bluuebunny/crossref_metadata_2025_split huggingface dataset:
EXTERNAL VALIDATION OF THE MANCHESTER ACUTE CORONARY SYNDROMES (MACS) DECISION RULE
Authors: Carlton E , Body R , Greaves K 
Published: November 2015

Objectives & BackgroundThe Manchester Acute Coronary Syndromes (MACS) decision rule has been shown to be a powerful diagnostic tool in emergency department (ED) patients with suspected acute coronary syndromes (ACS). It has the potential to improve system efficiency by identifying patients suitable for discharge after a single blood draw, for high-sensitivity troponin and heart-type fatty acid binding protein analysis, at presentation to the ED. We aimed to externally validate the MACS decision rule and establish its diagnostic accuracy as a discharge tool in a new set of prospectively recruited ED patients.MethodsIn this post-hoc analysis of a prospectively recruited single-centre cohort we included consecutive ED patients ≥18 years with suspected ACS. Testing for heart-type fatty acid binding protein and high-sensitivity troponin T was undertaken on serum drawn on arrival and clinical features required to calculate the MACS rule recorded. The primary outcome was major adverse cardiac events (MACE) within 30 days (acute myocardial infarction (AMI), death or revascularisation). The secondary outcome was AMI alone, adjudicated using 6 h troponin results.ResultsOf the 782 participants included, 78 (10.0%) developed MACE and 61 (7.8%) had an AMI. Of participants, 133 (17.0%) were identified as ‘very low risk’ and therefore suitable for immediate discharge with a 0% incidence of MACE or AMI. The sensitivity was 100% (95% CI 95.4–100) for MACE at 30 days and 100% (95% CI 94.1–100) for AMI. Of the ‘high risk’ group, 53.3% had a MACE within 30 days (Figure 1). The area under the ROC curve was 0.87 (95% CI 0.83–0.91) for the MACS rule in the prediction of MACE (Figure 2).ConclusionIn this prospectively recruited cohort, the MACS decision rule identifies a significant proportion of patients who are suitable for immediate discharge after a single blood draw at presentation, with a 0% risk of MACE. The rapid assessment and discharge of these patients is likely to reduce healthcare resource burden and costs.Figure 1Rates of AMI and MACE stratified by the MACS rule risk groups.Figure 2Receiver operating characteristic (ROC) curve showing the diagnostic accuracy of the MACS rule.
THE SIMPLIFIED MORTALITY IN SEVERE SEPSIS IN THE EMERGENCY DEPARTMENT (MISSED) SCORE TO RISK STRATIFY ED SEPSIS
Authors: Sivayoham N , Holmes P , Cecconi M , Rhodes A 
Published: November 2015

Objectives & BackgroundIn patients with sepsis, early intervention in the emergency department (ED) has been shown to reduce mortality. Early treatment requires early risk stratification. The criteria defining shock identifies some of the sickest patients. But not all patients who go on to die present with shock. Other scoring systems are available but they are labour intensive to use in a busy ED. The MISSED (Mortality in Severe Sepsis in the ED) score is a simple and easy to use score that was derived and validated to risk stratify ED patients with sepsis. But the population studied were ED patients admitted to the intensive care unit (ICU). This score has now been refined and simplified. The independent variables associated with mortality are: age ≥65 years, serum albumin ≤27g/l and an international normalised ratio (INR) ≥1.3. The simplified MISSED score ranges from 0 to 3 depending on the number of variables present.We aim to validate the simplified MISSED score in the ED population admitted with sepsis. The primary end point was in-hospital all-cause mortality. The secondary endpoint was the validation of the risk stratification for mortality and ICU admission.MethodsED patients admitted with a primary diagnosis of presumed infection in the year 2012 were studied. Patients missing data on any of the variables and those on warfarin were excluded. The simplified MISSED score was calculated for each patient. The test characteristics for mortality of the simplified MISSED score and the odds ratios of the high risk groups for the secondary end-points were calculated.Results674 patients including 65 deaths were studied. The area under the curve (AUC) for the simplified MISSED score was 0.74 [95% confidence interval (CI) 0.70–0.77]; p<0.0001. The test characteristics for mortality were: sensitivity 93.9% [85–98.3], specificity 37.9% [34.1–41.9], positive predictive value 13.9% [10.8–17.5] and negative predictive value 98.3% [95.7–99.5]. The addition of the septic shock criteria improves the sensitivity to 70.8% [55.9–83]. The odds ratio for mortality for a score≥2 was: 5.01 [2.93–8.57], p<0.0001 and that for ICU admission was 3.00 [1.70–5.28], p=0.0001. The specificity of a score of 3 for mortality is 97.7% (96.2–98.7).ConclusionThe simplified MISSED score could be used in addition to the septic shock criteria to risk stratify septic patients in the ED.
EARLY WHOLE BODY VERSUS FOCUSED COMPUTED TOMOGRAPHY IMAGING FOLLOWING MAJOR TRAUMA: EXISTING EVIDENCE AND ANALYSIS OF 10 YEARS OF TARN DATA
Authors: Hunt P , Bouamra O , Jenks T , Lecky FE , Edwards A , Woodford M , Yates D , Han K 
Published: November 2015

Objectives & BackgroundWhole Body Computed Tomography (WBCT) scanning is considered to be the chief imaging modality for patients with major trauma. There is growing evidence that the rate of survival is higher for patients undergoing early WBCT by facilitating rapid and accurate anatomical characterisation of potentially life-threatening injuries. There remains ongoing controversy whether this outweighs the potential risks from high-dose ionising radiation.MethodsData from the Trauma Audit and Research Network (TARN) trauma registry was analysed for all patients presenting from January 2005 to July 2014 inclusive aged 16 years or more admitted directly to hospital Emergency Departments (ED) with suspected severe blunt polytrauma. Survival was compared between two groups: (1) patients who underwent WBCT scans, and (2) those who underwent a focused CT (“non-WBCT”) scanning approach within the first four hours of arrival at the ED.Results14,598 (23·2%) of 62,942 eligible cases underwent WBCT directly from the ED within four hours of arrival. The calculated crude survival rate for the WBCT group was 89·2%, compared to 88·9% in the non-WBCT group (p=0·260). The results of multivariate regression analysis, taking account of all possible confounders, demonstrated a trend towards improved survival in the WBCT scan group, with an OR=1·080 (95% CI 0·986–1·183) compared to the non-WBCT group (p=0·098).ConclusionThe results of our investigation demonstrate a trend towards improved survival for adult patients with suspected severe blunt polytrauma undergoing WBCT scanning early in their management in the ED. Our analysis of the largest series of trauma cases investigating WBCT so far is the first to take account of all possible confounding factors including centre effect – often a major limitation for generalisability in previous studies of this kind. The existing evidence for the use of WBCT during the management of major trauma is also discussed in the context of these new results.Figure 1Figure 2
COLD, CRAMP & CANNOT CONTINUE IN SNOWDONIA MOUNTAIN CASUALTIES
Authors: Brazel N , Dykes L 
Published: November 2015

Objectives & BackgroundEach year, about 120 casualties from Snowdonia attend our ED following assistance from Search & Rescue (SAR) services. We have noticed an increase in uninjured mountain users requiring evacuation due to “cold, cramp & cannot continue” (CCCC). We offered to investigate further, in order to help target injury prevention education.MethodsWe interrogated our database of mountain casualties brought to our hospital following contact with Mountain Rescue Teams and/or RAF SAR helicopter 01/01/2004–16/11/2014. Age, sex & home postcode of CCCC casualties was noted. Surnames were used as a proxy estimate of ethnic origin.www.surmanedb.com was used to ascertain origin of surnames (Anglo-Saxon, W/E European – “European”; SE Asian, Middle East/Indian Subcontinent & African – “Black & Ethnic Minority/BME”).ResultsOf 1159 patients on the database, 56/1159 (4.8%) were CCCC. In 2004, the number of CCCC cases was one, remaining <5/yr until 2009, since when the number has been consistently >8/yr.Of 1115 casualties with a European surname, 43 (4%) were CCCC cf. 13/43 (29%) with a BME surname (p<0.0000001, Fishers Exact test) with an OR of 10.12 (95% CI 4.96–20.64).European surnames: 25/43 (58%) male, median age 32 (range 6–79, mean 36.7). BME surnames: 10/13 (77%) male, median age 26 (range 16–67, mean 29.7). 77% lived in the Birmingham or London conurbations.ConclusionNational Parks across the UK have been working since 2009 to increase the diversity of park users, so an increase in mountain casualties of BME origin is to be expected.We acknowledge that surname analysis provides only a crude estimate of likely ethnicity, and our database is smaller than the populations for which this technique is generally used. Nevertheless, there is a stark difference in the proportion of mountain casualties requiring rescue for CCCC whose surnames are of BME vs. European origin. This confirms anecdotal reports by SAR personnel.The most likely explanation is cultural. Few urban BME mountain users are taken hill-walking as children and may be unfamiliar with the misery of being wet, cold & weary with 2 hours walk to the car. There are also well-documented cultural differences in response to pain/discomfort.Alongside encouraging people of BME origin to utilize the fantastic leisure opportunities of Britain's National Parks, we must step up efforts to alert them to the challenges of outdoor activities in what can be a lethal environment for the unprepared.
IMPROVING THEIR EXPERIENCE—HOW CAN WE ENHANCE THE LEARNING ENVIRONMENT FOR MEDICAL STUDENTS IN THE ED?
Authors: Burton J , Turner C 
Published: November 2015

Objectives & BackgroundEDs and AMUs are potentially a rich source of learning for medical students. Spending time in emergency departments has been shown to be a great motivator for student learning, however these areas can be difficult environments for students to learn. Students are regularly asked to provide feedback on teaching. Little is known, however, about the factors students find important in providing high quality teaching. We aimed to complete a pilot study to ascertain which factors students consider to be important in delivering high and low quality teaching in busy clinical environments.MethodsWe decided on a sample size of 70, as it was felt this would represent a reasonable cross section of opinion.This is a 2 centre, multi department study of final year medical students in Warwickshire.A voluntary, anonymous questionnaire was given to each of the students undertaking the block.Demographics and free text responses around both the positive and negative experiences of the students were collected.Three clinical teaching fellows conducted a qualitative thematic analysis of the responses. Comments were coded through iterative discussion and consensus among the panel.ResultsThe ED was cited most frequently as the most valuable learning experience (84%) with majors the most popular area (38%).Being involved in patient care and friendly enthusiastic staff were most commonly cited as reasons for these being good learning experiences.Reasons for poor clinical experiences included a perceived lack of learning opportunities, being too busy and not feeling involved.Positive experiences included history taking, patient assessment and management/knowledge of specific conditions.Where students had a negative learning experience 13% stated that they did not learn anything, although others noted they learned of the life of a junior Dr.ConclusionThrough this pilot study a number of themes have emerged. Students wish to feel involved in patient care and friendly, enthusiastic staff have been identified as facilitators to student learning. The most frequently cited barrier to learning appears to be staff not helping identify the opportunities. This could be overcome by encouraging a culture where staff actively identify opportunities for the medical students, promoting interactive, inductive training in the acute setting.
WHAT MAKES A GOOD MEDICAL SHOP FLOOR LEADER?
Authors: Pell M , Khan R , Turner C , ilyas H , Rehman SR , gill S 
Published: November 2015

Objectives & BackgroundHigh quality leadership is associated with improved outcomes for patients and increased staff satisfaction. A combined team of clinicians from UHCW and HEFT felt that during this time of particular pressure, shop floor leadership qualities, as stated by other staff, would be of use to guide behaviours.AimsWe aimed to identify the qualities staff valued in shop floor medical leadership. We also aimed to identify behaviours that were felt to be unhelpful as well as identifying Senior tier doctors (Consultant/Middle Grade) who were most felt to run a good floor.MethodsWe conducted a qualitative survey across 3 departments in the West Midlands over one month in early 2015.We used an anonymous questionnaire which first collected demographics then responses to the following questions1) What characteristics do you associate with effective shop floor leadership?2) What characteristics do you associate with ineffective shop floor leadership3) Are any staff particularly good? Please tell us why.The responses were assessed to spot themes and agreed upon by the authors. Answers were codified by a group of 4 of the authors with disputes settled by discussion.ResultsA total of 101 responses were received with a broad spectrum of staff answering. All codified results were assessed and it was deemed the best way to represent the data was in the form of word clouds. Each word present in the cloud has a larger presence in relation to the frequency of it being mentioned as a response. Interestingly the attributes most highly regarded by staff were that the senior shop floor doctor was approachable and supportive. With less of a need for good communication skills or their enthusiasm at work. This would imply that staff see the senior doctor as being somebody to be able to turn to in need without fear of rebuke. This is reinforced by a high number of the negative attributes being aspects of interpersonal interactions and areas that would represent a barrier to being a supportive and approachable member of staff. The ability to aid decision making when turned to for advice is clearly relied upon as a key with both a lack of availability and then being unable to make decisions seen as negatives. Communication is not seen as positive attribute to be good at as much as it is seen to be a negative if its done poorly.ConclusionBeing approachable is viewed as a good characteristic in a leader with unavialability and bad interpersonal skills as a negative attribute.Figure 1Positive Attributes.Figure 2Negative Attributes.
PRE-HOSPITAL EMERGENCY SKILLS FOR MEDICAL STUDENTS
Authors: Wheeler C 
Published: November 2015

Objectives & BackgroundThere is an expectation amongst Doctors and the public that Doctors should be able to assist in medical and traumatic emergencies in the community. It is also a requirement of the General Medical Council that Doctors offer assistance. Pre-hospital care receives little attention in the majority of medical courses in the UK. At Manchester Medical School there is opportunity to study and gain experience in basic pre-hospital care for only a few students pursuing student selected modules. The aim of this study is to assess competence and confidence of medical students when dealing with pre-hospital emergencies.MethodsAll of the 115 students from the 3rd year medical students based at Manchester Royal Infirmary were asked to complete a questionnaire. Confidence with pre-hospital scenarios was assessed with Likert scale questions and competence was assessed using multiple choice questions.ResultsConfidence67% of participants reported they would be willing to try to approach the scene of an accident. Airway and cervical spine control, and motorcycle helmet removal received low confidence with 45% and 74% respectively reporting feeling really anxious or not very confident. Assessment of breathing had high levels of confidence with 61% reporting quite or very confident in this skill. Control of haemorrhage received average confidence (50%).CompetenceThe majority of students answered “Get help” for the scene approach question but only 33% assessed danger of the scene first. The immobilisation question was answered well with 82% of participants correct. There were relatively poor results for the questions regarding catastrophic haemorrhage and airway control with only 48% and 57% respectively answering correctly.Over 90% would be interested in attending a session focussed on pre-hospital care but relatively few have actually come across an incident where they were required to offer assistance.ConclusionThese results show that there is some anxiety amongst students about being able to manage pre-hospital emergencies in which the public might expect them to cope or in which they feel obliged to help. The results show that although students would be willing to help they may not posess the necessary knowledge to do so. They show that there is a demand for teaching focussed on these skills but that there is not necessarily a need for it taking into account the frequency of incidents encountered. A trial teaching programme will take place in July.
SYSTEMATIC REVIEW: INTRAVENOUS PARACETAMOL VERSUS INTRAVENOUS MORPHINE IN THE MANAGEMENT OF ACUTE RENAL COLIC
Authors: Navaratnam R , Parker S 
Published: November 2015

Objectives & BackgroundRenal colic is commonly managed in emergency departments worldwide. Initial treatment requires prompt and effective analgesia. The mainstay of analgesia revolves around non-steroidal analgesics and opiates. Though effective they are associated with a number of significant side effects.Paracetamol is available in a number of preparations. The intravenous route has been shown to be effective within 10 minutes of administration and is associated with few adverse side effects.The aim of this review is to assess the available evidence comparing the analgesic effect of intravenous paracetamol versus intravenous morphine in renal colic.MethodsA systematic review of medical databases was undertaken (June 2015). Databases searched included Embase (1946 to May 2015 Week 1), Medline (1946 to June 2015) Google Scholar and the Cochrane Database of Systematic Reviews.The terms searched were:1. (Renal colic OR ureteric colic OR nephrolithasis)2. (Acetaminophen OR paracetamol) AND morphineAfter the searches were combined, the following limits were imposed: English language, human subjects, aged 18–60, presenting acutely, use of intravenous forms of the drugs, the diagnosis of renal colic radiologically confirmed.ResultsA total of 66 papers were returned after the initial search. 3 further papers were identified following analysis of the references of search results. Abstracts were reviewed for inclusion, resulting in the exclusion of 66 studies.A total of 348 patients were analysed over 3 studies. Patient demographics, doses of paracetamol and morphine used and the measure of effect was similar across the studies.Mean baseline visual analogue pain scores were similar across studies (Mean: Paracetamol 8.05, Morphine 8.40). All 3 studies showed paracetamol reduced visual analogue pain scores at both 15 minutes (Mean: Paracetamol=4.32 vs Morphine=5.26) and 30 minutes (Mean: Paracetamol=2.55 vs Morphine=3.67) following administration. The need for ‘rescue’ analgesia was reduced in patients receiving paracetamol. The number of adverse events experienced by patients recieving paracetamol was less versus those receiving morphine.ConclusionReview of the literature suggests intravenous paracetamol is as effective as intravenous morphine in providing analgesia in acute renal colic. This effect was associated with a reduced incidence of adverse events and need for supplemental analgesia.
THE EFFECT OF TRIAGE ON PAEDIATRIC WAITING TIMES IN A PAEDIATRIC ASSESSMENT UNIT
Authors: Brittain C , Forster A 
Published: November 2015

Objectives & BackgroundOur hospital is in the process of increasing the number of hours its paediatric assessment unit (PAU) remains open in order to help patient flow within the emergency department. Previously we have used our ward based Paediatric Early Warning Score (PEWS) charts to triage these patients. However, in view of the increased demand on the department, a more PAU focussed triage tool was deemed necessary to primarily improve patient safety, but also patient experience through reducing waiting times.Whilst various paediatric triage tools have been developed for use within paediatric emergency departments, we could not find a tool for use within the PAU, which primarily sees the unwell rather than the injured child.Our aim was to assess whether we could construct a triage tool to identify the unwell child in order to result in them being seen sooner by a member of the medical team. We also hoped it would improve waiting times compared with the currently used PEWS method.MethodsWe devised a triage tool that was suitable for our PAU. This was based on The Emergency Severity Index, Leicester's Paediatric Observation Priority Score, the Modified Manchester Triage system, and the PEWS and Paediatric Acute Warning Score (PAWS) charts that are already in use within our hospital. We then compared waiting times for children to be seen who were assessed by the previously used PEWS, with those assessed with the triage tool. We also compared our breaches for waiting within the department for more than 6 hours.ResultsFor the week of the PEWS scoring, 89% had a PEWS 0–1, 5% had a score of 2–3, and 6% of 4+. The mean length of time to be seen was 39 min, 29 min and 0 min respectively. For the week using our triage tool, 69% scored green, 22% amber and 9% red. Average time to be seen was 44 min, 22 min and 32 min respectively.Using the PEWS method, senior review was outside the target time of two hours in 16%, compared with 3.7% with the triage tool. Patients were staying more than the recommended 6 hours in 5.8% of cases with PEWS and 2.96% with the triage tool.ConclusionOur triage tool appears to have improved breaches for time to senior review and as such has resulted in a reduction in length of stay within the department; thus improving patient turnover and flow between the emergency department and PAU. It has not however, improved the speed at which the unwell child is reviewed, this may be due to poor specificity of the tool.