bluuebunny/crossref_metadata_2025 huggingface dataset:
984 Evaluation of the effectiveness of a Welsh Physician Response Unit (PRU) at reducing ED footfall;identifying the rates and reasons for ED attendance after discharge at the scene by a PRU
Authors: Andrew Fiona , Morley Kosta
Published: June 2022

Aims/Objectives/Background

The Aneurin Bevan University Health Board (ABUHB) Physician Response Unit (PRU) aims to alleviate the pressure on its emergency departments (EDs) through the provision of physician-led community emergency medicine. An increasingly common prehospital model, the PRU brings the ED doctor to the patient with the aim of reducing the number of 999-callers requiring an ED visit. However, with no published ED follow-up studies amongst UK PRU services, how can physicians and commissioners ensure that PRU discharge in the community is synonymous with a prevented ED attendance?

This study aims to be the first to follow up and identify the proportion of patients attending the ED within 7 days of discharge by a PRU and to establish the factors associated with attendance.

Methods/Design

Pilot retrospective observational analysis of 3 months of adult patients discharged by the ABUHB PRU in 2020. ED database searches identified patients attending the ED within 7 days of discharge. Patients were contacted for a scripted telephone satisfaction survey and responses alongside demographics were analysed for associations with ED attendance through odds ratios (OR), relative risk (RR) and Pearson’s chi-squared tests.

Results/Conclusions

The 7-day ED attendance rate was 11.7% (12 out of 103 patients). Two thirds presented due to continued symptoms. Nine patients were admitted. Male sex was associated with an increased likelihood of ED attendance (OR=4.067, 95% CI 1.134–14.587, p=0.023) alongside being in the 40–50 and 51–61 age groups (RR 3.93; 95% CI 1.153–13.327 and RR 8.25; 95% CI 3.556–19.139 respectively). The modal satisfaction rating for overall experience with the PRU was ‘very satisfied’ but no association between satisfaction level and ED attendance was identified (p=0.210) despite a 94% response rate.

This study reinforces perceptions that the PRU is effective at delivering definitive care in the community whilst paving the way for future follow-up studies amongst other PRU services.
1060 All-cause presentations to emergency facilities in low-income and low-middle income Sub-Saharan African countries: a systematic review
Authors: Richardson Sarah , Luggya Tonny , Gray Alasdair , Grant Liz
Published: June 2022

Introduction

Emergency conditions constitute a large proportion of the total global burden of disease and annual global deaths. All 10 leading causes of death in LMICs are conditions which are amenable to emergency care. Much of the research performed in the sub-Saharan African region focuses on single disease processes or particular causations, giving a skewed impression of disease burden. The lack of comprehensive information concerning emergency care delivery has stalled attempts to improve emergency care systems in LMICs.

Objective

To understand the current evidence base available regarding the all-cause demographics, characteristics and epidemiology of patient presentations to an emergency setting within LMIC/LIC sub-Saharan African countries.

Methods

A systematic search was conducted on 23rd January 2020 of PubMed, Embase, Global Health and Google Scholar for peer reviewed literature published in English from January 2000 to January 2020 describing all-cause presentations at facility-based emergency care in Sub-Saharan LIC or LMIC countries. Articles were screened at title and full text level.

Results

19227 articles were screened at title level, 43 were screened at full-text level. 21 articles fit the inclusion criteria. Of 41 LMIC/LIC sub-Saharan African countries included, 31 were unrepresented due to lack of published data. Overall data quality was poor. Only 1 study fulfilled the suggested minimum core data set for emergency care surveillance. Outcome data was lacking or only partially reported in a number of papers. Chief complaints and disease categorisation reporting lacked a unified approach or reporting system making comparisons both within and between countries extremely challenging.

Conclusion

Despite considerable progress being made in recognising the need for integrated emergency care systems in all global regions, the data available to policy makers and system implementers remains sparse. This review demonstrates that critical investment is required to produce quality data from the current emergency systems in LMIC/LICs.
1042 Improving the accuracy of frontline clinicians in detecting SARS-COV-2 on chest X-rays using a bespoke virtual training platform
Authors: Bahra Jasdeep , Ather Sarim , Wilson Sarah , Keating Liza , Gulati Divyansh , Banerji Abhishek , Gleeson Fergus , Novak Alex
Published: June 2022

Aims/Objectives/Background

The non-specific symptoms of COVID-19 and the lack of a highly-sensitive point-of-care test make it difficult to reliably detect and diagnose in acute care settings. The early identification of COVID-19 using chest X-rays (CXR) in the Emergency Department (ED) is a crucial skill for frontline clinicians. We wanted to measure the accuracy of ED clinicians in detecting COVID-19 CXR changes and assess for improvement using an adaptive online learning module.

Methods/Design

ED clinicians working across five hospitals in the Thames Valley Emergency medicine Research Network (TaVERN) were recruited over six months. Participants’ reporting performance was assessed by interpreting 30 anonymised CXR via the Report and Image Quality Control (RAIQC) online platform, using an image bank which contained both COVID-19 and non-COVID-19 pathological findings. Participants subsequently completed an online training module, and repeated the assessment using different image sets. Diagnostic accuracy and speed of CXR reporting was assessed both before and after training, with results compared against radiologists. The ground truth for each case was established by consensus of three thoracic radiologists. RT-PCR results were reviewed for each case to ensure that all the COVID-19 cases were positive and all COVID-19 cases were negative.

Results/Conclusions

ED clinicians working in emergency departments across five hospitals in the Thames Valley Emergency Medicine Research Network (TaVERN) were recruited over a six month period. 112 clinicians completed the initial assessment. 56 clinicians completed all three training components. The initial mean accuracy for clinicians in identifying COVID-19 on chest X-rays was 43%. The mean accuracy was 57% amongst clinicians who completed all three online training components. These clinician showed improved reporting speed with mean time reduction to CXR interpretation from 69 to 50 seconds.

ED clinicians do not perform well at detecting COVID-19 CXR related changes on CXR, but accuracy and speed can be improved by online training.
1114 Neutrophil to lymphocyte ratio: An added outcome predictor in spontaneous intracerebral hemorrhage
Authors: Arun KT
Published: June 2022

ackground

Hemorrhagic stroke accounts for 10–15% of all types of strokes. It carries higher mortality and morbidity in comparison to ischemic stroke. Evidence suggests that inflammatory mechanisms are involved in the pathophysiology of brain injury due to intracranial hemorrhage. Peripheral blood neutrophil to lymphocyte ratio (NLR) has recently emerged as a reliable marker of subclinical systemic inflammation. The aim of this study was to explore the significance of Neutrophil to Lymphocyte ratio in the functional outcome of patients with hemorrhagic stroke.

Methods

Patients who presented to the Emergency Department with symptoms suggestive of stroke were evaluated with CT brain to identify hemorrhagic stroke. Patients with history of trauma, coagulopathy, fever or prior cerebrovascular accidents were excluded. The Modified ICH score and NLR were estimated at the time of admission. Functional outcome was assessed with Modified Rankin score after 3 months of initial presentation by telephonic conversation. A Modified Rankin score equal to or more than 3 was categorized as poor outcome group. Receiver operating curve (ROC) was used with NLR and Modified ICH score to analyze their influence in predicting poor functional outcome.

Results

A total of 158 patients were recruited for the study. After 3 months, 107 patients were identified as the poor outcome group as per their Modified Rankin score. The mean NLR and Modified ICH score at presentation were significantly higher for the poor outcome group (6.577 and 2.83) compared to the good outcome group (2.754 and 1.49) respectively with a p value of 0.001. The cut off value of 3.2 for NLR has a sensitivity of 75% and specificity of 70% to predict poor outcome.

Conclusion

In patients with hemorrhagic stroke, a higher Neutrophil to Lymphocyte ratio at presentation is associated with poor functional outcomes at 3 months.
798 Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study
Authors: Marincowitz Carl , Goodacre Steve , Stone Tony , Campbell Richard , Hasan Madina , Thomas Benjamin , Turner Janette , Pilberry Richard , Bell Fiona
Published: June 2022

Aims/Objectives/Background

To reduce the risk of spreading infection and hospitals being overwhelmed, on the 18thFebruary 2020, NHS England advised patients with suspected COVID infection to contact NHS 111 instead of attending health care providers. In March 2020, 3 million NHS 111 calls were made; a record number and double the number of the previous year. Concerns have been raised that telephone triage may not be sufficiently accurate in identifying need for emergency care.

We aim to assess accuracy of telephone triage in identifying patients who need emergency care amongst those with suspected COVID-19 and identify factors which affect triage accuracy.

Methods/Design

A cohort study of adults who contacted NHS 111 services provided by Yorkshire Ambulance Service between the 18thMarch 2020 and 29thJune 2020 with symptoms indicating possible COVID-19 infection was completed. Callers were linked to ONS death registrations and routine health care data collected by NHS Digital.

The accuracy of triage outcome (self-care/non-urgent assessment versus ambulance/urgent assessment) was assessed for death or organ support 30 days from first contact. Multi-variable logistic regression was used to identify factors associated with risk of false negative or false positive triage.

Abstract 798 Figure 1

STROBE flow diagram of study population selection

Abstract 798 Table 1

Performance of binary NHS 111 triage (ambulance or urgent assessment 4 hours or less) for composite outcome (death or organ support)

Adverse outcome up to 30 days(3%, 2.8-3.2%)N=40, 261Adverse OutcomeNo Adverse OutcomeAmbulance/urgent assessment89015, 035Sensitivity 74.2% (71.6- 76.6%)
Positive Predictive Value
5.6% (5.2 - 6%)Self-care/non-urgent assessment31024, 025Specificity 61.5% (61% - 62%)
Negative Predictive Value
98.7% (98.6 - 98.9%)

Results/Conclusions

3% of the 40,261 callers experienced an adverse outcome. Self-care/non-urgent assessment was recommended for 60%, with a small but non-negligible (1.3%) risk of subsequent deterioration. Triage achieved 74.2% sensitivity (95% CI: 71.6 to 76.6%) and 61.5% specificity (61% to 62%) for the primary outcome. Multivariable analysis suggested some co-morbidities (e.g. respiratory disease) may be over-estimated, and others (e.g. diabetes) underestimated, as predictors of deterioration. Repeat contact with services appears to be an important under recognised predictor of adverse outcomes with 2 contacts (OR 1.77 95% CI: 1.14 to 2.75) and 3+ contacts (OR 4.02 95% CI: 1.68 to 9.65) associated with clinical deterioration when not provided with an ambulance/urgent clinical assessment.
809 Survey of current and former academic clinical fellows in emergency medicine in the UK
Authors: Shanahan Thomas , Barrett Liam , Body Richard , Newcombe Virginia , Fish Rebecca , Jafar Anisa
Published: June 2022

Aims/Objectives/Background

Academic emergency medicine (EM) is a young field in the United Kingdom (UK) with a small critical mass of clinical academics, who have protected time to conduct research alongside clinical duties. There is a little published information on the academic training available to emergency physicians.

In the UK, academic clinical fellowships (ACFs) offer a structured opportunity for trainees to develop skills and experience in research alongside clinical training. We aimed to capture information on the prior experience of emergency medicine (EM) fellows, as well as how the ACFs were structured and the next career steps for fellows upon completion.

Methods/Design

A ten-question survey was designed by the project steering committee and circulated UK wide to all current fellows in EM and those that completed the programme in the last five years. Fellows were identified by contacting programme leads in every region. Data was collected via SurveyMonkey® between 18thFebruary 2021 and 25thMarch 2021.

Results

We approached a total of 34 EM ACFs. The survey yielded a 91% (n=31) response rate (13 current, 18 completed within 5 years). One university from Wales and ten from England have supported EM ACF schemes. 59% (n=10) of those who have completed the scheme had their clinical training extended to accommodate research time. In the remainder, fellows were expected to achieve clinical competencies in the same time as trainees who did not spend time on research. In those who had completed the ACF programme (n=18), one third of respondents are doing PhD training (n=6) and one is an academic clinical lecturer.

Conclusion

We found variation in how the schemes are implemented. Future research is required to explore the experiences of those undertaking EM ACFs in more detail to identify the features of successful ACF training schemes, and whether any aspects may benefit from standardisation.
775 Assessment of headache in the emergency department to rule out subarachnoid haemorrhage: a systematic review of diagnostic accuracy
Authors: Wade Ros , Walton Matthew , Harden Melissa , Hodgson Robert , Eastwood Alison , Storey James , Hassan Taj
Published: June 2022

Aims/Objectives/Background

Acute headache accounts for around 2% of Emergency Department attendances. Headache guidelines recommend non-contrast head computed tomography (CT) followed by lumbar puncture to exclude subarachnoid haemorrhage (SAH). Advances in imaging technology have led emergency physicians to question the necessity of routine lumbar puncture after negative CT. This systematic review assessed diagnostic strategies for neurologically intact headache patients.

Methods/Design

In February 2020, 18 electronic databases (including MEDLINE and Embase) were searched for studies of any clinical decision rule or diagnostic test for assessing neurologically intact severe headache patients, reaching maximum intensity within an hour. Studies were quality assessed using the QUADAS-2 tool. Diagnostic accuracy data were extracted into 2x2 tables to calculate sensitivity, specificity, false-positive and false-negative rates. Where appropriate, hierarchical bivariate meta-analysis was used to synthesise results.

Results/Conclusions

Thirty-seven studies were included. Eight studies assessing the accuracy of the Ottawa SAH clinical decision rule were pooled; sensitivity was 99.5%, specificity was 23.7%. Four studies (with neuroradiology expertise) assessing CT within six hours of headache onset were pooled; sensitivity was 98.7%, specificity was 100%. CT sensitivity beyond six hours was considerably lower (≤90%; 2 studies). Three studies assessing lumbar puncture (spectrophotometric analysis) following negative CT were pooled; sensitivity was 100%, specificity was 95.2%. LP-related adverse events were reported in 5.3–9.5% patients (2 studies).

The evidence suggests that the Ottawa Rule has limited value for ruling out SAH; the high false positive rate means that its use would potentially result in 76% SAH-negative patients undergoing further investigation with no additional benefit. Modern CT within six hours of headache onset (with images assessed by a neuroradiologist) is highly accurate and likely to be sufficient to rule out SAH. However, sensitivity reduces considerably over time. The CT-LP pathway remains a highly sensitive pathway for detecting SAH, although LP resulted in some false-positives and adverse events.
943 Creating and employing an admission bloods based diagnostic aide for COVID-19 to assist cohort-based isolation strategies
Authors: Baker Jacob , Day Sara , Marsh Adrian
Published: June 2022

Aims/Objectives/Background

In the COVID-19 pandemic the Shrewsbury and Telford Hospital NHS Trust has isolated suspected cases in high and low suspicion cohort bays to reduce nosocomial infection. Before rapid PCR swabs were in routine use, we sought tools to aide identifying COVID-19 positive patients.

Methods/Design

We collected data from two cohorts in April and June 2020 totalling 317 patients, with positivity rates of 33% and 5% respectively. We retrospectively correlated neutrophil count, lymphocyte count, LDH and AST to positive and negative swab results. Predictive value of COVID-19 positivity was assessed via their receiver operator characteristic. Areas under the curve were as follows: Neutrophils 0.75, lymphocytes 0.64, combined neutrophil and lymphocyte count 0.82, AST 0.65 and LDH 0.7.

We developed a diagnostic aide to assist in allocation of high and low suspicion based on parameters for neutrophil count, lymphocyte count and LDH, each of which was assigned red (higher probability) or green (lower probability) in a ‘traffic light’ system. Combined and applied retrospectively to 252 patients with suspected COVID-19, with a positivity prevalence of 5%, three green values generated a negative predictive value for COVID-19 of 100%, two greens 98% and three reds a positive predictive value for COVID-19 of 44%.

Abstract 943 Figure 1

Results/Conclusions

This diagnostic aide was applied from August 2020 within the Trust Emergency Departments and Acute Medical Units to aide cohort decisions. A retrospective application to all 213 patients with positive swabs admitted from August to November 2020 demonstrated that 69% were highlighted as at least two ‘red lights’ and only 1.4% were erroneously highlighted as three ‘green lights’. The aide is an example of a rapidly developed evidence based tool and, particularly if updated with data from other centres, could be widely employed in low-resource healthcare settings.
1023 Improving diagnosis and appropriate specialty referral with a syncope pathway
Authors: Biggers Richard , McIvor Aidan , Reed Matthew J , Thethy Ishwinder , Wojtowicz Martyna
Published: June 2022

Aims/Objectives/Background

Syncope is a common presentation to ED. Patients with an underlying cardiac cause have increased risk of adverse outcome. Initially, aetiology can be unclear leading to high admission rates and associated costs. In August 2018, a syncope pathway was introduced at the Royal Infirmary of Edinburgh (RIE) ED to aid diagnosis and direct patients to appropriate services. Our aim was to assess the impact of this pathway on syncope diagnosis, admission rates, patient outcomes and specialty input.

Methods/Design

A search of electronic patient records (EPR) eight months before and after the pathway’s introduction was conducted to identify patients presenting with ‘fainting episode +/- loss of consciousness’. EPR’s were reviewed and non-syncopal presentations excluded. Two reviewers consecutively sampled from both groups. Remaining patients had their EPR’s scrutinised to determine history, examination findings, immediate and 1-year outcomes and referrals to specialties.

Results/Conclusions

Our search identified 1055 pre-pathway and 1073 post-pathway patients. Following exclusion of non-syncopal diagnoses, 673 patients remained in the pre-pathway group and 480 in the post-pathway group. Consecutive sampling from these groups generated 199 patients pre-pathway and 102 patients post-pathway with a median age of 65 (range 13–100).

A greater proportion of patients were admitted or referred to outpatient services following the pathway’s introduction (46.1% versus 30.2%). Of these, 25.5% were referred to outpatient clinics compared to 20% pre-pathway. Of those admitted, 77.1% received specialty input related to their syncope compared to 25% in the pre-pathway group. After 1-year follow-up, 8.8% of patients had alternative diagnoses for their syncope compared to 2.5% pre-pathway. Post pathway, there were two syncope related deaths – both situational syncope causing falls.

Following the introduction of our syncope pathway there was no significant reduction in unscheduled care admissions. However, we have seen more specialty input and improved diagnosis with importantly, no significant increase in syncope related deaths.
766 How emergency physicians make their careers sustainable on the shop-floor and away from it: results from an ethnographic and interview-based study
Authors: Darbyshire Daniel
Published: June 2022

Aims/Objectives/Background

This study aims to understand how emergency physicians work sustainably in an increasingly challenging environment in the context of a retention crisis across all grades of emergency physician.

Senior clinicians provide better care in the emergency department; performing fewer unnecessary investigations, receiving fewer complaints and making fewer errors. Seniority is dependent on retention. Exodus from training and consultant grades is expensive.

The problems of staffing an emergency department has not been previously addressed by focusing on how those who work in them manage to do so.

Methods/Design

Ethnography conducted at a UK emergency department for 12-weeks, totalling nearly 200-hours of observation. A second site was planned but not possible due to COVID-19.

Interviews with emergency physicians of all grades from the two initially planned sites, with doctors who have left emergency medicine, and with individuals working for stakeholder organisations. 40 interviews in total, averaging 45 minutes.

Systematic scoping review of the relevant academic and policy literature.

Reflexive thematic analysis of the ethnographic field notes, interview transcripts and literature.

Results/Conclusions

Emergency physicians are active in managing their working day to mitigate the labour and environment. These actions have multiple overlapping motives but are demonstrably forms of retention work. They utilise objects and the environment in creative ways (materialities), for example completing paperwork in the resuscitation room because it is calm and air-conditioned.

They utilise humour in a primarily self-deprecating manner and prioritise education as a means of valuing other staff and creating variety in their workday. Emergency physicians describe teamwork as vital to retention, but this is disparate and developed over long periods of time and therefore better described ascommunity.

The principle sustainability strategies employed limit exposure to shop floor working. This is achieved through less-than-full-time working and portfolio careers. These strategies predate policy which describes them in terms of flexible working.
752 External validation of a novel TRIP (Cast) score to identify patients at risk of venous thromboembolism after temporary immobilisation for lower limb injury
Authors: Horner Daniel , Howard Stephanie , Campbell Michael , Collins James
Published: June 2022

Aims/Objectives/Background

Temporary immobilisation after lower limb injury incurs a significant risk of venous thromboembolism (VTE). These events are potentially preventable through patient education and risk based pharmacological thromboprophylaxis. Recent evidence has identified a potentially optimal risk assessment model, the TRIP (cast) score. We sought to evaluate the potential impact of implementation within a UK Emergency Department (ED).

Methods/Design

A retrospective cohort study, using prospectively collected routine data accessible through electronic health records. All ED patients with temporary lower limb immobilisation and documented VTE risk assessment during 2019 were included. TRIP (cast) scores were calculated retrospectively. Rapid case note review was undertaken to identify VTE, bleeding and mortality events up to 90 days post discharge. The project was formally approved as a service evaluation and had R&D oversight throughout (Ref: S21HIP25).

Abstract 752 Figure 1

Type of immobilisation applied (N=520)

Abstract 752 Figure 2

Diagnostic coding data (N=520)

Abstract 752 Figure 3

Frequency histogram of TRIP (Cast) scores (N=520)

Results/Conclusions

We identified 670 relevant ED patients with lower limb injury. We excluded all subsequent hospital admissions and patients already established on anticoagulation. 520 patients were included in the final dataset, with a mean age of 40.7 (SD 17.1) and a median ED stay of 170 minutes. Discharge diagnoses and immobilisation method are shown in figures 1 and 2.

89 (17.0%) patients were offered pharmacological thromboprophylaxis. No VTE events were recorded in this group. However, in 435 (83%) patients who did not receive prophylaxis, 5 VTE events were recorded, including 3 proximal thrombi. We found no evidence of major or clinically relevant non-major bleeding.

A frequency histogram of derived TRIP (Cast) score values is shown in figure 3. A threshold of ³6 for prophylaxis would result in 111 (21.1%) patients being offered prophylaxis, with all 3 of the proximal VTE events potentially prevented.

In conclusion, use of the TRIP (Cast) score in our ED population appears to outperform current risk assessment practice, at a small overall increase in the population eligible for prophylaxis.
1117 Early and delayed traumatic intracranial bleeding in the anticoagulated head injured patient: a systematic review and meta-analysis
Authors: O’Neill Gavin
Published: June 2022

Aims/Objectives/Background

Patients taking anticoagulant medication frequently attend the Emergency Department following head injuries. Whilst previously these patients were taking warfarin, they are now increasingly taking DOACs. Both classes of anticoagulant are believed to increase the incidence of traumatic intracranial haemorrhage (tICH). However, it is unclear whether DOACs confer the same risks as warfarin. There are also concerns that anticoagulated patients, who have had an initially normal CT scan, are at risk of delayed tICH.

This systematic review and meta-analysis compares the incidence of early and delayed tICH in patients attending the Emergency Department on DOACs and warfarin.

Methods/Design

A literature search was conducted using the Medline(OVID and PubMed), EMBASE, Web of Science and Cochrane libraries using defined keywords. Prospective studies and retrospective studies were included. The primary outcomes were the incidences of early and delayed tICH. Mortality rates were also assessed. Meta-analyses were performed to compare the rates of early and delayed tICH between the anticoagulant groups. The rates of injury were also compared to patients not receiving anticoagulation.

Results/Conclusions

The literature search found 42 relevant studies. Twenty three studies investigated the incidence of early tICH and 26 assessed delayed tICH. The pooled incidence of early tICH was 5.7% for DOACs and 7.3% for warfarin. Odds ratio for early tICH on DOACs was 0.47% (95% CI 0.34–0.66) when compared to warfarin and 0.96 (95%CI 0.68–1.36) compared to no anticoagulation. The incidence of delayed tICH was 1.2% for DOACs and 1.8% for warfarin (OR 0.70 (95% CI 0.38–1.31)). Odds ratio of mortality following a head injury on DOACs compared to warfarin was 0.4 (95%CI 0.17–0.94).

The systematic review and meta-analysis suggests the rate of early tICH and mortality may be lower for patients on DOACs as compared to warfarin. It also finds that the rate of delayed tICH bleeding is low in both groups.
925 Management of older major trauma patients: the impact on mortality since implementation of dedicated guidelines
Authors: Park Stephen , Hicks Derek , Smith Andrea , Kosuge Hannah , Cole Elaine , Woodgate Adam
Published: June 2022

Aims/Objectives/Background

Older trauma is an increasing challenge for trauma networks and many clinical protocols do reflect age-related changes in physiology and management. In 2018 older trauma guidance was introduced in our trauma system to improve early recognition of injury, admission pathways, clinical management and outcomes for those aged ≥65yrs (LMTS Older Trauma Guidance). The aim of our study was to assess the impact of the guideline on our trauma processes and patient outcomes.

Methods/Design

This retrospective analysis of TARN compared process and outcome data for patients aged ≥65yrs admitted to hospitals within the North East London and Essex Trauma Network, pre (01/01/2016–31/07/2018) and post (01/08/2018–31/07/2020) guidance introduction. The primary outcome was mortality at 30 days post injury.

Results/Conclusions

There were 4317 patients pre and 3992 patient post guidance. Time to CT reduced on average by 57 minutes, Neurotrauma transfers decreased from 2116 patients to 1519 patients and more older patients were discharged for rehabilitation. Older trauma mortality reduced across the network post guidance (13.59% vs 10.64%). The greatest mortality reductions were seen in Trauma Units, (19.20% pre vs 6.99% post) with increasing benefit seen with advancing age: reduced 75–84 years by 2.20%; 85–94 years 2.41%; 95+ years by 7.44%.

This analysis suggests that dedicated guidance highlighting the special needs and risk profiles of older trauma patients significantly improves processes and outcomes. Improvements in early assessment and time to imaging appear to result in enhanced survival. Further research at a system level is required.
1062 Disease burden, acuity and patient management in emergency care presentations to Ugandan facilities
Authors: Richardson Sarah , Luggya Tonny , Gray Alasdair , Grant Liz
Published: June 2022

Aims/Background

Emergency care is being provided to, and utilised by, Ugandan patients despite there being no formal system capable of producing optimal outcomes. For the country’s emergency care system to be appropriate and contextualised, there must first be an understanding of the actual utilisation of emergency care services. Current coding systems for analysing and comparing disease burden across sites do not adequately represent the patient population and resources required for quality emergency care to be delivered.

Objective

To describe the burden of disease, acuity and management of emergency patients presenting to secondary Ugandan health facilities.

Methods/Design

A retrospective review of 4704 emergency care patient charts from November 2018 to April 2019 was performed from 11 sites throughout Uganda. A novel diagnosis coding system was developed for use in LMIC emergency care context consisting of 482 codes, 158 sub-categories and 7 disease classes.

Results

6506 diagnoses were recorded, 34.98% of patients had 2 or more diagnoses. 33.8% were conditions of non-infective origin, 30.1% conditions of infective origin and 25.7% injury. Top 5 diagnoses were malaria, anaemia, pneumonia, head injury and soft tissue injury. Patient charts documented triage in 0.13% of cases, at least 1 vital sign in 42.3% of cases and at least 1 form of examination in 41.4% of cases. 62.3% patients had at least 1 form of investigation. 73.2% of patients received an IV treatment, most commonly antibiotics (52.5%) and IV crystalloids (33.1%).

Conclusion

This is the first study of all-cause disease burden and management of emergency patients presenting across multiple Ugandan facilities. The development and application of an emergency care specific diagnostic coding system applicable to LMICs is a vital step to enable understanding and comparison across facilities. By appreciating the burden of emergency care disease, strategies can be put in place to implement an integrated emergency care system in Uganda.
780 Treatment of life-threatening digoxin toxicity with digoxin immune fab antibody: findings from the UK DigiFab®patient registry
Authors: Thomas Emma , Tomlinson Sam , Thomas Siwan , Ward Suzanne , Daugherty Claire , Gallardo Eva , Hill Christon
Published: June 2022

Aims/Objectives/Background

Digoxin continues to play an important role in the management of atrial fibrillation (AF) and heart failure. Toxicity due to acute over-ingestion of digoxin is generally mild and manageable but can be life-threatening.1Digoxin immune Fab (DIF; DigiFab®) is the mainstay of treatment for life-threatening digoxin toxicity (LTDT). We report findings on efficacy and safety of DIF from the UK DigiFab Patient Registry.

Methods/Design

This prospective, observational study was a post-authorisation requirement from the MHRA. Physicians in all UK hospitals using DIF were invited to submit data for any patient who received DIF for LTDT. All AEs were followed-up according to Good Pharmacovigilance Practice.

Results/Conclusions

Between April 2012 and June 2017, 94 patients were enrolled; 10 were excluded (off-label DIF, n=2; outcome not recorded, n=8). Patients were typically elderly (mean: 81 years) and >80% cases involved chronic vs acute toxicity. Most frequently reported symptoms were bradycardia (74%), abnormal mental status/visual disturbance (40%), hyperkalaemia (33%) and gastrointestinal effects (32%). Other cardiac arrhythmias included 2nd/3rd degree heart block (19%), AF (13%), asystole (5%) and ventricular tachycardia (5%); 85% of patients experienced ≥1 arrhythmia. DT resolved in 57 (67.9%) and persisted in 24 (28.6%) patients at the time of reporting. For the remaining 3 (3.6%) patients, the recorded outcome was death. 7 patients reported adverse drugs reactions, including death (n=3) and AF, bradycardia, cardio-respiratory arrest, acute renal failure, cellulitis and hypoglycaemia (all n=1). No cause was reported/established for the 3 deaths and so these were conservatively assessed as possibly related to DIF but were most likely complications of underlying medical conditions. The results were consistent with earlier reports with digoxin-specific antibody Fab fragments,2with DIF highly effective in resolving LTDT in a real-world setting.

References

Gummin DD,et al. Clin Toxicol2020;58:1360–541.

Schaeffer TH,et al. J Am Osteopath Assoc2010;110:587–92.
797 Diurnal trends in medical student first responder availability and demand
Authors: Watson Adam
Published: June 2022

Aims/Objectives/Background

Medical Student First Responders (MSFRs) are volunteer Community First Responders, who respond to emergency calls and can provide life-saving interventions before the arrival of an ambulance. There is no data on diurnal trends in ambulance service demand for MSFRs, who do not typically work fixed shift patterns and therefore at present do not know when the most beneficial time of day to volunteer is. Thus, the aim of this service evaluation was to asses when demand for MSFRs is highest in central Oxfordshire and assess if MSFRs were available to respond at those times.

Methods/Design

All MSFRs shifts on a single Dynamic Response Vehicle between 1 October to 31 December 2020 were included. The MSFRs operated exclusively in central Oxfordshire (post codes OX1 – OX4) on behalf of South Central Ambulance Service. MSFR dispatch probability was calculated by comparing total time on duty (for each hour between 9 am – 1 am) with the respective number of incidents attended within that hour, and then plotted as a 3-point moving average against time. No patient data was collected.

Results/Conclusions

163 ‘on duty’ hours and 58 incidents (44% ‘Category 1’ responses, 88% MSFR first on scene) were included. There were clear diurnal trends in MSFR availability and demand (Abstract 797 figure 1). The probability of MSFR dispatch was highest at 56.3% between 6–7 pm; however, MSFRs were most likely to be available later in the day between 9–10 pm.

These findings suggest that the majority of MSFRs shifts occur at times when demand is relatively low. MSFRs are a highly flexible resource and should be encouraged to volunteer earlier in the day, as this would significantly improve coverage during the late afternoon when demand is greatest.

Abstract 797 Figure 1
784 The landscape of paediatric procedural sedation in UK & Irish emergency departments; a PERUKI study
Authors: Hall Dani , Moriarty Tadgh , O’Sullivan Ronan , Blackburn Carol , Roland Damian , Hartshorn Stuart , Messahel Shrouk , Lyttle Mark D
Published: June 2022

Aims/Objectives/Background

Approximately 250,000 children undergo paediatric procedural sedation (PPS) in UK and Irish emergency departments (ED) annually. In comparison to other countries, PPS practice in our setting has not been described. We therefore aimed to evaluate PPS practice in UK and Irish EDs.

Methods/Design

Online survey distributed through Paediatric Emergency Research in the UK and Ireland (PERUKI) during June 2020. One respondent per ED completed the survey, including questions on indications, agents, staffing and governance. Results are presented using descriptive statistics.

Results/Conclusions

61/72 (85%) sites responded, of which PPS was performed in 50 (82.0%). Intravenous ketamine was the most common agent (43/50; 86%), followed by fixed concentration nitrous oxide (FCNO, 35/50; 70%), and variable concentration nitrous oxide (VCNO, 13/50; 26%). PPS was mostly performed a few times a week (17/50; 34%) or daily (9/50; 18%). The most frequent indications were wound closure (31/50; 62%), orthopaedic reduction (28/61; 56%) and foreign body removal (17/61; 34%). Required sedationist seniority was highest for propofol and ketamine/es-ketamine (requiring consultant, registrar, or ANP), whilst FCNO was widely delivered by nurses and SHOs. Most sites had a guideline (43/61; 70.5%), documentation proforma (39/61; 63.9%) and equipment (36/61; 59.0%) and patient checklists (41/50; 82%). Explicit discharge criteria were required for ketamine/es-ketamine (40/45; 88.9%), midazolam (9/10; 90%), propofol (7/10; 70%) and VCNO (9/13; 69.2%). Databases existed in 24/61 (39.3%).

We have demonstrated wide PPS use, but non-standardised practice, with only two-thirds of sites using a PPS guideline and standardised proforma. This leads to potential issues of risk and variability, highlighting a need for a UK and Ireland sedation package to standardise PPS practice and data collection, informed by international guidance and evidence. We propose development of a prospective ED sedation registry to facilitate data collection to support research within this area.
Fuzzy logic applied in the prospecting of suitable areas for the establishment of commercial forest plantations
Authors: Ramalho Antonio Henrique Cordeiro , Fiedler Nilton Cesar , Santos Alexandre Rosa dos , Peluzio Telma Machado de Oliveira , Carmo Flávio Cipriano de Assis do , Silva Evandro Ferreira da , Maffioletti Fernanda Dalfiôr , Moreira Taís Rizzo , Lacerda Leonardo Cassani
Published: June 2022

Finding suitable areas for the establishment of commercial forest plantations is a crucial step towards the technical and financial viability of forestry enterprises. Thus, this study aimed to propose an alternative methodology to define areas with greater potential for the establishment of commercial forest plantations through the application of fuzzy logic. Edaphoclimatic zoning of the main forest genetic materials used in the state, land use classes, road networks, terrain slopes, and environmental regulation of rural properties was included in the modeling. In addition, a network analysis was applied to delimit the optimal transport radius. The results referring to the optimal areas for forest planting, according to the model, obtained an average of 80.39% assertiveness in the validation test in relation to areas already consolidated with forest plantations in the study area, demonstrating the potential of fuzzy logic to find areas favorable for future plantations, with low cost involved in prospecting areas. Therefore, it is concluded that the proposed methodology has high accuracy and low processing cost and can be used to improve planning. Its application can be expanded to other Brazilian regions as well as other countries.
Innate and adaptive immune cells associate with arteriovenous fistula maturation and failure
Authors: Samra Gunimat , Rai Vikrant , Agrawal Devendra K.
Published: June 2022

Creation of arteriovenous fistula (AVF) causes local injury, resulting in immune response of the body and infiltration of immune cells. Acute inflammation is favorable to control inflammation and proceed AVF toward maturation while chronic inflammation in AVF leads to AVF maturation failure. Chronic inflammation in AVF is due to chronic infiltration of immune cells and secretion of inflammatory cytokines. A balance between proinflammatory and anti-inflammatory response is a must for AVF maturation and an overwhelmed proinflammatory infiltrate causes chronic inflammation and AVF failure. As immune cell infiltration plays a critical role in maturation and failure of AVF, it is important to investigate the role of immune cells as well as their density in early and late phase of AVF maturation. The role of inflammation has been discussed in the literature and this review article focuses on the role of pro- and anti-inflammatory immune cells, including macrophages, dendritic cells (DCs), T-cells, and T-regulatory (Treg) cells in AVF maturation and maturation failure.
Considerations on combined-function optics for high-energy storage rings and colliders
Authors: Giovannozzi M.
Published: June 2022

In a recent paper, the proposal of using combined-function optics for the arcs of the Future Circular hadron Collider (FCC–hh) was presented and discussed in detail. In this paper, further considerations are presented on the same topic, reflecting the progress made since the previous publication. The studies presented here focus mainly on two aspects. Firstly, the layout of the combined-function periodic cell is optimised with the goal of fixing the number of main magnets. Secondly, possible layouts of the dispersion suppressor in the framework of this novel proposal for the optics of the arcs of the FCC hadron collider.
Gauge fixing and metric independence in topological quantum theories
Authors: Guadagnini Enore , Rottoli Federico , Thuillier Frank
Published: June 2022

In this paper, we consider topological gauge theories in three dimensions which are defined by metric independent lagrangians. It has been claimed that the functional integration necessarily depends nontrivially on the gauge-fixing metric. We demonstrate that the partition function and the mean values of the gauge invariant observables do not really depend on the gauge-fixing metric.
Geometric quantization: Particles, fields and strings
Authors: Berman David S. , Cardoso Gabriel
Published: June 2022

These notes present an introduction to the method of geometric quantization. We discuss the main theorems in a style suitable for a theoretical physicist with an eye towards the physical motivation and the interpretation of the geometric construction as providing a solution to Dirac’s axioms of quantization. We provide in detail the examples of free relativistic particles, their corresponding quantum fields, and the bosonic string using formalism of double field theory. This paper is based on lectures written by Gabriel Cardoso.
Deforming integrable models of AdS3 strings
Authors: Pawełczyk J.
Published: June 2022

In this paper, we discuss an integrable model of strings on [Formula: see text] in a thermodynamic bath. We show that scattering of the excitations above equilibrium states has some novel features. Thermodynamics points to interesting deformations of the original model for which we discuss finite-size effect through the mirror TBA equations.
Sulfur isotopes as biosignatures for Mars and Europa exploration
Authors: Moreras-Marti A. , Fox-Powell M. , Cousins C. R. , Macey M. C. , Zerkle A. L.
Published: June 2022

Sulfur (S) isotopes are used to trace metabolic pathways associated with biological S-cycling in past and present environments on Earth. These pathways (sulfate reduction, sulfur disproportionation and sulfide oxidation) can produce unique S isotope signals that provide insight into biogeochemical S-cycling. The S cycle is also relevant for extraterrestrial environments and processes. On early Mars, sulfur existed in different redox states and was involved in a large range of surface processes (e.g. volcanic, atmospheric, hydrothermal and aqueous brines). Sulfur compounds have also been detected on Europa's icy moon surface, with the S cycle implicated in Europa's surface and ocean geochemistry. Given the well-established utility of S isotopes in providing a record for past life on Earth, S isotopes are a valuable tool for identifying biosignatures on Mars and Europa. Here, we review S isotopes as a biosignature, in light of two recent advances in understanding the S cycle in both Mars and Europa: (1) the measurements of

δ

34
S
in situ
at Gale Crater and quadruple S isotopes (QSI) in Martian meteorites; (2) the identification of a likely exogenous origin of sulfur on Europa's surface. We discuss important considerations for unravelling QSI biosignatures in Martian environments, considering high- and low-sulfur environments, atmospheric mass-independent fractionation of sulfur isotopes (S-MIF) signals and metabolic energy-limited niches. For Europa, we describe the potential for S isotopes to probe biogeochemistry, and identify key knowledge gaps to be addressed to unlock S isotopic tools for future life detection efforts. The resulting picture demonstrates how S isotopes will be a valuable tool for Mars sample return, and how future missions can focus on the search for environments where QSI signatures of microbial S-cycling processes have a greater chance of being preserved. For Europa, the first step will be to account for the S isotope composition of the various S pools, to recognize or rule out non-biologically mediated S isotope values, with a focus on experimental examination of potential S isotope signatures from exogenous sulfur sources.

Thematic collection:
This article is part of the Sulfur in the Earth system collection available at:
https://www.lyellcollection.org/cc/sulfur-in-the-earth-system
A Look Behind the Curtain: Traffic Classification in an Increasingly Encrypted Web
Authors: Akbari Iman , Salahuddin Mohammad A. , Ven Leni , Limam Noura , Boutaba Raouf , Mathieu Bertrand , Moteau Stephanie , Tuffin Stephane
Published: June 2022

Traffic classification is essential in network management for operations ranging from capacity planning, performance monitoring, volumetry, and resource provisioning, to anomaly detection and security. Recently, it has become increasingly challenging with the widespread adoption of encryption in the Internet, e.g., as a de-facto in HTTP/2 and QUIC protocols. In the current state of encrypted traffic classification using Deep Learning (DL), we identify fundamental issues in the way it is typically approached. For instance, although complex DL models with millions of parameters are being used, these models implement a relatively simple logic based on certain header fields of the TLS handshake, limiting model robustness to future versions of encrypted protocols. Furthermore, encrypted traffic is often treated as any other raw input for DL, while crucial domain-specific considerations are commonly ignored. In this paper, we design a novel feature engineering approach that generalizes well for encrypted web protocols, and develop a neural network architecture based on Stacked Long Short-Term Memory (LSTM) layers and Convolutional Neural Networks (CNN). We evaluate our approach on a real-world web traffic dataset from a major Internet service provider and Mobile Network Operator. We achieve an accuracy of 95% in service classification with less raw traffic and smaller number of parameters, out-performing a state-of-the-art method by nearly 50% fewer false classifications. We show that our DL model generalizes for different classification objectives and encrypted web protocols. We also evaluate our approach on a public QUIC dataset with finer application-level granularity in labeling, achieving an overall accuracy of 99%.