bluuebunny/crossref_metadata_2025_split huggingface dataset:
PP29 Paramedics’ experiences of administering fascia iliaca compartment block to patients with suspected hip fracture
Authors: Evans Bridie , Brown Alan , Bulger Jenna , Fegan Greg , Ford Simon , Guy Katy , Jones Sian , Keen Leigh , Khanom Ashrafunnesa , Pallister Ian , Rees Nigel , Russell Ian , Seagrove Anne , Snooks Helen 
Published: April 2019

BackgroundRoutine pre-hospital pain management for hip fracture is inadequate, with risk of potentially fatal complications, particularly from morphine. Fascia Iliaca Compartment Block (FICB) is used in Emergency Department and orthopaedic wards. The RAPID trial tested feasibility of paramedics administering FICB to patients with suspected hip fracture at the scene of injury.ObjectiveTo explore paramedics’ experience of delivering FICB pre-hospitally.MethodsWe held three focus groups with 11 paramedics serving one district hospital, audio-recorded with participants’ consent. We conducted thematic analysis of interview transcripts. Two researchers, one paramedic and one lay member were in the analysis team.ResultsRespondents believed FICB was a suitable intervention for paramedics to deliver. It aligned with their routine practice and was within people’s capabilities to administer, they reported. They said it took up to 10 min longer than usual care to prepare and deliver, in part due to nervousness and unfamiliarity with a new procedure. They praised the training provided but said they were anxious about causing harm by injecting into the wrong location. Confidence increased after one paramedic team successfully treated a patient for toxic reaction. Reported challenges related to the emergency context: patients often waited many hours for ambulance arrival; they sometimes needed to be moved from awkward locations which exacerbated pain; family and neighbours were present as paramedics administered treatment. Most respondents treated few or just one patient with FICB. Although uncertain whether FICB reduced patients’ pain more effectively than other pain relief options, respondents believed it was safer for elderly people at risk of pneumonia.ConclusionsParamedics are willing and able to administer FICB to patients with suspected hip fracture before ambulance transport to hospital. Feasibility study findings will inform a research proposal for a definitive multi-centre trial of paramedic administered prehospital FICB.
03 The use of scratchcards for allocation concealment and treatment allocation in a prehospital randomised controlled trial
Authors: Keen Leigh , Bulger Jenna , Rees Nigel , Snooks Helen , Fegan Greg , Ford Simon , Evans Bridie , Longo Mirella 
Published: April 2019

BackgroundRAPID (Rapid Analgesia for Prehospital Hip Disruption) study was a small study to determine the feasibility of undertaking a randomised controlled trial to test the clinical and cost-effectiveness of paramedics administering Fascia Iliaca Compartment Block (FICB) as early pain relief to patients who have fractured a hip at the scene of their injury.ObjectivesTo devise a simple and effective method of random allocation concealment suitable for use by Paramedics whilst in the mobile emergency prehospital setting.MethodsTraditional Methods of randomly allocating patients were considered, however none were suitable for paramedics to use during their shift. Scratchcards have been used successfully in other studies, though not prehospitally to our knowledge. Scratchcards were produced using scratch-off silver stickers which concealed the trial arm allocation. Paramedics were each allocated a unique range of consecutive numbers, used as both the scratchcard number and patient’s study ID. The cards were designed to allow the paramedic to write on the incident number, date and signature. A small envelope holding the cards was prepared for each paramedic.ResultsNineteen trial paramedics used 71 scratchcards throughout the study and reported no problems randomly allocating patients using the scratchcards. Five protocol deviations reported in relation to scratchcard use. On auditing the scratchcards, all unused cards were located and no evidence of tampering with the silver panel was found.ConclusionParamedics can use scratchcards as a method of randomly allocating patients in trials in prehospital care. In future a method that allows only the top card to be selected should be sought. Also a more protective method of storing the cards should be used. Scratchcards can be considered for wider use in randomised controlled trials in the emergency prehospital setting.
PP31 Data awareness for sending help (DASH): policy opportunities & challenges
Authors: Drake Archie , Pollitt Alex , Smith Leanne , Sklar Elizabeth 
Published: April 2019

BackgroundThe DASH project is a collaboration between King’s College London and the London Ambulance Service (LAS). Its goal is to explore the potential impact of integrating new and emerging data sources and technologies on emergency response, using technical and policy approaches in tandem. Computer science and public health both emphasise dynamic systems thinking in which elements should be connected to others, e.g. ‘data linkage’, ‘health in all policies’. EMS research has started to demonstrate the value of connecting LAS information systems to transport and environmental as well as emergency department data. Policy research question: what are the opportunities and challenges for EMS, wider healthcare providers and the public in the integration of new and emergent data sources and technologies in ambulance dispatch?MethodsMixed Methods study, including literature review, framework analysis, stakeholder and process mapping, open policy development and interviews. Primary data collection (thematic analysis) entails approximately: 15 semi-structured interviews with LAS staff and 60 unstructured interviews with a variety of stakeholders. Secondary data analysis of LAS incident and response datasets over calendar year 2016 with other publicly available administrative data.ResultsA wide range of new and emergent data sources have a potential impact on ambulance dispatch decision-making. The opportunities extend beyond the operational level into tactical and strategic dimensions. But the challenges are significant across a range of perspectives, impeding efforts to realise the benefits in practice. The study suggests a prioritisation of new and emergent data sources and technologies for LAS based on a utility/feasibility matrix which is presented to provoke discussion.ConclusionsMore effective, dynamic ‘data aware’ dispatch systems are likely to improve patient outcomes. Ambulance services can usefully raise awareness to seek the necessary data and support – simultaneously furthering health system integration and wider public health goals. See https://dash.kcl.ac.uk/reports/ for project outputs.
OP6 An investigation into suicide amongst ambulance service staff
Authors: Hird Kelly , Bell Fiona , Mars Becky , James Catheryn , Gunnell David 
Published: April 2019

BackgroundIn 2015, Ambulance Service Medical Directors raised concerns regarding a perceived increase in suicide deaths among ambulance service staff. The Association of Ambulance Chief Executives (AACE) then commissioned a research study to investigate these concerns and provide recommendations towards a suicide prevention strategy. The aim of this study was to determine whether staff who work in the UK ambulance services (AS) are at higher risk of suicide than staff who work in other professions.MethodsData was requested from the Office for National Statistics (ONS) regarding AS staff suicide. Eighteen AS were invited to return data on Occupational Health (OH). AS in England and Wales (n=11) were also asked to return data on staff suicides. Coroners were contacted to request permission to review the records of the deaths.ResultsThe ONS analysis of occupational suicide risk between 2011 and 2015 indicated that there were 20 suicide deaths amongst paramedics in England during that period. The risk of suicide amongst male paramedics was 75% higher than the national average.Over a 2 year period, 8 AS trusts identified 15 staff suicides (11 male, 4 female). The mean age of those dying by suicide was 42 years. Findings from coroners’ records indicated that the predominant suicide method used was hanging (66.7%).ConclusionsThe following recommendations have been accepted by the AACE: a) Develop a mental health strategy for all staff which includes specific emphasis on suicide prevention b) Review and assess suicide risk at times of increased vulnerability c) Collect and monitor data on AS suicides d) Review occupational health, counselling and support services e) Training for staff in identifying and responding to a colleague in distress f) Return to work discussions should consider and establish the status of an individual’s mental health and wellbeing.
PP8 Paramedic views and experiences of the ethical considerations in ambulance based clinical trials: an interview study
Authors: Armstrong Stephanie , Langlois Adele , Siriwardena Niroshan 
Published: April 2019

BackgroundPrehospital ambulance based research has unique ethical considerations due to urgency, time-limitations and the locations (home, ambulance) involved. We sought to explore these issues through interviews with paramedics that have research experience.MethodsWe undertook semi-structured interviews with paramedics, seeking their views and experiences of undertaking research in ambulance based clinical trials. Participants were purposively chosen because they were actively involved research and had enrolled one or more patients into a clinical trial. Participants were questioned regarding their experiences of the enrolment and consent process, and their opinions regarding the facilitators and barriers to ambulance based research. Transcripts were digitally recorded, transcribed verbatim, and analysed thematically.ResultsWe interviewed 15 paramedics. They ranged from newly qualified to experienced advanced paramedics. Mental capacity and consent were discussed and the time and complexity for undertaking these processes were highlighted. Participants discussed problems with completing paperwork due to the complexity of recording systems. Most highlighted paramedic training and experience as a potential barrier to research, stating that those that had gone through a university education in general seemed more open to research than those that had ‘learnt on the job’. It was also felt that more information on the benefits of a trial to both patients and practice were needed from the outset to allow paramedics to make an informed decision about whether to take part in research or not. Several stated that they did additional reading around the subject before signing up. All stated that the training given prior to commencing the research was good and appropriate to each trial.ConclusionsWe identified patient capacity and consent, paramedic training and experience and complexity of processes as important potential barriers to prehospital research. There is scope to improve guidance for prehospital research studies in future.
PP9 A systematic review and meta-analysis of pre-hospital diagnostic accuracy studies
Authors: Wilson Caitlin , Harley Clare , Steels Stephanie 
Published: April 2019

BackgroundPre-hospital clinicians are involved in examining, treating and diagnosing patients. The accuracy of pre-hospital diagnoses is evaluated using diagnostic accuracy studies. We undertook a systematic review of published literature to provide an overview of how accurately pre-hospital clinicians diagnose patients compared to hospital doctors. A bivariate meta-analysis was incorporated to examine the range of diagnostic sensitivity and specificity.MethodsWe searched MEDLINE, CINAHL, Embase, AMED and the Cochrane Database of Systematic Reviews from 1946 to 7th May 2016 for studies where patients had been given a diagnosis by pre-hospital clinicians and hospital doctors. Key words focused on study type (‘diagnostic accuracy’), outcomes (sensitivity, specificity, likelihood ratio?, predictive value?) and setting (paramedic*, pre-hospital, ambulance, ‘emergency service?’, ‘emergency medical service?’, ‘emergency technician?’). The sole researcher screened titles and abstracts to ensure eligibility criteria were met, as well as assessing methodological quality using QUADAS-2.Results2941 references were screened by title and/or abstract. Eleven studies encompassing 3 84 985 patients were included after full-text review. The types of diagnoses in one of the studies encompassed all possible diagnoses and in the other studies focused on sepsis, stroke and myocardial infarction. Sensitivity estimates ranged from 32%–100% and specificity estimates from 14%–100%. Eight of the studies were deemed to have a low risk of bias and were incorporated into a meta-analysis, which showed a pooled sensitivity of 0.74 (0.62, 0.82) and a pooled specificity of 0.94 (0.87, 0.97).ConclusionsCurrent published research suggests that diagnoses made by pre-hospital clinicians have high sensitivity and even higher specificity. However, the paucity and varying quality of eligible studies indicates that further pre-hospital diagnostic accuracy studies are warranted especially in the field of non-life-threatening conditions and trauma.
Five-year costs from a randomised comparison of bilateral and single internal thoracic artery grafts
Authors: Little Matthew , Gray Alastair , Altman Doug , Benedetto Umberto , Flather Marcus , Gerry Stephen , Lees Belinda , Murphy Jacqueline , Campbell Helen , Taggart David 
Published: April 2019

BackgroundThe use of bilateral internal thoracic arteries (BITA) for coronary artery bypass grafting (CABG) may improve survival compared with CABG using single internal thoracic arteries (SITA). We assessed the long-term costs of BITA compared with SITA.MethodsBetween June 2004 and December 2007, 3102 patients from 28 hospitals in seven countries were randomised to CABG surgery using BITA (n=1548) or SITA (n=1554). Detailed resource use data were collected from the initial hospital episode and annually up to 5 years. The associated costs of this resource use were assessed from a UK perspective with 5 year totals calculated for each trial arm and pre-selected patient subgroups.ResultsTotal costs increased by approximately £1000 annually in each arm, with no significant annual difference between trial arms. Cumulative costs per patient at 5-year follow-up remained significantly higher in the BITA group (£18 629) compared with the SITA group (£17 480; mean cost difference £1149, 95% CI £330 to £1968, p=0.006) due to the higher costs of the initial procedure. There were no significant differences between the trial arms in the cost associated with healthcare contacts, medication use or serious adverse events.ConclusionsHigher index costs for BITA were still present at 5-year follow-up mainly driven by the higher initial cost with no subsequent difference emerging between 1 year and 5 years of follow-up. The overall cost-effectiveness of the two procedures, to be assessed at the primary endpoint of the 10-year follow-up, will depend on composite differences in costs and quality-adjusted survival.Trial registration numberISRCTN46552265
Pericardial diseases in patients with hypothyroidism
Authors: Chahine Johnny , Ala Chandra K , Gentry James L , Pantalone Kevin M , Klein Allan L 
Published: April 2019

Hypothyroidism is a well-known cause of pericardial effusion (with an incidence of 3%–37%) and can cause cardiac tamponade in severe cases. In this review, we present the current knowledge on the epidemiology of hypothyroid-induced pericardial diseases, the mechanism through which low thyroid hormone levels affect the pericardium, the associated clinical manifestations, diagnostic tests and management options. Hypothyroidism causes pericardial effusion through increased permeability of the epicardial vessels and decreased lymphatic drainage of albumin, resulting in accumulation of fluid in the pericardial space. Interestingly, autoimmunity does not seem to play a major role in the pathophysiology, and a majority of effusions are asymptomatic due to slow fluid accumulation. The diagnosis is generally made when the pericardial disease is associated with an elevated thyroid-stimulating hormone level, and other secondary causes are excluded. Management consists of thyroid replacement therapy, along with pericardial drainage in case of tamponade.In conclusion, hypothyroidism-induced pericardial diseases are underdiagnosed. Initiating treatment early in the disease process and preventing complications relies on early diagnosis through systematic screening per guidelines.
Iron deficiency in heart failure with preserved ejection fraction: a systematic review and meta-analysis
Authors: Beale Anna L , Warren Josephine Lillian , Roberts Nia , Meyer Philippe , Townsend Nick P , Kaye David 
Published: April 2019

ObjectiveIron deficiency (ID) has an established impact on outcomes in patients with heart failure with reduced ejection fraction; however, there is a lack of conclusive evidence in patients with heart failure with preserved ejection fraction (HFpEF). We sought to clarify the prevalence and impact of ID in patients with HFpEF.MethodsA systematic search of Cohcrane, MEDLINE, EMBASE, Web of Science and CINAHL electronic databases was performed to identify relevant studies. Included studies defined HFpEF as heart failure with an ejection fraction ≥50%. We used a random-effects meta-analysis to determine the composite prevalence of ID in patients with HFpEF across the included studies. Other outcomes were assessed with qualitative analysis due to a paucity of studies with comparable outcome measures.ResultsThe prevalence of ID in the included studies was 59% (95% CI 52% to 65%). ID was associated with lower VO2max in three of four studies reporting VO2max as an outcome measure, lower functional status as determined by dyspnoea class or 6 min walk test in two of three studies, and worse health-related quality of life in both studies reporting on this outcome. Conversely, ID had no impact on death or hospitalisation in three of the four studies investigating this.ConclusionsID is highly prevalent in patients with HFpEF and is associated with worse exercise capacity and functional outcomes, but not hospitalisation or mortality. Our study establishes that ID may play an important a role in HFpEF.
Injury-Induced Shedding of Extracellular Vesicles Depletes Endothelial Cells of Cav-1 (Caveolin-1) and Enables TGF-β (Transforming Growth Factor-β)–Dependent Pulmonary Arterial Hypertension
Authors: Oliveira Suellen D.S. , Chen Jiwang , Castellon Maricela , Mao Mao , Raj J. Usha , Comhair Suzy , Erzurum Serpil , Silva Claudia L.M. , Machado Roberto F. , Bonini Marcelo G. , Minshall Richard D. 
Published: April 2019

Objective—
To determine whether pulmonary arterial hypertension is associated with endothelial cell (EC)–Cav-1 (caveolin-1) depletion, EC-derived extracellular vesicle cross talk with macrophages, and proliferation of Cav-1 depleted ECs via TGF-β (transforming growth factor-β) signaling.

Approach and Results—

Pulmonary vascular disease was induced in Sprague-Dawley rats by exposure to a single injection of VEGFRII (vascular endothelial growth factor receptor II) antagonist SU5416 (Su) followed by hypoxia (Hx) plus normoxia (4 weeks each–HxSu model) and in WT (wild type;
Tie2.Cre
−
;
Cav1

lox/lox

) and EC-
Cav1
−/−
(Tie2.Cre
+
;
Cav1

fl/fl

) mice (Hx: 4 weeks). We observed reduced lung Cav-1 expression in the HxSu rat model in association with increased Cav-1+ extracellular vesicle shedding into the circulation. Whereas WT mice exposed to hypoxia exhibited increased right ventricular systolic pressure and pulmonary microvascular thickening compared with the group maintained in normoxia, the remodeling was further increased in EC-
Cav1
−/−
mice indicating EC Cav-1 expression protects against hypoxia-induced pulmonary hypertension. Depletion of EC Cav-1 was associated with reduced BMPRII (bone morphogenetic protein receptor II) expression, increased macrophage-dependent TGF-β production, and activation of pSMAD2/3 signaling in the lung. In vitro, in the absence of Cav-1, eNOS (endothelial NO synthase) dysfunction was implicated in the mechanism of EC phenotype switching. Finally, reduced expression of EC Cav-1 in lung histological sections from human pulmonary arterial hypertension donors was associated with increased plasma concentration of Cav-1, extracellular vesicles, and TGF-β, indicating Cav-1 may be a plasma biomarker of vascular injury and key determinant of TGF-β–induced pulmonary vascular remodeling.

Conclusions—
EC Cav-1 depletion occurs, in part, via Cav-1+ extracellular vesicle shedding into the circulation, which contributes to increased TGF-β signaling, EC proliferation, vascular remodeling, and pulmonary arterial hypertension.
Circulating TNFSF14 (Tumor Necrosis Factor Superfamily 14) Predicts Clinical Outcome in Patients With Stable Coronary Artery Disease
Authors: Hsu Chien-Yi , Tseng Wei-Kung , Wu Yen-Wen , Lin Tsung-Hsien , Yeh Hung-I. , Chang Kuan-Cheng , Wang Ji-Hung , Chou Ruey-Hsing , Huang Chun-Yao , Huang Po-Hsun , Leu Hsin-Bang , Yin Wei-Hsian , Wu Chau-Chung , Lin Shing-Jong , Chen Jaw-Wen 
Published: April 2019

Objective—
Basic research indicates that TNFSF14 (tumor necrosis factor superfamily 14) may be involved in the pathogenesis of atherosclerosis. Given the requirements of new biomarkers for risk classification in coronary artery disease (CAD), we conducted a longitudinal analysis to investigate if TNFSF14 levels are associated with the risk of cardiovascular events among patients with stable CAD.

Approach and Results—
In total, 894 patients with CAD were enrolled in a multicenter prospective study. The primary outcome was the occurrence of cardiovascular death, nonfatal myocardial infarction, and stroke. The secondary outcome was the occurrence of all-cause death, nonfatal myocardial infarction, stroke, revascularization, and hospitalization because of angina or heart failure. During the mean follow-up period of 22±9 months, 32 patients reached the primary outcome and 166 patients reached the secondary outcome. Kaplan-Meier analysis showed that the event-free survival was significantly different in the first and fourth quartile groups in subjects categorized by TNFSF14 levels. In multivariate Cox proportional hazard regression analysis, TNFSF14 was independently associated with the risk of cardiovascular events after adjustment for various relevant factors (adjusted hazard ratio, 1.14; 95% CI, 1.04–1.25). In the validation cohort of 126 multivessel patients with CAD, TNFSF14 was confirmed to provide good prognostic predictive value for composite cardiovascular events (adjusted hazard ratio, 1.11; 95% CI, 1.04–1.19).

Conclusions—
This is the first study to demonstrate that increased TNFSF14 levels were independently associated with the occurrence of cardiovascular events in patients with stable CAD. Future studies are worthy to validate if TNFSF14 could be a novel prognostic biomarker for CAD outcomes over different populations.