bluuebunny/crossref_metadata_2025_split huggingface dataset:
PP18 Interim analysis of ambulance logistics and timings in patients recruited into the rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 (right-2)
Authors: Dixon Mark , Scutt Polly , Appleton Jason P , Spaight Robert , Johnson Roderick , Niroshan Siriwardena A , Bath Philip M 
Published: September 2017

BackgroundStroke is a severe condition with high morbidity and mortality. Despite treatment effects in acute stroke being predominantly time dependent (e.g. thrombolysis and thrombectomy), proven treatments are hospital based and require prior brain scanning to identify intracerebral haemorrhage. Commencing treatment in the ambulance could dramatically reduce time to treatment.MethodsThe rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 (RIGHT-2) is a multicentre prospective randomised single-blind blinded-endpoint parallel group trial assessing the safety and efficacy of ambulance-based, paramedic-delivered glyceryl trinitrate (GTN) when administered within 4 hours of stroke onset. Paramedics trained in RIGHT-2 procedures assess, take appropriate consent and enrol eligible FAST-positive patients and apply the first of four GTN or sham transdermal patches that are continued during hospital admission. Timings, vital signs and distances are recorded.Results317 participants enrolled across five UK NHS ambulance services were assessed in this interim analysis. Median [interquartile range] timings in minutes were: symptom onset to 999 call 14 [5, 52], call-dispatch 2 [1, 6], onset-randomisation 60 [40, 105], scene-randomisation 21 [14, 31] with no difference between participants scoring FAST 2 or 3, scene-departure 32 [25, 40]), departure-hospital 16 [10, 24]. All timings were comparable to a cohort of 49 stroke patients across East Midlands Ambulance Service who were not enrolled in to RIGHT-2, e.g. scene-departure 32 [23, 40].ConclusionsRandomisation of participants to an ambulance-based stroke trial is possible with paramedics rapidly identifying eligible patients, gaining appropriate consent, randomising and commencing treatment en route to hospital without prolonging time spent on scene.
PP19 A study of the prevalence of impaired awareness of hypoglycaemia in people who have had a severe hypoglycaemic emergency and been attended by the ambulance service
Authors: Duncan Edward AS , Fitzpatrick David , Evans Josie 
Published: September 2017

BackgroundSevere hypoglycaemia is a serious condition and accounts for 0.6%–1.0% of all UK emergency ambulance calls per annum. Our previous qualitative research suggested that many Diabetes related hypoglycaemia patients attended by the ambulance service experienced impaired awareness of hypoglycaemia (IAH), a treatable condition which reduces patients’ awareness of the signs and symptoms of an impending severe hypoglycaemic emergency. The prevalence of IAH among people with type 1 Diabetes is approximately 25%. In type 2 its prevalence is approximately 10%. However the prevalence of IAH in people who use the ambulance service due to a hypoglycaemic emergency was unknown. Our aim therefore was to investigate the prevalence of IAH in patients who require ambulance service attendance due to severe hypoglycaemia.MethodsWe undertook a national cross-sectional survey of the prevalence of IAH. An a priori target sample size of 415 was set to allow estimation of proportions of IAH within a 5% margin of error (99% CI). From January–June 2016, patients (>16 years) attended by the Scottish Ambulance Service due a Diabetes related emergency with a blood glucose <4 mmol/L were identified as potential participants. A questionnaire with two standardised IAH measures (Gold et al. and Clarke et al) was posted to potential participants within a month of their severe hypoglycaemic event. Consent to participate was assumed through questionnaire return. Ethical approval was received from the National Research Ethics Service (15/EE/0383).ResultsFive hundred and ninety-two questionnaires were returned. The prevalence of impaired awareness of hypoglycaemia in among participants as measured using the two standardised measures was 53% and 57% respectively.ConclusionIAH is considerably more prevalent among people who have a severe hypoglycaemic emergency and call the ambulance service than in the general Diabetic population. This knowledge will assist in the development of an intervention to reduce hypoglycaemic emergencies and may lead to improved outcomes and cost savings.
PP22 Alternative care pathways for patients with low risk tia attended by emergency ambulance: a national survey
Authors: Porter Alison , Bulger Jenna , Hampton Chelsey , Jones Charlene , Rees Nigel , Seagrove Anne , Snooks Helen 
Published: September 2017

BackgroundPatients presenting to emergency ambulance services with TIA are usually conveyed to the nearest Emergency Department (ED) with subsequent referral to specialist assessment at a TIA clinic within one week if at low risk of stroke. There is the opportunity for paramedics to refer patients with TIA at low risk of recurrent stroke directly to specialist TIA clinic, if such protocols can be shown to be safe and cost effective.We aimed to describe current service developments across the UK for the pre-hospital emergency care of patients with TIA, to inform the development of an intervention for testing.MethodsWe surveyed all UK Ambulance Trusts (n=13) by email, asking them to identify initiatives related to the management of TIA, and followed up services reporting an alternative TIA pathway by telephone to gather further details.ResultsTwelve ambulance services responded to our survey. Nine reported that they had no current TIA referral pathway; of these, one had a pathway which was discontinued due to service reconfiguration. Three reported currently using a TIA referral pathway. All (4/4) pathways which had been introduced used the FAST test and ABCD2 tool to screen patients, in line with national guidelines, and classified patients as low risk if the ABCD2 score was 3 or below. All pathways indicated that eligible low-risk TIA patients should be referred by paramedics to specialist care, 2/4 by telephone, and 2/4 by fax. Non-conveyance exclusion criteria varied.Although protocol compliance was audited in an initial pilot in one service, no formal evaluation of effectiveness was reported.ConclusionSeveral UK ambulance services have introduced referral pathways for low risk TIA patients, avoiding the ED. None have evaluated the safety (subsequent stroke or serious misdiagnosis) or cost effectiveness. A clinical trial to evaluate the safety and effectiveness of alternative care pathways for patients with suspected TIA presenting to emergency ambulance services is indicated.
PP26 Missed opportunities in ambulance sepsis care?
Authors: Prothero Larissa S , de Carteret Emma , Nicholls Tracy 
Published: September 2017

BackgroundTwo-thirds of severe sepsis patients are initially seen in the emergency department, with the majority arriving via ambulance. Since early sepsis recognition, diagnosis and clinical management are considered key for optimal patient outcomes, ambulance clinicians are well placed to have a key role in sepsis care. This study aims to identify key patient, clinician and organisation-derived factors which lead to missed sepsis recognition and delayed access to definitive care in the ambulance setting.MethodsThe East of England Ambulance Service NHS Trust declares any missed cases of sepsis as a Serious Incident (SI; NHS England Serious Incident Framework 2015) to support clinician and service learning and prevent reoccurrence. A qualitative thematic review, based on the Yorkshire Contributory Factors Framework, has being conducted using seventeen sepsis-related SI reports generated between March 2014 and March 2016.ResultsSIs were usually associated with emergency/999 calls resulting in non-conveyance. Breathing/respiratory problems were the most prevalent chief complaint. Perceived contributory factors to these incidences were:‘Patient-derived’: unwell patients with capacity choosing to remain at home, despite advice to attend hospital; presence of co-morbidities and other medical conditions.‘Clinician-derived’: inadequate patient assessment and triage; failure to recognise sepsis markers and use screening tools; low index of suspicion for sepsis and rapid patient deterioration; insufficient safety-netting and documentation; communication errors.‘Organisation-derived’: increasing service demands; mismatch between clinician and vehicle response allocation; lower acuity calls receiving delayed responses at peak demand; variable provision of staff training; lack of clinical practice monitoring; lack of safety culture; promotion of alternative care pathways.ConclusionsErrors in pre-hospital sepsis care occur at all service levels. SI reports provide invaluable systems-based analyses of healthcare episodes and offer concise guidance to prevent error reoccurrence and improve future care. The study findings will inform the development of a prospective sepsis risk assessment tool using prospective hazards analysis methodologies.
OP07 Might ambulance service organisational culture affect ambulance non conveyance rates?
Authors: Knowles Emma , Ahmed Nisar , Bishop-Edwards Lindsey , O’Cathain Alicia 
Published: September 2017

BackgroundAmbulance services are experiencing increasing demand for response to emergency calls. In response, they have increased the proportion of patients not conveyed to an emergency department (ED). Alternatives to transporting patients to an ED include the provision of telephone advice only (‘hear and treat’), treatment at the scene (‘see and treat’) and transport to another facility (‘see and convey elsewhere’). There is considerable variation in the rates of different types of non-conveyance, and in non-conveyance overall, between ambulance services in England. Understanding of the reasons for this variation has been limited and relatively unexplored. We will explore if there is variability in perceptions of the organisational culture within each individual ambulance service and show this in the context of non conveyance rates.MethodsWe undertook 50 qualitative telephone interviews with ambulance service providers and commissioners in the 10 larger ambulance services in England, to identify factors that may explain variation in rates of ambulance non-conveyance. Data was analysed using a Framework model.ResultsAmongst interviewees there was variation in the perceptions they held regarding the organisational culture of the ambulance service which they were employed by. Recent management restructuring within the ambulance service, perception of management support across the organisation, motivation of the organisation to undertake non conveyance, and perceptions of support for staff undertaking non conveyance varied across the 10 ambulance services. We will present this qualitative data alongside routine data identifying non conveyance rates in each service, and explore whether organisational culture appears to be related to ambulance non conveyance rates.ImplicationsOrganisational culture is a complex issue but one which is potentially modifiable. Building a greater understanding of ambulance service organisational culture and how this relates to ambulance non conveyance may help identify ways of improving service delivery across all ambulance services.
PP08 Does current pre-hospital analgesia effectively reduce paediatric pain within a uk ambulance service: a service evaluation
Authors: Whitley Gregory , Bath-Hextall Fiona 
Published: September 2017

IntroductionPain is one of the most common symptoms presented by patients of all ages to ambulance services, however very few children receive analgesia. Analgesic treatment of pre-hospital injured children is viewed as ‘suboptimal’. The aim of this study was to explore current analgesia given to traumatically injured children in the pre-hospital setting and examine whether a clinically meaningful reduction in pain was achieved.MethodsWe evaluated electronic patient report forms over a two-year period (2013–2014) within a UK ambulance service NHS trust. All traumatically injured children within the age range 1–17 with a clinical impression of a fracture, dislocation, wound or burn were included. Patients with a Glasgow Coma Scale of <15 were excluded. The outcome measure was a reduction in numeric pain rating scale or Wong and Baker faces of ≥2 out of 10.ResultsOf the evaluable patients (n=11,317), 90.8% had a documented pain score, or a reason why a pain score could not be documented. For patients reporting pain (n=7483), 51.6% (n=3861) received analgesia, 9.6% (n=717) received no analgesia but did receive alternative treatment and 38.8% (n=2905) received no analgesia and no alternative treatment. Morphine sulphate IV, oral morphine, Entonox, paracetamol suspension and poly-analgesia all achieved a clinically meaningful median reduction in pain score; –3.0 (IQR, –5.0 to –2.0),–2.0 (–5.0 to –2.0),–2.0 (–4.0 to –1.0),–2.0 (–4.0 to 0.0) and –3.0 (–4.0 to –1.0), respectively.ConclusionsAnalgesia administered to traumatically injured children in the pre-hospital setting within this UK ambulance service NHS trust produces clinically meaningful reductions in pain for these patients. The concern is that a large number of patients received neither analgesia nor alternative treatment. There is a real need to identify barriers to analgesia administration in this patient group.
PP09 Pre-hospital diagnostic accuracy for hyperventilation syndrome
Authors: Wilson Caitlin , Harley Clare , Steels Stephanie 
Published: September 2017

BackgroundHyperventilation syndrome (HVS) encompasses a wide variety of symptoms and is diagnosed by excluding organic causes for patients’ symptoms. Literature suggests that HVS should be diagnosed and treated pre-hospitally to avoid costly attendances at Accident and Emergency departments. The study aim was to determine diagnostic accuracy for HVS of paramedics and emergency medical technicians (index test) in comparison to hospital doctors (reference standard).MethodsA retrospective cross-sectional audit of routine data utilising linked pre-hospital and in-hospital patient records of adult patients (age ≥18 years) transported via emergency ambulance to two Accident and Emergency departments in the United Kingdom from January 2012 – December 2013. Agreement between pre-hospital and in-hospital HVS diagnoses was calculated using percent agreement, Cohen’s kappa and prevalence-adjusted bias-adjusted kappa. Accuracy was measured using sensitivity, specificity, predictive values and likelihood ratios with 95% confidence intervals.ResultsA total of 19 386 records were included in the analysis. Percent agreement between pre-hospital clinicians and hospital doctors was 98.73%, producing kappa of κ=0.57 and adjusted kappa of PABAK=0.97. Pre-hospital clinicians had a sensitivity 0.88 (0.82, 0.92) and specificity 0.99 (0.99, 0.99) for diagnosing HVS, with PPV 0.42 (0.37, 0.47), NPV 1.00 (1.00, 1.00), LR +75.2 (65.3, 86.5) and LR- 0.12 (0.08, 0.18). Subgroup analyses for sensitivity were statistically non-significant but for positive predictive values were statistically significant (p<0.001) for the number of pre-hospital diagnoses and patient age.ConclusionsParamedics and emergency medical technicians were able to diagnose HVS pre-hospitally with almost perfect specificity and good sensitivity. Pre-hospital diagnostic accuracy was highest for patients less than 30 years of age and if HVS was the sole diagnosis documented. Following this study, a review of the local ambulance service policy excluding adult HVS patients from referrals to Primary Care Services is anticipated.
Cost-effectiveness of neighbourhood slow zones in New York City
Authors: Jiao Boshen , Kim Sooyoung , Hagen Jonas , Muennig Peter Alexander 
Published: September 2017

BackgroundNeighbourhood slow zones (NSZs) are areas that attempt to slow traffic via speed limits coupled with other measures (eg, speed humps). They appear to reduce traffic crashes and encourage active transportation. We evaluate the cost-effectiveness of NSZs in New York City (NYC), which implemented them in 2011.MethodsWe examined the effectiveness of NSZs in NYC using data from the city’s Department of Transportation in an interrupted time series analysis. We then conducted a cost-effectiveness analysis using a Markov model. One-way sensitivity analyses and Monte Carlo analyses were conducted to test error in the model.ResultsAfter 2011, road casualties in NYC fell by 8.74% (95% CI 1.02% to 16.47%) in the NSZs but increased by 0.31% (95% CI −3.64% to 4.27%) in the control neighbourhoods. Because injury costs outweigh intervention costs, NSZs resulted in a net savings of US$15 (95% credible interval: US$2 to US$43) and a gain of 0.002 of a quality-adjusted life year (QALY, 95% credible interval: 0.001 to 0.006) over the lifetime of the average NSZ resident relative to no intervention. Based on the results of Monte Carlo analyses, there was a 97.7% chance that the NSZs fall under US$50 000 per QALY gained.ConclusionWhile additional causal models are needed, NSZs appeared to be an effective and cost-effective means of reducing road casualties. Our models also suggest that NSZs may save more money than they cost.
Do we need bone mineral density to estimate osteoporotic fracture risk? A 10-year prospective multicentre validation study
Authors: Marques Andréa , Lucas Raquel , Simões Eugénia , Verstappen Suzanne M M , Jacobs Johannes W G , da Silva Jose A P 
Published: September 2017

ObjectiveEvaluate the performance of FRAX®, with and without bone mineral densitometry (BMD), in predicting the occurrence of fragility fractures over 10 years.MethodsParticipants aged ≥40 years at baseline, with a complete set of data and a minimum of 8.5 years of follow-up were identified from three cohorts (n=2626). Ten-year fracture risk at baseline were estimated with FRAX® and assessed by comparison with observed fractures and receiver operating characteristic analysis.ResultsDuring a mean (SD) follow-up of 9.12 (1.5) years, 178 participants suffered a major osteoporotic (MOP) fracture and 28 sustained a hip fracture. The predictive performance of FRAX® was superior to that of BMD alone for both MOP and hip fractures. The area under the curve (AUC) of FRAX® without BMD was 0.76 (95% CI 0.72 to 0.79) for MOP fractures and 0.78 (95% CI 0.69 to 0.86) for hip fractures. No significant improvements were found when BMD was added to clinical variables to predict either MOP (0.78, 95% CI 0.74 to 0.82, p=0.25) or hip fractures (0.79, 95% CI 0.69 to 0.89, p=0.72).AUCs for FRAX® (with and without BMD) were greater for men than for women. FRAX®, with and without BMD, tended to underestimate the number of MOP fractures and to overestimate the number of hip fractures in females. In men, the number of observed fractures were within the 95% CI of the number predicted, both with and without BMD.ConclusionFRAX® without BMD provided good fracture prediction. Adding BMD to FRAX® did not improve the performance of the tool in the general population.
Structural transition of carbon nanoparticles caused by energetic collisions
Authors: Cai Ri , Ye Jun , Wang Qingbin , Chen Guohui , Liu Junting , Shi Liangyuan , Lin Mingwei , Xie Zhuoming , Liang Jianfu , Huang Hui , Liu Jinming , Li Mingjun , Liu Cheng , Song Hanbiao 
Published: September 2017

A broad general interest in the process of affecting the energetic deposition of flying nanoparticles has prompted a new opportunity to consider the medium-energy region in which the nanoparticles maintain their integrity and must respond to the energetic shock caused by collisions. We herein report our experimental results on the structural transition of the carbon nanoparticles induced by such energetic collisions. The beam energy was varied from 0 keV to 30 keV for a nanoparticle with over 5000 carbon atoms. Electron energy loss spectroscopy, X-ray photoemission spectroscopy, and Raman spectroscopy were carried out on the samples using a series of beam energies. These tests revealed that some graphitic sheets were formed at the higher beam energy while the sp3 ratio was unexpectedly higher for a medium beam energy.
O tempo e o vento: notas sobre a arte de burocratizar políticas de cotas na USP
Authors: De Fiori Ana Letícia , Assênsio Cibele Barbalho , Andrade Fabiana , Teixeira Jacqueline Moraes , Patriarca Letizia , Dal Bo Talita Larazin 
Published: September 2017

Por que cotas na pós-graduação? Este texto enfrenta essa indagação apresentando uma descrição densa dos muitos trajetos burocráticos que a implementação de uma política de ações afirmativas mobiliza.Trata-se de um processo que acaba por produzir uma tensão quase que insustentável entre a temporalidade perdurável da burocracia versus os ventos necessários de mudança social que, nesse caso específico, demandam a transformação das tecnologias para a produção da ciência e para a abertura dos espaços reconhecidos de formulação dos saberes científicos.Para tanto, partimos da exposição do contexto e dos eventos referentes à formulação e tramitação de uma proposta de cotas no Programa de Pós-Graduação em Antropologia Social da Universidade de São Paulo (PPGAS/USP). Com isso, formulamos uma cartografia das políticas decotas nos Programas de Pós-Graduação em Antropologia no Brasil, bem como uma reflexão acerca do lugar das políticas afirmativas dentro da conjuntura geral da USP. Por fim, apresentamos uma posição mais epistêmica acerca de como a abertura dos espaços de produção de conhecimento é fundamental para produzir instâncias plurais e democráticas na composição dos saberes antropológicos.
Baseline Quality of Life and Risk of Stroke in the ALLHAT Study (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial)
Authors: Shams Tanzila , Auchus Alexander P. , Oparil Suzanne , Wright Clinton B. , Wright Jackson , Furlan Anthony J. , Sila Cathy A. , Davis Barry R. , Pressel Sara , Yamal Jose-Miguel , Einhorn Paula T. , Lerner Alan J. 
Published: September 2017

Background and Purpose—
The visual analogue scale is a self-reported, validated tool to measure quality of life (QoL). Our purpose was to determine whether baseline QoL predicted strokes in the ALLHAT study (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial) and evaluate determinants of poststroke change in QoL. In the ALLHAT study, among the 33 357 patients randomized to treatment arms, 1525 experienced strokes; 1202 (79%) strokes were nonfatal. This study cohort includes 32 318 (97%) subjects who completed the baseline visual analogue scale QoL estimate.

Methods—
QoL was measured on a visual analogue scale and adjusted using a Torrance transformation (transformed QoL [TQoL]). Kaplan–Meier curves and adjusted proportional hazards analyses were used to estimate the effect of TQoL on the risk of stroke, on a continuous scale (0–1) and by quartiles (≤0.81, >0.81≤0.89, >0.89≤0.95, >0.95). We analyzed the change from baseline to first poststroke TQoL using adjusted linear regression.

Results—

After adjusting for multiple stroke risk factors, the hazard ratio for stroke events for baseline TQoL was 0.93 (95% confidence interval, 0.89–0.98) per 0.1 U increase. The lowest baseline TQoL quartile had a 20% increased stroke risk (hazard ratio=1.20 [95% confidence interval, 1.00–1.44]) compared with the reference highest quartile TQoL. Poststroke TQoL change was significant within all treatment groups (
P
≤0.001). Multivariate regression analysis revealed that baseline TQoL was the strongest predictor of poststroke TQoL with similar results for the untransformed QoL.

Conclusions—
The lowest baseline TQoL quartile had a 20% higher stroke risk than the highest quartile. Baseline TQoL was the only factor that predicted poststroke change in TQoL.

Clinical Trial Registration—

URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00000542.