bluuebunny/crossref_metadata_2025 huggingface dataset:
d
-Alanine Modification of a Protease-Susceptible Outer Membrane Component by the Bordetella pertussis
dra
Locus Promotes Resistance to Antimicrobial Peptides and Polymorphonuclear Leukocyte-Mediated Killing
Authors: Taneja Neetu Kumra , Ganguly Tridib , Bakaletz Lauren O. , Nelson Kimberly J. , Dubey Purnima , Poole Leslie B. , Deora Rajendar
Published: September 2013

Bordetella pertussis
is the causative agent of pertussis, a highly contagious disease of the human respiratory tract. Despite very high vaccine coverage, pertussis has reemerged as a serious threat in the United States and many developing countries. Thus, it is important to pursue research to discover unknown pathogenic mechanisms of
B. pertussis
. We have investigated a previously uncharacterized locus in
B. pertussis
, the
dra
locus, which is homologous to the
dlt
operons of Gram-positive bacteria. The absence of the
dra
locus resulted in increased sensitivity to the killing action of antimicrobial peptides (AMPs) and human phagocytes. Compared to the wild-type cells, the mutant cells bound higher levels of cationic proteins and peptides, suggesting that
dra
contributes to AMP resistance by decreasing the electronegativity of the cell surface. The presence of
dra
led to the incorporation of
d
-alanine into an outer membrane component that is susceptible to proteinase K cleavage. We conclude that
dra
encodes a virulence-associated determinant and contributes to the immune resistance of
B. pertussis
. With these findings, we have identified a new mechanism of surface modification in
B. pertussis
which may also be relevant in other Gram-negative pathogens.
Porins Increase Copper Susceptibility of Mycobacterium tuberculosis
Authors: Speer Alexander , Rowland Jennifer L. , Haeili Mehri , Niederweis Michael , Wolschendorf Frank
Published: September 2013

Copper resistance mechanisms are crucial for many pathogenic bacteria, including
Mycobacterium tuberculosis
, during infection because the innate immune system utilizes copper ions to kill bacterial intruders. Despite several studies detailing responses of mycobacteria to copper, the pathways by which copper ions cross the mycobacterial cell envelope are unknown. Deletion of porin genes in
Mycobacterium smegmatis
leads to a severe growth defect on trace copper medium but simultaneously increases tolerance for copper at elevated concentrations, indicating that porins mediate copper uptake across the outer membrane. Heterologous expression of the mycobacterial porin gene
mspA
reduced growth of
M. tuberculosis
in the presence of 2.5 μM copper by 40% and completely suppressed growth at 15 μM copper, while wild-type
M. tuberculosis
reached its normal cell density at that copper concentration. Moreover, the polyamine spermine, a known inhibitor of porin activity in Gram-negative bacteria, enhanced tolerance of
M. tuberculosis
for copper, suggesting that copper ions utilize endogenous outer membrane channel proteins of
M. tuberculosis
to gain access to interior cellular compartments. In summary, these findings highlight the outer membrane as the first barrier against copper ions and the role of porins in mediating copper uptake in
M. smegmatis
and
M. tuberculosis
.
Suicide and accidental deaths in children and adolescents in England and Wales, 2001–2010
Authors: Windfuhr Kirsten , While David , Hunt Isabelle M , Shaw Jenny , Appleby Louis , Kapur Nav
Published: September 2013

Objectives

To investigate the impact of narrative verdicts on suicide statistics among 10–19-year-olds; to identify the number and rate of suicide and accidental deaths, particularly in 10–14-year-olds.

Design

National cohort study.

Setting

England and Wales.

Methods

Mid-year population estimates from the Office for National Statistics (ONS) were used to calculate rates per 100 000 population for suicide (undetermined and suicide verdicts) and accidental deaths (poisoning, hanging) for those aged 10–14 and 15–19. Trends in rates over time (2001–2010) were investigated using Poisson regression. Interaction tests were carried out to determine differences in trends between the two time periods (2001–2005 and 2006–2010).

Results

There were 1523 suicides (2.25/100 000). Suicide rates were highest in those aged 15–19 years (4.04/100 000) and in males (3.14/100 000). Between 2001 and 2010, rates significantly decreased among those aged 15–19 years (incidence rate-ratio (IRR): 0.95; 95% CI 0.93 to 0.97), with no change in rates of accidental deaths (IRR: 1.01, 95% CI 0.95 to 1.07). However, there was a significant interaction between the two time periods for accidental poisonings (2001–2005: IRR: 0.79 (95% CI 0.69 to 0.91); 2006–2010: IRR: 1.01 (95% CI 0.89 to 1.15), interaction p=0.012) and accidental hangings (2001–2005: IRR: 0.93 (95% CI 0.76 to 1.14); 2006–2010: IRR: 1.25 (95% CI 1.04 to 1.49), interaction=0.01) Undetermined deaths significantly decreased among females aged 15–19 yeras (IRR: 0.93; 95% CI 0.88 to 0.98). There were no significant trends among 10–14-year-olds.

Conclusions

Rates of suicide are higher among older adolescents and males. There was a significant fall in suicide rates in males aged 15–19 years that was not accounted for by changes in rates of accidental death. The absence of a significant trend in suicide or accidental deaths in those aged 10–14 years may have been the result of small numbers. However, monitoring should continue to identify longitudinal trends in all young people.
Aneurysmal bone cyst of temporal bone
Authors: Ansari Sajid , Ahmad Kaleem , Gupta Mukesh Kumar , Rauniyar Raj Kumar
Published: September 2013

Aneurysmal bone cysts (ABC) are benign neoplasms frequently occurring in the long tubular bones. It is very rare in temporal bone. We report a case of ABC of the left temporal bone in an 8-year-old Asian boy who presented clinically with swelling over the left temporal region for 5 months. CT and MRI features were suggestive of ABC. Surgical resection was performed and on follow-up the patient was doing well. CT and MRI are the imaging modalities for proper evaluation of ABC, aiding to diagnosis and helpful in treatment planning.
Bilateral femoral fractures in a 21-year-old man following a simple fall
Authors: French Rachel , Oweis Deyana , Kurup Vijay
Published: September 2013

We present a case of a 21-year-old man with hip pain to the orthopaedic team. During the initial assessment he was found to be hypercalcaemic (adjusted calcium 3.55) due to the primary hyperparathoidism (PTH 1285), with all other screening for multiple endocrine neoplasia negative. During his time on the ward while being treated for the hypercalcaemia he had a fall resulting in bilateral femoral fractures, requiring surgical management. He underwent an emergency exploration of neck and excision of a large parathyroid adenoma, measuring 5.5 cm. He also developed renal failure as a result of nephrocalcinosis. This case highlights the importance of early detection and management of hyperparathyroidism with the aim of preventing long-term complications. This patient ultimately required a renal transplant and multiple orthopaedic procedures as a result of undiagnosed PTH and recently underwent excision of the remaining parathyroid glands.
Progressive external ophthalmoplegia (PEO) due to a mutation in theC10orf2(PEO1) gene mimicking a myasthenic crisis
Authors: Gonzalez-Moron Dolores , Bueri Jose , Kauffman Marcelo Andres
Published: September 2013

We described a case of a patient with autosomal dominant progressive external ophthalmoplegia (PEO) who presented with the acute onset dysphagia, quadriparesis, ptosis and respiratory insufficiency following a cardiac procedure and mimicking a myasthenic crisis. A pathogenic mutation in theC10orf2(PEO1) gene was confirmed. The unusual presentation of our patient contributes to expand the clinical phenotype of PEO1 mutations and reinforces the need to consider mitochondrial myopathy as differential diagnosis of myasthenia gravis even in the case of acute onset symptoms.
Bilateral optic neuropathy in a patient with familial amyloidotic polyneuropathy
Authors: Hamann Steffen , Jensen Peter Koch , Fledelius Hans Callø
Published: September 2013

Amyloidogenic transthyretin (ATTR)-related familial amyloidotic polyneuropathy (FAP) is an autosomal-dominant hereditary disease characterised by slowly progressive peripheral sensorimotor and autonomic neuropathy and tissue involvement of the heart, kidneys and central nervous system. Secondary glaucoma has been reported following intraocular surgery, but optic nerve involvement unrelated to glaucoma has not previously been described. We reported a male patient in his late 40s when deceased, who previously had a liver transplant in order to reduce the abnormal protein synthesis underlying his FAP ATTR Val30Met mutation. After 11 years of ophthalmic follow-up best-corrected visual acuity was 20/100 in his seeing eye, which further had visual field findings suggestive of optic neuropathy. This was also the diagnosis underlying the preceding insidious full loss of vision in the fellow eye, with colour Doppler imaging to support an ischaemic aetiology. To our knowledge, this is the first report of ischaemic optic neuropathy in this familial amyloid disorder.
Hutch diverticulum presenting as acute urinary retention in early life
Authors: Singh Bhupendra Pal , Nagathan Deepak Sharanappa , Sankhwar Satyanarayan , Yadav Rahul
Published: September 2013

There are only a few reports of recurrent acute urinary retention caused by obstruction from congenital paraureteral diverticulum. We review the literature and present a case of a 14-month-old boy with bilateral hutch diverticuli who had his first episode of acute urinary retention in the neonatal period caused by left-sided diverticulum. We emphasised the fact that hutch diverticulum should be considered as one of the possible differential diagnoses in a child presenting with acute urinary retention.
The prevalence, variety and impact of wrist problems in elite professional golfers on the European Tour
Authors: Hawkes Roger , O'Connor Phil , Campbell Doug
Published: September 2013

Objectives

Golf is a popular sport played by an estimated 57 million people. Previous studies on wrist injuries in elite golfers have been of simple design and have demonstrated such injuries to be frequent, although no studies report the incidence, variety, severity or impact on the activity of wrist injuries in detail. This prospective cross-sectional study assesses these factors in a cohort of elite professional golfers.

Methods

European Tour golfers eligible to compete at the 2009 BMW PGA Championship at Wentworth were studied. Study design involved the completion of a structured questionnaire supplemented by interview and examination when required, with performance statistics provided by the European Tour. The severity of injury was assessed by the number of missed tournaments and the amount of time of missed practice.

Results

128 of 153 eligible golfers, (84%) completed the study with 38 golfers (30%) reporting 43 problems. The majority of injuries (67%) occurred in the leading wrist at the most common location, the ulnar side of the wrist (35%). 87% of all ulnar-sided and 100% of radial-sided problems were in the leading wrist.

Conclusions

There were clear side differences reported by the players with the lead wrist demonstrating much higher injury rates in all areas. The most significant injury, in terms of absence from competition, was extensor carpi ulnaris tendon subluxation. Specific injuries are explained in relation to the biomechanics of the golf swing. Most structural injuries have a specific treatment and rehabilitation plan, which can involve significant periods of time away from the sport, while the management of many of the more minor problems is through alterations in technique or practice regimes, aiming to keep a golfer playing during recovery.
Effects of telephone health mentoring in community-recruited chronic obstructive pulmonary disease on self-management capacity, quality of life and psychological morbidity: a randomised controlled trial
Authors: Walters Julia , Cameron-Tucker Helen , Wills Karen , Schüz Natalie , Scott Jenn , Robinson Andrew , Nelson Mark , Turner Paul , Wood-Baker Richard , Walters E Haydn
Published: September 2013

Objectives

To assess benefits of telephone-delivered health mentoring in community-based chronic obstructive pulmonary disease (COPD).

Design

Cluster randomised controlled trial.

Setting

Tasmanian general practices: capital city (11), large rural (3), medium rural (1) and small rural (16).

Participants

Patients were invited (1207) from general practitioner (GP) databases with COPD diagnosis and/or tiotropium prescription, response rate 49% (586), refused (176) and excluded (criteria: smoking history or previous study, 68). Spirometry testing (342) confirmed moderate or severe COPD in 182 (53%) patients.

Randomisation

By random numbers code, block stratified on location, allocation by sequentially numbered, opaque and sealed envelopes.

Intervention

Health mentor (HM) group received regular calls to manage illness issues and health behaviours from trained community health nurses using negotiated goal setting: problem solving, decision-making and action planning. Control: usual care (UC) group received GP care plus non-interventional brief phone calls.

Outcomes

Measured at 0, 6 and 12 months, the Short Form 36 (SF-36) and St George’s Respiratory Questionnaire (SGRQ, primary); Partners In Health (PIH) Scale for self-management capacity, Hospital Anxiety and Depression Scale (HADS), Center for Epidemiologic Studies-Depression (CES-D) questionnaire, Post-Traumatic Stress Disorder Checklist, Satisfaction with life and hospital admissions (secondary).

Results

182 participants with COPD (age 68±8 years, 62% moderate COPD and 53% men) were randomised (HM=90 and UC=92). Mixed model regression analysis accounting for clustering, adjusting for age, gender, smoking status and airflow limitation assessed efficacy (regression coefficient, β, reported per 6-month visit). There was no difference in quality of life between groups, but self-management capacity increased in the HM group (PIH overall 0.15, 95% CI 0.03 to 0.29; knowledge domain 0.25, 95% CI 0.00 to 0.50). Anxiety decreased in both groups (HADS A 0.35; 95% CI −0.65 to −0.04) and coping capacity improved (PIH coping 0.15; 95% CI 0.04 to 0.26).

Conclusions

Health mentoring improved self-management capacity but not quality of life compared to regular phone contact, which itself had positive effects where decline is generally expected.
THE 3MG TRIAL: A RANDOMISED CONTROLLED TRIAL OF INTRAVENOUS OR NEBULISED MAGNESIUM SULPHATE VERSUS PLACEBO IN ADULTS WITH SEVERE ACUTE ASTHMA
Authors: Gray A , Goodacre S , Cohen J , Braidburn M , Benger J , Coats T
Published: September 2013

Objectives & Background

Previous studies suggest intravenous or nebulised magnesium sulphate may improve respiratory function in patients with acute asthma. We aimed to determine whether intravenous or nebulised MgSO4improve symptoms of breathlessness and reduce the need for hospital admission in adults with severe acute asthma.

Methods

In a double-blind, placebo-controlled trial, we enrolled adults with severe acute asthma at emergency departments of 34 UK hospitals. We excluded patients with life-threatening features. Allocated participants received IV MgSO4(2 g in 20 min) or nebulised MgSO4(3×500 mg doses in 1 h)+standard therapy, or placebo+standard therapy. We assessed two primary outcome measures in all participants according to treatment group: the proportion of patients admitted to hospital within 7 days and breathlessness measured on a 100 mm VAS in the 2 h after initiation of treatment. We adjusted for multiple testing. Study registration no:ISRCTN04417063.

Results

1109 patients were recruited (Jul 2008 to Jun 2012). 261 (79%) of 332 patients allocated nebulised MgSO4were admitted to hospital, as were 285 (72%) of 394 patients allocated intravenous MgSO4and 281 (78%) of 358 controls. Breathlessness was assessed in 296 (89%) patients allocated nebulised MgSO4, 357 (91%) patients allocated intravenous MgSO4, and 323 (90%) controls. Rates of hospital admission did not differ between patients treated with either form of MgSO4compared with controls or each other. Change in VAS breathlessness did not differ between active treatments and control, but change in VAS was greater for patients in the intravenous MgSO4group than the nebulised MgSO4group (5.1 mm, 0.8 to 9.4; p=0.019). Intravenous or nebulised MgSO4did not significantly decrease rates of hospital admission and breathlessness compared with placebo: intravenous MgSO4was associated with an odds ratio of 0.73 (95% CI 0.51 to 1.04; p=0.083) for hospital admission and a change in VAS breathlessness of 2.6 mm (−1.6 to 6.8; p=0.231) compared with placebo; nebulised MgSO4was associated with an odds ratio of 0.96 (0.65 to 1.40; p=0.819) for hospital admission and a change in VAS breathlessness of −2.6 mm (−7.0 to 1.8; p=0.253) compared with placebo.

Conclusion

These data suggest nebulised MgSO4has no role in the management of severe acute asthma in adults and at best suggest only a limited role for intravenous MgSO4in the ED.
CAN AMBULANCE DATA BE USED TO REDUCE COMMUNITY VIOLENCE? EXPLORATORY RECORD LINKAGE STUDY
Authors: Boyle A , Ariel B , Weinborn C
Published: September 2013

Objectives & Background

Emergency Department information sharing with Community Safety Partnerships and the Police is well established, Emergency Department Data about the location, time of assault and weapon type is shared with the police to support targetted policing and licensing decisions. It is not established whether ambulance data, which routinely collects automated location and time data, provides additional information to police and emergency department data. We aimed to find out what proportion of ambulance call outs to assault was not recorded by the police or the emergency department services.

Methods

We compared routine, anonymous aggregate data from the police and ambulance service about calls for service to violent crime in Peterborough, England in 2011–2012. We used two methods of identifying matches. The first is ‘hotspotting' which uses spatio-temporal methods to identify clusters. The second is by manually matching individual cases in time and location.

Results

775 calls for service were made to the ambulance service to victims of assault. 347 (49%) of these cases were transported to hospital. 3,997 calls for police service to victims of violence were made in the same time period. The demographic and temporal characteristics of the two lists were similar. Between 125 and 204 cases could be matched, depending on case definition.

Conclusion

The ambulance service is responding to many victims of community violence that are not recorded by the police and probably not recorded by the emergency department. Ambulance data has potential to inform licensing and targetted policing. It is not proven whether this will reduce community violence.
DEATH AND SERIOUS INJURY CAUSED BY STABBING IN ENGLAND AND WALES 2000–2010
Authors: Davies M , Lecky F
Published: September 2013

Objectives & Background

Following a spate of high profile murders there is concern that injuries and deaths caused by knives is increasing in England and Wales, especially within the teenage population. Excluding police and Home Office statistics, there are few UK studies examining Emergency Department data.

Methods

A retrospective analysis was performed of stab injuries from the Trauma Audit and Research Network (TARN) database (2000-2010), the largest national registry of serious injuries. Data were analysed to determine temporal trends in the prevalence of stab injuries and demographic characteristics of those injured. The UK Office of National Statistics provided data on deaths by stabbing.

Results

Of 102,562 cases in the TARN database, 3052 (3%) were due to stabbing. There were 2755 men and 297 women with a median age of 28 and 33 years respectively. The median NISS was 18 with a mortality rate of 6.5% in men and 7.7% in women. The highest rate of stabbings as a proportion of all injuries was submitted from London (7.8%), with the South East submitting the least (1.5%). 92% resided in urban areas, 90% were due to assault and 36% presented to the ED between 00.00-08.00. Following a peak in the middle of the decade, serious stab injuries are falling. ONS data recording death from stabbing also follows this pattern, mainly due to a fall in homicides.

Conclusion

Both from TARN and ONS data, the rate of death and serious injury from stab wounds rose in the middle of the last decade but since 2006 is falling. Stabbings account for a low proportion of overall injury deaths and hospitalised trauma patients. The vast majority are due to assault and affect young men in urban areas, particularly London, the North East and the North West. Accidental death from stabbing is rare although suicide using sharp implements, particularly amongst older men, is perhaps more common than previously thought.
PREDICTION OF UNSUCCESSFUL TREATMENT IN PATIENTS WITH SEVERE ACUTE ASTHMA: AN ANALYSIS FROM THE 3MG TRIAL
Authors: Gray A , Goodacre S , Braidburn M , Cohen J , Benger J , Coats T
Published: September 2013

Objectives & Background

Clinical assessment can be used to identify which patients with acute asthma are at risk of unsuccessful initial treatment. We aimed to determine, using data from the 3MG trial, which elements of clinical assessment predict unsuccessful treatment, defined as needing critical care or any unplanned additional treatment.

Methods

We analysed data from a large multicentre trial (the 3Mg trial). Adults with severe acute asthma underwent standardised clinical assessment, including peak expiratory flow rate (PEFR), up to two hours after initiation of treatment. Standard care was provided other than blinded random allocation to trial treatment or placebo. Patients were followed up by record review up to 30 days. Unsuccessful treatment was defined as needing (1) critical care or (2) critical care or any unplanned additional treatment within seven days of presentation. Logistic regression was used to identify predictors and derive a prediction model for each outcome.

Results

Out of 1084 patients analysed, 81 (7%) received critical care and 157 (14%) received critical care or unplanned additional treatment. Baseline PEFR (p=0.017), baseline heart rate (p<0.001), other serious illness (p=0.019), PEFR change (p=0.015) and heart rate change (p<0.001) predicted need for critical care. Baseline PEFR (p=0.010), baseline heart rate (p<0.001), baseline respiratory rate (p=0.017), other serious illness (p=0.023), PEFR change (p=0.003) and heart rate change (p=0.001) predicted critical care or additional unplanned treatment. Models based on these characteristics had c-statistics of 0.77 and 0.69 respectively.

Conclusion

PEFR, heart rate and other serious illness are the best predictors of unsuccessful treatment, but models based on these variables provide only modest predictive value.
EMERGENCY CARE HANDOVER (ECHO STUDY) ACROSS CARE BOUNDARIES–THE NEED FOR JOINT DECISION-MAKING AND CONSIDERATION OF PSYCHOSOCIAL HISTORY
Authors: Sujan M , Chessum P T , Rudd M , Fitton L , Inada Kim M , Spurgeon P , Cooke M W
Published: September 2013

Objectives & Background

Handover in emergency care is an important patient safety issue and has particular problems due to different environmental, professional, organisational and cultural backgrounds. Previous work as focussed on the standardisation of handover content (including use of checklists), relatively little is known about the verbal behaviours that shape handover conversations. This study looks at both the content of the handover and the verbal behaviours during different types of handovers around the emergency department.

Methods

Three handovers were studied: ambulance service to ED in ‘Resuscitation’ and ‘Majors’ areas and referrals to acute medicine. They were audio recorded in three NHS emergency departments. Handover conversations were segmented into utterances. Frequency counts for content and language forms were derived for each type of handover using Discourse Analysis. Verbal behaviours were identified using Conversation Analysis.

Results

203 handover conversations were analysed. Handover conversations involving ambulance services were mainly descriptive (60%–65% of utterances), unidirectional and focused on patient's clinical presentation (75%–80%). Referrals entailed more bidirectional conversation focused on the decision to admit and immediate care needs. Across all types of handover, only 1.5%–5% of handover conversation content related to the patient's social and psychological status and needs.

Conclusion

Handover may entail both descriptive (aimed at information transfer) and collaborative (aimed at joint decision-making) elements. Standardisation of handover needs to accommodate collaborative aspects with their greater variability according to the individual situation, and should incorporate communication of information relevant to the patient's social and psychological needs to establish appropriate care arrangements at the earliest opportunity.
ALCOHOL ATTENDANCE WITHIN THE EMERGENCY DEPARTMENT
Authors: Kelly G , Crick J , Hall T
Published: September 2013

Objectives & Background

How much does alcohol contribute to the demands on the Emergency Department (ED)? York is a popular tourist destination, particularly amongst hen and stag parties. But a quarter of the resident population have previously been identified as higher risk drinkers. So therefore, how much does alcohol contribute to the pressures on York ED? Additionally, clinical coding of alcohol within the ED is anecdotally unreliable. How true is this? We therefore undertook an alcohol needs assessment within York ED looking at general demographics, reasons for attendance and evidence of alcohol linked to the attendance. We also looked at the discrepancy between how much the ED was paid for these patients by commissioners and the actual cost to the acute trust.

Methods

We randomly selected 1 week per quarter in 2011 and hand searched every ED record for evidence of alcohol-related attendance. We also included patients for whom it was felt alcohol was highly likely although not directly mentioned. We undertook a concordance assessment around the alcohol question and achieved 94%.

Results

The 4 randomly selected weeks amounted to a 5,704 patient sample, 7.2% of the total number of attendances in 2011.

9.8% of attendances were alcohol-related (553 patients)

Between 21:00 and 09:00, this rose to 19.7%

Alcohol was involved in 45% of mental health attendances

The alcohol group was heavily over-represented in the patients removed by police (100%), refusing treatment (55%) and leaving prior to their treatment (41%)

10.3% of alcohol-related attendees remained in the ED for >4hours compared with 5.9% of non-alcohol-related attendees

62.8% of alcohol-related attendees were living within the City of York

18% of all ambulance journeys were due to alcohol

Although 553 patients had evidence of alcohol in their attendance, it was only coded as such in 46 computer records

If these figures are extrapolated to cover the annual patient population, the discrepancy between what the commissioners pay and the true cost of these patients is £552,431

Conclusion

Alcohol poses a disproportionate burden on York Emergency Department and Yorkshire Ambulance Service. With pressures on staffing, the 4 hour standard and ambulance turnaround times at an all-time high, how different would the ED be if the alcohol burden were reduced? This needs assessment fuels the argument for an 'invest to save' attitude to reduce alcohol-related attendance.
A PILOT PROJECT TARGETING FREQUENT ATTENDERS AT THE EMERGENCY DEPARTMENT WITH MEDICALLY UNEXPLAINED SYMPTOMS
Authors: Baker M , Stallard J , Gibson S
Published: September 2013

Objectives & Background

We identified that there is a cohort of people who attend our Emergency Department (ED) extremely frequently (>24 times per year) or who have frequent admissions (>12 per year). Analysing hospital clinical records identified that in many cases medically unexplained symptoms (MUS) drive the frequent presentation. The needs of these patients were not being met by a traditional dualistic approach in which people are seen in either physical or mental health settings. Indeed, despite frequent medical investigations/treatments, their symptoms persist, their problems are not resolved, they frequently complain and they keep coming back. This carries risk and distress for the patients, and heavy use of resources for the hospitals involved.

Methods

Each month we looked at attendance data for the previous 3 months (this identified people who in an acute phase of repeat presentations). By accessing patients clinical records we determined the main factors which appeared to drive their frequent attendance and admissions and identified those who presented with MUS. Care plans were developed and each patient was contacted and offered weekly Cognitive Behavioural Therapy (CBT) sessions to help them manage their symptoms. This was part of a case management approach in which coordinated, multidisciplinary reviews were undertaken resulting in an individualised care plan.

Results

Thus far the pilot has seen a reduction in attendances at ED for 100% of patients included in study (N=20). Crucially, all now attend less than once per month. In total 245 attends were saved after the CBT interventions

Conclusion

Providing a psychological intervention to this patient cohort is effective in reducing hospital costs by containing the most frequent attenders. CBT and care plans have reduced attendance to under once per month and subsequently reduced medical interventions and prescribing costs.
LYRICA NIGHTS–RECREATIONAL PREGABALIN ABUSE IN AN URBAN EMERGENCY DEPARTMENT
Authors: Millar J , Sadasivan S , Weatherup N , Lutton S
Published: September 2013

Objectives & Background

Since ‘legal highs' emerged as drugs of abuse in the UK, Emergency Physicians have battled to keep up with the latest drug craze. Whilst many of these drugs present with recognisable toxidromes, the effect of new compounds or medications cannot be readily predicted. In Belfast, we have witnessed a recent increase in the number of patients presenting after recreational abuse of Pregabalin (Lyrica). Patients, state that the medication induces a state similar to drunkenness, hence the street name ‘Budweiser's’. To our knowledge this is the first case series detailing the recreational abuse of Pregabalin, a drug which has become popular in primary care.

Methods

We conducted a one year review of all patients presenting to our department after recreational drug abuse. Those who admitted to Pregabalin usage were identified and case notes were reviewed.

Results

Between 02/12–02/13, 10 patients presented to our ED following recreational Pregabalin abuse. All were aged between 20 and 35 years of age. Dosages ranged from 500–1400 mg. Six patients presented with seizures (5 of which were ‘first' seizures). Two patients required intubation and ventilation and were admitted to the ICU. In total, nine patients were admitted for a minimum of 24 hours, whilst one patient discharged against advice.

Conclusion

Emergency Physicians should be aware of the current use of Pregabalin as a recreational drug. Patients are either taking tablets whole or cutting and snorting them. 60% of patients in this case series presented to the ED with seizures and 20% required ICU admission. We recommend that patients who present with potential Lyrica toxicity should be admitted for observation with the treating physician being mindful of the potential for seizure activity.
TACKLING KNIFE CRIME–A JOINT VENTURE BETWEEN ED AND POLICE IN REDBRIDGE TO IDENTIFY PATTERNS OF ATTENDANCE OF DOMESTIC VIOLENCE VICTIMS
Authors: Ahsan S , Leung J Y , Hicks D
Published: September 2013

Objectives & Background

Redbridge Tackling Knife Crime Programme was an initiative run between Redbridge Safer Communities Partnership, a London-based police force and Barking, Havering and Redbridge University Hospital Trust. It comprised of data collection resulting in the analysis of types of assault, locations, demographics of both assailant and victim and were police informed. Domestic violence (DV) was identified as a category of assault. The inspiration came from the 1996 ‘Cardiff-model’–the Violence Prevention Group shared ED assault data with its police force. The outcome led to enhanced effectiveness of the police in managing alcohol-related violence. The TKAP aim is it identify DV locations and patterns, otherwise unknown to police by improved intelligence gathered through ED data. As a result police deployment can reflect areas of need and allow police to compare their own figures allowing a more informed service for DV victims.

Methods

The patient recording system, Symphony, was adjusted to accommodate data vital for intelligence gathering. Parameters recorded included arrival in ED, assault date and time, location, were the police called, number of attackers, relationship to the victim, body part assaulted, object if any used, or body part and was this a repeat assault. If the assailant was either a family member, spouse or partner the assault is identified as DV.

Results

The 10-month data collection identified 221 patients as DV out of the 2011 total figure of assault victims from TKAP. ED data showed 66% were female and 24% were male, differing from police data which shows 83% as female. The majority of females were aged 18–44 years at 74%, with males aged 35–59 years at 58% and 29% between 1–25 years. For both male and female, 5% were under 16 years old.

Conclusion

Data identified a significant number of female assault patients who were DV victims were repeat victims and had not called the police. Overall figures acknowledged some DV victims treated in ED were not involved in the data collection. This is attributed to the victim refusing to implicate the assailant. Those that participated had the most significant injuries–suggesting they were subject to extended cycles of abuse and were reaching out for help.

Results

will be used to implement police enforcement activities and prevention work, hence improving safe-guarding.
THE ANTICOAGULATION OF CALF THROMBOSIS (ACT) PROJECT: RESULTS FROM THE RANDOMISED CONTROLLED EXTERNAL PILOT TRIAL
Authors: Horner D , Hogg K , Body R , Nash M J , Mackway-Jones K
Published: September 2013

Objectives & Background

There is currently little evidence defining the clinical importance of detecting and treating isolated distal deep vein thrombosis (IDDVT). Contemporary international guidelines vary regarding diagnostic and therapeutic advice. The potential benefits of anticoagulation remain poorly defined. We sought to evaluate the feasibility of a randomised controlled trial within a modern emergency department cohort.

Methods

A pragmatic, open label, external pilot randomised controlled trial conducted from January 2011 to April 2012. Consecutive ambulatory symptomatic IDDVT patients were approached for inclusion. Participants were randomised to receive either conservative management (control) or phased therapeutic anticoagulation (intervention). All patients underwent assessor blinded color duplex imaging after 7 and 21 days, and clinical follow up at three months. Principal feasibility outcomes were recruitment rate and attrition. The primary clinical outcome was a composite of proximal propagation, pulmonary embolism, death attributable to venous thromboembolic disease or major bleeding. Analysis was by intention to treat.

Results

Acute IDDVT was detected in 93 cases. 79 were subsequently deemed eligible and 70 (88.6% of those eligible) recruited. 59/70 (84.3%, 95% CI 74.0–91.0%) patients completed the full protocol. All patients but 1 were followed up by direct contact after 90 days. Allocation crossover occurred in 15 (21.4%) cases. All predefined feasibility outcomes were achieved. The primary clinical outcome occurred in 4/35 (11.4%) controls and 0/35 in the intervention group (Absolute Risk Reduction [ARR] 11.4%, 95% Confidence Interval [CI] −1.5 to 26.7, p=0.11, number needed to treat [NNT] of 9). There were no cases of major bleeding in either group. Propagation to any site occurred in 11/35 (31.4%) of conservatively treated patients compared with 2/35 (5.7%) of those randomized to anticoagulation (ARR 25.7%, 95% CI 5.9 to 44.3%, P=0.001, NNT 4). Minor bleeding occurred in 3/35 (8.6%) controls and 7/35 (20.0%) anticoagulated patients (p=0.31).

Conclusion

We have established feasibility for a definitive trial on the value of therapeutic anticoagulation for IDDVT. Our pilot study currently provides the largest prospective randomised clinical dataset on this topic and demonstrates a non-significant trend towards reduction in complications with anticoagulation.
FRACTURE PATHWAY REDESIGN IMPROVES EMERGENCY DEPARTMENT EFFICIENCY
Authors: Vardy J , Rymaszewski L , Begbie K , Anthony I , Chekroud M , Clark K , Ireland A J
Published: September 2013

Objectives & Background

The Redesigned Fracture Pathway has revolutionised fracture management, decreased orthopaedic workload and improved the patient journey. The Pathway consists of guideline driven treatment of patients with fractures. There is no follow up for many stable injuries, virtual review of other fractures and orthopaedic registrar referral for admission decisions. Many discharged patients never receive a clinic appointment necessitating the development of discharge information leaflets and a move from plaster casts to Velcro splints. Have orthopaedics simply passed their workload onto the Emergency Department?

1) Patients with fractures are discharged with no follow up, does this necessitate longer consultations in ED?

2) Without routine follow up do patients simply pitch back up to ED?

3) Has the admissions process actually improved?

Methods

We examined length of consultations, unplanned reattendances to ED within 7 days, number of Orthopaedic admissions and time from first assessment to admission before and after Fracture Clinic Redesign.

Results

1) Length of consultation was unchanged for discharges without follow up, (p=0.316, 0.508, 0.571). Consultations were shorter when splints replaced casts, (p=0.046, 0.588, 0.032).

2) Unplanned reattendances within 7 days did not increase as a proportion of ED attendances, (p=0.779).

3) Orthopaedic admissions fell by 7.9% and time from first assessment to admission by 9.6% per annum (p=0.002, p=0.011). Orthopaedic breaches decreased significantly, (p<0.001).

Conclusion

Direct discharges from ED do not require longer consultations nor do they return to ED. Orthopaedic admission is increasingly efficient and breaches are down. Is Fracture Pathway Redesign good for the Emergency Department? Yes!
A STUDY TO ASSESS THE VALUE OF THORACIC COMPUTED TOMOGRAPHY IN PAEDIATRIC TRAUMA PATIENTS
Authors: Avanis M C , Liu Y M , McLeod K , Thorpe E , Masters J , Vaidya M
Published: September 2013

Objectives & Background

Computed tomography (CT) is becoming increasingly popular as a primary imaging modality in adult trauma patients. This study aims to examine the added value of thoracic CT (TCT) in the context of paediatric trauma.

Methods

Retrospective review of the case notes of 182 consecutive paediatric trauma patients aged 16 and younger who received a chest X-ray (CXR) prior to TCT between January 2010 and April 2012 at a large tertiary paediatric trauma centre in East London.

Results

The main mechanisms of injury involved were road traffic accidents (50%), stab injuries (31%), and falls (14%). One hundred and twenty one patients (66%) underwent a TCT scan following a normal CXR. Of these, thirty four (28%) patients had new injuries detected. These included lung contusions (n=20), small pneumothoraces (n=5) and rib fractures (n=3). Of the 61 (34%) patients that had a TCT scan following an abnormal CXR, 26 (43%) had additional injuries detected. These included lung contusions (n=8), fractured ribs (n=6) and small pneumothoraces (n=6). The additional information from the TCT did not alter clinical management in any of the above cases.

Conclusion

This study indicates a need for a comprehensive guideline for imaging in paediatric trauma, where the use of TCT is limited to specific patients, especially in view of the health implications that CT poses and source of financial burden for the NHS.
DELAYED ONSET OF SUBGALEAL HAEMATOMAS ASSOCIATED WITH SKULL FRACTURE FOLLOWING ACCIDENTAL HEAD TRAUMA
Authors: Melhem N Z , Abrahamson E L
Published: September 2013

Objectives & Background

Subgaleal haematoma is associated with skull fracture in infants and young children. If the onset is reported to have appeared some time after the suggested mechanism, history may be placed in doubt raising safeguarding concerns. This can lead to social care intervention driven by medical opinion. We performed this study to evaluate our hypothesis that delay in haematoma is common in simple accidental head trauma.

Methods

We performed a 10 year retrospective review (2003–13) of all cases of skull fracture under 2 years of age presenting to our paediatric emergency department. We analysed the case records of those who had a delayed presentation with subgaleal haematoma, as defined as more than 24 hours after the injury, or where no injury was recalled.

Results

A total of 47 eligible patients were included. 12 (26%) presented more than 24 hours after reported injury (24 to 504 hours, mean 137) and a further 3 (6%) had no reported accident to explain a fracture. All of these cases presented with isolated subgaleal haematomas and no other clinical symptoms or signs. One case had intracranial abnormalities on CT scan whilst the remainder had simple linear skull fractures. In 8 of the 12 cases with a history of injury (67%), safeguarding concerns were carefully considered and excluded. No safeguarding considerations were documented in the 4 other cases. In the 3 cases with no history of injury, full child protection assessments occurred.

Conclusion

Whilst every case of skull fracture in infants and young children must be thoroughly assessed for safeguarding concerns, our findings suggest that delayed onset of a subgaleal haematoma can be consistent with accidental injury. It is important to take this into account when offering medical opinion on such cases, to avoid unnecessary social care and legal intervention.
HOW DOES CONFIDENCE IN PRACTICAL AND CLINICAL MANAGEMENT CHANGE FOLLOWING FOUR MONTHS WORKING IN THE EMERGENCY DEPARTMENT?
Authors: Everitt E , Whitehead A
Published: September 2013

Objectives & Background

There is a lack of information available about how the skills of Foundation Doctors develop over their time spent working in the Emergency Department (ED). Knowing this could better focus future training. We wanted to examine to what extent working in the ED influences confidence of Year 2 Foundation Doctors in managing common conditions seen in the ED and in performing practical procedures.

Methods

Questionnaires were given to F2 doctors at the beginning and end of their four month EM jobs at sites within the Pennine Acute Hospitals NHS Trust. These measured confidence in performing eleven practical skills and managing eleven common scenarios seen in the ED. Subjects scored confidence from 0 to 10.

Results

11 full sets of data were obtained. There was a global improvement in confidence. The greatest mean improvement in skills was in suturing (mean improvement of 5 points) and the smallest in arterial stab (mean improvement 0.9 points). The lowest confidence rating before and after the study period was removing a foreign body from an eye (Mean improvement 1.5 to 5/10). Confidence in patient management improved most in paediatric emergencies; managing a wheezy child and a febrile child with a rash (mean improvements 3.2 and 3.0 points respectively). The smallest improvement was in managing chest pain though initial scores for this were high (mean 7 improving to 9/10). Confidence managing a febrile child with a rash was initially the lowest (mean 5 increasing to 8/10).

Conclusion

The ED provides good exposure for improving the skills of foundation doctors. The greatest improvement was in areas doctors had not experienced elsewhere (e.g. paediatrics, suturing, diagnosing fractures).
STREET DOCTORS ARE WE MAKING AN IMPACT?
Authors: McCartan N , Colclough J M , Crewe J P , Munn C J , Berry S A , Reeder C , Loster N
Published: September 2013

Objectives & Background

Street Doctors is an initiative set up by Liverpool medical students in 2008. The organisation aims to reduce the morbidity and mortality associated with violent crime by equipping ‘at risk' young people with basic life support and first aid skills. The high prevalence of violent crime is indicated by NHS data from 2011/12, showing that 4,490 people were admitted to hospitals across England due to assault with a sharp object. With over 120 student volunteers, Street Doctors is now established in 6 cities where knife crime is becoming a persistent and worrying concern.

Methods

A survey was carried out to assess the impact that Street Doctors make during teaching sessions. For each group, there were two teaching sessions; covering basic management of haemorrhage, the recovery position and cardiopulmonary resuscitation. A questionnaire was created in which answers were quantified on a scale of 0–10 (with 10 representing the most positive score). These were given to the young offenders to be answered at the beginning and end of each session.

Results

The results showed that 50% of the young people had seen someone be shot or stabbed. Of these, 93% felt comfortable speaking about their experiences within the sessions (scoring ≥5/10). 71% of the young offenders noted that they would feel more confident dealing with these situations after attending our teaching, associated with a mean improvement of 1.42 (p=0.04).

Conclusion

These results show the positive impact that street doctors are making. The vast majority of attendees leave feeling more confident in their ability to deal with a knife or gunshot wound in the critical moments before an ambulance arrives. As an ever expanding organisation, Street Doctors has an increasing potential to pass on the valuable skills that may one day be used to save a person's life.