckley , Mason Suzanne
Published: April 2023

Background

Patients taking direct oral anticoagulant medications (DOACs) commonly undergo computed tomography (CT) head scanning following mild head injury, regardless of symptoms or signs. International guidelines have noted a lack of evidence to support management decisions in such patients.

Methods

A systematic review, pre-registered (CRD42017071411) and following Cochrane Collaboration recommendations, was performed. Studies of adults with mild head injury (GCS 13–15) taking DOACs, which reported the risk of adverse outcome following the head injury, were eligible for inclusion. A comprehensive range of bibliographic databases and grey literature were examined using a sensitive search strategy. Selection of eligible studies, data extraction, and risk of bias was evaluated independently by separate reviewers. A random effects meta-analysis was used to provide a pooled estimate of the risk of adverse outcome. The overall quality of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation Working Group approach.

Results

4,185 articles were screened for inclusion, of which 7 cohort studies, including 346 patients, met inclusion criteria. All studies were at high or unclear risk of bias secondary to selection and information bias. Estimates of adverse outcome (any death, intracranial hematoma (ICH), or neurosurgery) ranged from 0% to 8%. A random effects meta-analysis showed a weighted composite outcome risk of 4% (95% CI 2–6%, I2=3%). The overall quality of the body of evidence was low secondary to imprecision, indirectness and risk of bias.

Conclusions

There is limited data available to characterize the risk of adverse outcome in patients taking DOACs following mild head injury. A sufficiently powered prospective cohort study is required to validly define this risk, identify clinical features predictive of adverse outcome, and inform future head injury guidelines.
044 Stemming the flow
Authors: Honour Patrick , McAlpine Graeme
Published: April 2023

Standardising the practice of epistaxis care in an emergency department to improve patient outcomes.

Having a regional ENT centre on site we see a disproportionate number of epistaxis patients with over 500 cases a year.

All atraumatic haemodynamically stable epistaxis patients who had active ongoing bleeding in the department were included.

Developing a standard operating procedure based around the standard treatment arm of the NoPac study we focused on the step by step management of epistaxis to measure if this improves patient outcomes.

A tailored education package for the protocol was used in the department with posters, emails and information during handover to all staff in the department.

It follows a step by step method, starting with nasal pegs in triage, clot removal, cautery and adrenaline soaked rolls, depending on the persistence of the bleeding, eventually discharge or referral.

I Analysed TRAK data for all ‘Epistaxis’ diagnoses prospectively for 2 months pre and post intervention.

Any patient with a documented ‘active’ bleeding that was not haemodynamically unstable or a traumatic injury for the following outcomes;

Primary outcome was rate of Admission to ENT.

Secondary outcomes were, time in department and reattendance within 2 weeks.

A total of 34 patients were studied, 17 before and after the intervention.

Primary outcome of ENT admissions – Down from 41% to 11%.

Secondary outcomes of time in department - reduced by 39 minutes to 2h36 from 3h03.

And re-attendance rate remains the same at 24%

In conclusion we have seen a significant drop in ENT admissions alongside a decreased time in department without increasing re-attenders. Having a standardised plan for all epistaxis patients to receive early intervention with a clear protocol for the medical staff has improved patient safety and outcomes. These projects further benefit our department by keeping up with active research projects.

Abstract 044 Figure 1
045 We’re going to need a bigger boat! Evening opening of mothballed outpatient areas to reduce crowding in a children’s emergency department
Authors: Hance Katherine , Lyttle Mark , Humphreys Sue
Published: April 2023

Background

EDs are increasingly crowded, with negative impact on care quality. This is multifactorial, but tends to peak during evenings. On mapping our contributing constraints, staffing was adequate, but available ED space was a major factor. We identified evening opening of mothballed clinical areas as a potential strategy, of which one was our outpatient department (OPD); housed one minute away on the same floor this closes at 1700. Through the 2018/19 winter this opened between 1800–2330; we evaluated impact on service provision and staff morale.

Method and results

Continuous PDSA cycles were initiated; a living standard operational policy evolved based on staff/patient feedback. Flow and patient acuity markers were monitored using electronic tracking systems. Staff were surveyed to explore opinions and impact on morale.

Conclusions

During November 2018–April 2019 the OPD opened on 76 days (50%), with 1082 patients seen. Opening was more frequent during November-February; during peak activity >10% all daily attendances were seen in this stream. Mean time to see clinicians was 77 minutes and mean time to discharge was 133 minutes; both compared favourably with patients remaining in ED. This partly reflects lower patient acuity, but other crowding measures including total patients in department, and total patient minutes, also improved. The most common diagnoses were soft tissue injury, fracture, head injury, and URTI. No safety incidents occurred and <1% left without being seen. Staff feedback reflected increased morale, and lower stress and noise levels during peak activity.

Novel use of mothballed clinical areas during peak ED activity is an attractive option for families and staff, and appears to improve safety and effectiveness. Use of existing staff was cost effective, with total additional cost pressures for nurses (£20K) and support staff (£500), in comparison to projected costs of £100K for one embedded evening GP over the same period.
048 Computer beats doctor? Estimating the probability of acute coronary syndrome for individual patients
Authors: Oliver Govind , Reynard Charles , Morris Niall , Body Richard
Published: April 2023

Chest pain is one of the most common reasons for patients attending the Emergency Department (ED). Accurately assessing for Acute Coronary Syndromes (ACS) remains a challenge. There is strong evidence supporting use of the Troponin-only Manchester Acute Coronary Syndrome (T-MACS) risk prediction model. How clinicians perform compared to these models is unknown.

We aimed to externally validate the diagnostic accuracy of clinicians’ estimated probability of ACS (gestalt) compared to the T-MACS calculated probability of ACS.

The Bedside Evaluation of Sensitive Troponin prospective multi-centre diagnostic accuracy study included adults presenting to the ED with potential ACS. Alongside clinical, ECG and blood sample data, the emergency clinician recorded their estimated probability of ACS (%) following review. The probability of ACS was also calculated using T-MACS. The primary outcome was Major Adverse Cardiac Events (MACE) within 30-days. For this planned secondary analysis, patients from sites using the high-sensitivity cardiac troponin T (Roche Diagnostics Elecsys) were eligible.

Of 782 included, 116 (14.8%) had MACE. The C-statistic for clinician gestalt and T-MACS were 0.76 (95% CI 0.71–0.81) and 0.93 (0.90–0.95) respectively (p<0.0001). Compared to T-MACS, clinicians overestimated the probability of ACS (positive bias 18.0%) and were less likely to stratify patients to extremes of probability. For ‘rule out’ of ACS, clinicians identified 72 (9.3%) patients as ‘very low risk’ (<2%) compared to 385 (49.2%) with T-MACS. For ‘rule in’ of ACS, clinicians identified 16 (2.1%) patients as ‘high risk’ of ACS (≥95%) in comparison with 50 (6.4%) with T-MACS. Assessment of model calibration comparing observed against predicted outcomes gave an R square of 0.78 and 0.97 for clinicians and T-MACS respectively.

Clinician gestalt has inferior diagnostic accuracy to T-MACS. T-MACS requires a clinician’s skill for appropriate application. Our conclusion is therefore not that computers are better, but that clinician performance can be augmented using T-MACS.
Abstracts from international Emergency Medicine journals
Authors: Production EMJ
Published: April 2023

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.
BET 1: The role of remdesivir in COVID-19 infection
Authors: Baombe Janos P
Published: April 2023

A short-cut review of the available medical literature was carried out to establish whether remdesivir was an effective treatment for patients with confirmed COVID-19 infection. After abstract review, five papers were found to answer this clinical question using the detailed search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that despite some recent promising studies, further well-designed and larger trials are needed to answer this specific question.
Comaneci-assisted coiling of a right posterior communicating artery aneurysm: an unusual case of coil retention
Authors: Sioutas Georgios S , Salem Mohamed M , Burkhardt Jan-Karl , Srinivasan Visish M , Jankowitz Brian T
Published: April 2023

Although endovascular embolization has become the main treatment option for intracranial aneurysms,1 2 wide-necked intracranial aneurysms remain difficult to coil.3 Both stent- and balloon-assisted coiling are used for wide-necked aneurysms because they provide a scaffold that protects the parent vessel during coiling.4 5 However, stent-assisted coiling requires dual antiplatelet therapy, which increases the risk of bleeding, whereas balloon-assisted coiling temporarily obstructs blood flow.4 6 7 The Comaneci device (Rapid Medical, Yokneam, Israel) has recently received US Food and Drug Administration approval as a ‘temporary coil embolization assist device’.5 It temporarily covers the aneurysm neck and allows safe coiling, avoiding the disadvantages mentioned above.6–8 A potential complication of Comaneci-assisted coiling is coil retention when it adheres to the device on recapture; this complication should be promptly recognized and managed.5 9 10 In this video, we present an unusual case of coil retention with the Comaneci device (Video 1).

Video 1
Vitamin D status in active duty Navy military personnel: a systematic review
Authors: Henriques Moisés , Rodrigues Diogo , Viegas Susana , Serranheira Florentino , Sacadura-Leite Ema
Published: April 2023

Objectives

Active duty Navy military personnel are prone to vitamin D deficiency due to an occupational environment detrimental to sunlight exposure. The main objective of this systematic review is to provide a worldwide overview of vitamin D status in this population.

Methods

The Condition, Context, Population (CoCoPop) mnemonic was used to define the inclusion criteria (vitamin D status; all contexts; active duty Navy military personnel). Studies with recruits or veterans were excluded. Scopus, Web of Science and PubMed/Medline databases were searched from inception to 30 June 2022. Joanna Briggs Institute and Downs & Black checklists were used for quality assessment and data were synthesised in narrative and tabular formats.

Results

Thirteen studies published between 1975 and 2022 and conducted in northern hemisphere Navies, including mainly young and male service members, were included. The prevalence of vitamin D deficiency was globally reported as significant. Nine studies included a total of 305 male submariners who performed 30–92 days submarine patrol and reported the effect of sunlight deprivation in the decrease of vitamin D levels.

Conclusions

This new systematic review underlines the high prevalence of vitamin D deficiency in the Navy, especially in submariners, and the need to implement measures to prevent vitamin D deficiency. Serum 25(OH)D data available and the heterogeneity of the studies limited a pooled analysis. Most studies included only submariners, which may limit generalisability to all active duty Navy military personnel. Further research on this topic should be promoted.

PROSPERO registration number

CRD42022287057.
Risk factors for HIV infection at a large urban emergency department: a cross-sectional study
Authors: Ford James S , Mousa Mohammad A , Voong Stephanie , Matsumoto Cynthia G , Chechi Tasleem , Tran Nam , May Larissa
Published: April 2023

Objectives

In 2019, the US Preventative Services Task Force released updated guidelines recommending HIV screening in all individuals aged 15–64 years and all pregnant females. In the current study, we aimed to identify risk factors for HIV infection in an emergency department (ED) population.

Methods

We performed a cross-sectional study that employed a post hoc risk factor analysis of ED patients ≥18 years who were screened for HIV between 27 November 2018 and 26 November 2019, at a single urban, quaternary referral academic hospital. Patients were screened using HIV antigen/antibody testing and diagnoses were confirmed using HIV-1/HIV-2 antibody testing. The outcome of interest was the number of positive HIV tests. Multiple logistic regression models were used to identify risk factors associated with HIV positivity.

Results

14 335 adult patients were screened for HIV (mean age: 43±14 years; 52% female). HIV seroprevalence was 0.7%. Independent risk factors for HIV positivity included male sex (adjusted OR (aOR) 3.1 (95% CI 1.7 to 5.6)), unhoused status (aOR 2.9 (95% CI 1.7 to 4.9)), history of illicit drug use (aOR 1.8 (95% CI 1.04 to 3.13)) and Medicare insurance status (aOR 2.2 (95% CI 1.1 to 4.4)).

Conclusions

The study ED services a high-risk population with regard to HIV infection. These data support universal screening of ED patients for HIV. Risk factor profiles could improve targeted screening at institutions without universal HIV testing protocols.
Spinor walls in five-dimensional warped spacetime
Authors: Cui Zheng-Quan , Liu Yu-Xiao
Published: April 2023

We study domain wall solutions of a real spinor field coupling with gravitation in five dimensions. We find that the nonlinear spinor field supports a class of soliton configurations which could be viewed as a wall embedded in five dimensions. We begin with an illuminating solution of the spinor field in the absence of gravitation. In a further investigation, we exhibit three sets of solutions of the spinor field with nonconstant curvature bulk spacetimes and three sets of solutions corresponding to three constant curvature bulk spacetimes. We demonstrate that some of these solutions in specific conditions have the energy density distributions of domain walls for the spinor field, where the scalar curvature is regular everywhere. Therefore, the configurations of these walls can be interpreted as spinor walls which are interesting spinor field realizations of domain walls. In order to investigate the stability of these spinor configurations, the linear perturbations are considered. The localization of the zero mode of tensor perturbation is also discussed.
Quantum-Dynamical Semigroups and the Church of the Larger Hilbert Space
Authors: vom Ende Frederik
Published: April 2023

In this work we investigate Stinespring dilations of quantum-dynamical semigroups, which are known to exist by means of a constructive proof given by Davies in the early 70s. We show that if the semigroup describes an open system, that is, if it does not consist of only unitary channels, then the evolution of the dilated closed system has to be generated by an unbounded Hamiltonian; subsequently the environment has to correspond to an infinite-dimensional Hilbert space, regardless of the original system. Moreover, we prove that the second derivative of Stinespring dilations with a bounded total Hamiltonian yields the dissipative part of some quantum-dynamical semigroup — and vice versa. In particular this characterizes the generators of quantum-dynamical semigroups via Stinespring dilations.
Evaluation of the Effect of Change in Support Conditions on the Seismic Behavior of a Historical Masonry Bridge
Authors: Sözen Şahin , Doğangün Adem
Published: April 2023

It is believed that the Yılanlı (or Leylekli) Bridge (bridge with stork or snake figures) in Tokat, a city with high seismicity, was built during the Roman or Byzantine period. Although no structural damage was found on the bridge, which is still open to pedestrian traffic, it is very important to determine the seismic behaviour of the bridge considering the possible earthquakes to which the structure will be exposed. This article presents the seismic response of the historical Yılanlı (Leylekli) Bridge, which has been subjected to unfavourable human-made changes in geometric shape over time. The original and modified shapes of the bridge were modelled using the macro modelling approach in ANSYS finite element software. The structural performance of the models was evaluated in terms of stresses, deformations, and especially cracks on the arch and spandrel walls using nonlinear static and time history analyses. The results of the analysis show that the change in shape, which is not desirable from an architectural and aesthetic point of view, adversely affects the seismic performance of the historical bridge and makes it more vulnerable to possible earthquakes. In addition, the analyses clearly showed that both models are subject to serious structural damage that could lead to a collapse in the event of a potential large magnitude earthquake.
Low-light Image Enhancement via a Frequency-based Model with Structure and Texture Decomposition
Authors: Zhou Mingliang , Leng Hongyue , Fang Bin , Xiang Tao , Wei Xuekai , Jia Weijia
Published: April 2023

This article proposes a frequency-based structure and texture decomposition model in a Retinex-based framework for low-light image enhancement and noise suppression. First, we utilize the total variation-based noise estimation to decompose the observed image into low-frequency and high-frequency components. Second, we use a Gaussian kernel for noise suppression in the high-frequency layer. Third, we propose a frequency-based structure and texture decomposition method to achieve low-light enhancement. We extract texture and structure priors by using the high-frequency layer and a low-frequency layer, respectively. We present an optimization problem and solve it with the augmented Lagrange multiplier to generate a balance between structure and texture in the reflectance map. Our experimental results reveal that the proposed method can achieve superior performance in naturalness preservation and detail retention compared with state-of-the-art algorithms for low-light image enhancement. Our code is available on the following website.

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A Novel Electrochemical Sensor Based on a Cerium Oxide/Gold/Carbon Nanocomposite for the Detection of Hydroxyl Free Radicals
Authors: Ghaedamini Hamidreza , Alba-Rubio Ana C. , Kim Dong-Shik
Published: April 2023

Hydroxyl radicals (•OH) are well known as crucial chemicals for maintaining the normal activities of human cells; however, the excessive concentration of •OH disrupts their normal function, causing various diseases, including liver and heart diseases, cancers, and neurological disorders. The detection of •OH as a biomarker is thus essential for the early diagnosis of these serious conditions. Herein, a novel electrochemical sensor comprising a composite of cerium oxide nanoclusters, gold nanoparticles, and a highly conductive carbon was developed for detecting •OH. Cyclic voltammetry (CV) and electrochemical impedance spectroscopy (EIS) were employed to characterize the signals generated by the interaction of the composite with •OH radicals. The CV results revealed that the developed sensor could accurately and selectively detect •OH in the Fenton reaction. The sensor demonstrated a linear relationship between the current peak and •OH concentration in the range 0.05 − 0.5 mM and 0.5 − 5 mM with a limit of detection (LOD) of 58 μM. In addition, EIS studies indicated that this electrochemical sensor could distinguish between •OH and similar reactive oxygen species (ROS), like hydrogen peroxide (H2O2). It is also worth mentioning that additional merits, such as reproducibility, repeatability, and stability of the sensor were confirmed.
Optoelectronic Properties of Triphenylamine Organic Thin Film Layered Al/p-Si /TPA/Al Heterojunction for Photodiode Application
Authors: Çavdar Şükrü , Izmirli Selçuk , Koralay Haluk , Turan Neslihan , Eymur Serkan , Tuğluoğlu Nihat
Published: April 2023

Organic semiconductors provide many advantages in diode fabrication due to their variable electrical properties, flexibility and easy and cheap production processes. In this study, triphenylamine (TPA) organic compound was used for the Al/p-Si/TPA/Al Schottky structure. The effect of the triphenylamine on the electrical properties of the produced diode was studied by current-voltage measurements in dark and under various illumination intensities. The main electrical parameters such as barrier height (ΦB), ideality factor (n), series resistance (R
s), and interface state density (N
ss) were obtained from the I-V characteristics. The n,

Φ

B

and R

s
values of the diode were found as 1.88, 0.80 eV and 2195 Ω for dark, and 3.96, 0.71 eV and 17 Ω for 100 mW cm−2 illumination intensity. Besides, the fabricated device exhibited photodiode behavior as obtained from the photocurrent measurement for the diode, depending on the illumination intensity. Additionally, it was found that the Al/p-Si/TPA/Al diode had a higher photocurrent (I

ph
) in illuminated conditions than in dark conditions. The main photovoltaic parameters such as open circuit voltage (V

oc
) and short circuit current (I

sc
) were also investigated. Photo-responsivity and response time (τ
r, τ
d) of the diode was obtained as 0,015 A W−1 and 800 ms respectively. All these results show that the Al/p-Si/TPA/Al diode has potential in optoelectronic device applications.
Is the intestinal mucous layer a natural deep eutectic solvent-based digestion matrix?
Authors: van Kempen Theo A.T.G. , Boerboom Gavin M.
Published: April 2023

In plants, a third solubilization matrix (besides water and lipids) has been proposed, composed of natural deep eutectic solvents (NADESs). Such matrices allow for the solubilization of many biologically important molecules, such as starch, which are insoluble in water or lipids. NADES matrices also support enzyme activity, such as amylase, at higher rates than water or lipid-based matrices. We contemplated if a NADES environment could play a role in small intestinal starch digestion. The intestinal mucous layer (encompassing both the glycocalyx and the secreted mucous layer) has a chemical composition that fits well with NADES (e.g., glycoproteins with exposed sugars, amino sugars, and amino acids like proline and threonine, as well as quaternary amines like choline and ethanolamine and organic acids like citric and malic acid). Various studies have indeed shown that amylase binds to glycoproteins within the mucous layer of the small intestine where it performs its digestive action. Dislodging amylase from these binding sites impedes starch digestion and it may well cause digestive health problems as a result. Hence, we propose that the mucous layer in the small intestines harbors digestive enzymes like amylase, while starch, due to solubility, redistributes from the lumen into the mucous layer where it is subsequently digested by amylase. The mucous layer would thus constitute a NADES-based digestion matrix in the intestinal tract.
Effects of greater erythroid Cl−/HCO3− transporter (band 3) expression on ventilation and gas exchange during exhaustive exercise
Authors: Hsu Kate , Tseng Wei-Chin , Chen Li-Yang , Chen Pin-Lung , Lu Yu-Xian , Chen Yung-Sheng , Tseng Kuo-Wei , Swenson Erik R.
Published: April 2023

Higher expression of the Cl−/[Formula: see text] transporter band 3 anion exchanger-1 (AE1) on the red blood cell membrane, as in people with the GP.Mur blood type, increases the rate of CO2 excretion during exercise.
The synthetic aminoglycoside ELX-02 induces readthrough of G550X-CFTR producing superfunctional protein that can be further enhanced by CFTR modulators
Authors: Chen Jianguo , Thrasher Kari , Fu Lianwu , Wang Wei , Aghamohammadzadeh Soheil , Wen Hui , Tang Liping , Keeling Kim M. , Falk Libby Emily , Bedwell David M. , Rowe Steven M.
Published: April 2023

We found that forskolin-induced swelling in G550X-CFTR patient-derived intestinal organoids (PDOs) was significantly higher than in G542X-CFTR PDOs after treatment with ELX-02. Tryptophan (W) was the sole amino acid inserted in the G550X position after readthrough. Resulting G550W-CFTR protein exhibited supernormal CFTR activity, PKA sensitivity, and open probability. These results show that aminoglycoside-induced readthrough of G550X produces greater CFTR function because of the gain-of-function properties of the CFTR readthrough product.
Therapeutic effect of two strategies directed at disruption of pathogenic neutrophil extracellular vesicles in a murine emphysema model
Authors: Genschmer Kristopher R. , Madison Matthew , Viera Liliana , Margaroli Camilla , Gaggar Amit , Blalock J. Edwin , Russell Derek W.
Published: April 2023

Protamine sulfate facilitates the removal of neutrophil elastase (NE) from the surface of extracellular vesicles from activated neutrophils. This “free” NE is no longer protected from inhibition by its endogenous anti-protease, α-1-anti-trypsin. This function of protamine sulfate highlights it as a potential therapeutic strategy for COPD, which may attenuate the disease process.