bluuebunny/crossref_metadata_2025_split huggingface dataset:
IN PATIENTS WITH SUSPECTED CORD COMPRESSION, CAN DIRECT REQUEST FOR MRI IN THE EMERGENCY DEPARTMENT IMPROVE PATIENT SAFETY?
Authors: Padfield Emma , Hall Sharon J , Keep Jeff , Fleming Graham 
Published: August 2014

Objectives & BackgroundTo determine whether the Emergency Department (ED) could effectively identify patients with suspected cauda equina or cord compression who warranted further investigation with MRI, and thus request MRI without prior review from neurosurgeons.MethodsThe ED proforma for management of patients with back pain was assessed with focus on the referral pathway from the ED to neurosurgeons (NS). Patients attending the ED during a 3 month period with a complaint of back pain and subsequent referral to the neurosurgeons were identified using the Symphony database. Electronic records and paper notes were used to assess the time between arrival in the ED and referral to neurosurgeons, and the time from referral to MRI. The MRI request and patient notes were used to assess the appropriateness of the referral.Results1055 patients attended with back pain during the three month period. 40 patients were referred to the neurosurgeons by an ED doctor. 34/40 were deemed to require an MRI by the neurosurgeons. In 4/6 who did not have an MRI the proforma had not been followed correctly. 1/6 did not have an MRI but was later found to have cauda equina when imaged as an outpatient. 1 patient was admitted under neurology. 7/34 had either cauda equina or severe canal stenosis requiring surgery. Median time to MRI from ED referral was 237 minutes with a wait time of 100 minutes for NS review prior to MRI. On 7 occasions when NS requested MRI without seeing the patient first, time to MRI was 108 minutes compared with 290 minutes if requested after review by NS. If MRI was requested by the ED it is estimated time to MRI could be reduced by 182 minutes.ConclusionThere was good correlation between ED and NS opinion on the need for MRI. Detection rate for cauda equina/severe stenosis (20.6%) was in keeping with other studies in the literature. There is significant time delay in the current referral process which can delay emergency treatment and may adversely affect patient outcome, and one patient was missed despite the proforma recommending MRI. ED doctors should request MRIs directly in the case of suspected cauda equina/cord compression .Patient outcomes at each stage.Outcome of MRI including detection rate of cauda equina or severe spinal stenosis.Times between being seen by ED doctor, NS referral and MRI in all patients and patients subsequently requiring an emergency operation.
IMAGING PAEDIATRIC FACIAL INJURIES IN THE EMERGENCY DEPARTMENT
Authors: Long Linzie , Trivedy Chet , Crossman Richard J , Flowers Ms Joanne , Cooke Matthew W 
Published: August 2014

Objectives & BackgroundFacial injuries are a common presentation to the ED with data suggesting that this may be as high as 4%. There is little data on the epidemiology of paediatric facial injuries and how these are managed by the ED team. The exposure of structures such as the eyes, brain and thyroid to ionising radiation may be potentially harmful and at present there are no nationally agreed guidelines on which patients require imaging in the ED. The aim of this study was to look at the patterns of imaging in a cohort of paediatric facial injuries presenting to an ED in the West Midlands.A comparison of the imaging requests for the paediatric and adult facial injuriesCT HeadCT FacePA MandibleOPGTMJOMOrbitChild8117404864Adult100241714022669411MethodsA retrospective note review of all facial injuries presenting to any one of the three sites that make up the Heart of England NHS Foundation Trust in 2012 was conducted. Electronic records were examined to look for the mechanism of injury, disposal as well if any imaging had been performed during the initial presentation. Where imaging was performed the actual imaging as well as formal radiology reports were accessed to ascertain for the presence or absence of a facial fracture.ResultsPaediatric facial injuries made up 1131/3416 (33%) of the overall number of facial emergencies presenting to the ED in 2012. The mean age for the children was 6.9±4.3 years. 32% of the children were female as opposed to 68% who were male. 164/1131(14.5%) children were imaged and of these only 17/164 (10.4%) were confirmed to have a fracture. In contrast 47% of the adults were imaged and 26% of these were confirmed to have a facial fracture. Chi-squared tests demonstrated that the proportion of patients who had imaging requested was significantly lower in the paediatric cohort when compared to adults (P<0.005). Also the difference in the numbers of confirmed facial fractures in those who were imaged was significantly lower in children when compared to the adults (P<0.005). Occipitomental (OM) and orthopantomograms (OPG) were the commonest facial views requested for both the paediatric and adult facial injuries.ConclusionThe study highlights that paediatric facial injuries are less common than adult facial injuries and that facial fractures make up only 1.5% of all paediatric facial injuries. Clinicians should consider this when requesting facial X-rays given the potential harm of ionising radiation to the head and neck region. Further studies are in progress to develop evidence based guidelines for imaging children with facial injuries within the ED.The table refers to the total number of different imaging requests and not the number of patients imaged. Some patients had more than one type of imaging requested.
SAVING THE CRITICALLY INJURED TRAUMA PATIENT: A RETROSPECTIVE ANALYSIS OF 1000 USES OF INTRAOSSEOUS ACCESS
Authors: Lewis Pip , Wright Chris 
Published: August 2014

Objectives & BackgroundIntraosseous (IO) access is becoming increasingly accepted in adult populations as an alternative to peripheral vascular access, however there is still insufficient evidence in large patient groups supporting its use.MethodsRetrospective review. This paper reports on the use of intraosseous devices over a 7 year period from August 2006 to August 2013 during combat operations in Afghanistan. A search of the Joint Theatre Trauma Registry (JTTR-UK), a database of all trauma patients treated by Defence Medical Services in Iraq and Afghanistan, was carried out looking for all the incidences of intraosseous access use during this time. Adults were defined as patients aged 17 or above. Patient demographics, injuries, treatments and complications were retrieved. The results were collated and analysed using Excel TM (Microsoft).Results1014 intraosseous devices were used in 830 adult patients with no major complications. The rate of minor complications, the majority of which were device failure, was 1.38%. 5124 separate infusions of blood products or fluids occurred via intraosseous access, with 36% being of packed red cells. On average each casualty received 6.95 different infusions of blood products and fluids, and 3.28 separate infusions of drugs through intraosseous access. 32 different drugs were infused to 367 patients via IO, the most frequent being anaesthetic agents. Intraosseous access was used in the pre-hospital environment, during tactical helicopter evacuation and within hospitals.ConclusionIntraosseous access can be used for the infusion of a wide variety life saving medications, quickly, easily with low complication rates. This highlights its valuable role as an alternative method of obtaining vascular access, vital when resuscitating the critically injured trauma patient.
PAIN SOLUTION IN THE EMERGENCY SETTING (PASTIES); AN OPEN-LABEL RANDOMISED TRIAL OF PATIENT-CONTROLLED ANALGESIA (PCA) VERSUS ROUTINE CARE IN PATIENTS ATTENDING THE EMERGENCY DEPARTMENT WITH TRAUMATIC INJURIES
Authors: Smith Jason E , Rockett Mark , Squire Rosalyn , Hayward Chris , Creanor Siobhan , Ewings Paul , Barton Andy , Pritchard Colin , Benger Jonathan 
Published: August 2014

Objectives & BackgroundPain is the commonest reason that patients present to an Emergency Department (ED), but is often not treated effectively. Patient controlled analgesia (PCA) is used in other hospital settings but there is little evidence to support its use in emergency patients. This study (one of two parallel trials) aimed to assess the effectiveness and cost-effectiveness of PCA in emergency patients with traumatic injuries.MethodsProspective multi-centre randomised trial of PCA versus routine care (nurse-titrated analgesia) in emergency department patients presenting with traumatic injuries, who required IV opioid analgesia and admission to hospital. Participants were randomised to receive either routine care or PCA, and followed for the first 12 hours of their hospital stay. The primary outcome measure was hourly participant-recorded pain, scored using a visual analogue scale (VAS), with primary statistical analyses based on the standardised (scaled from 0–100) area-under–the-curve (AUC) of each participant's pain scores, with adjustment for time of admission, centre and baseline pain score.Results200 participants (71% male) were recruited from 4 centres, mean (SD) age of 43 (15.0) years. Preliminary analysis showed mean (SD) standardised pain AUCs were 47.2 (21.9) for the routine care group and 44.0 (24.0) for the PCA group. Provisional adjusted analyses indicated a slightly lower (but not statistically significant) standardised pain AUC in the PCA group than for the routine care group (mean difference (routine care -PCA): 2.7; 95% confidence interval; –2.4 to 7.8).ConclusionProvisional results indicate that there is no statistically significant reduction in pain using PCA compared to routine care for emergency department patients with traumatic injuries. Further analyses are in progress, in particular, of total morphine consumption and cost-effectiveness.
DETERMINING THE EFFECTIVENESS OF EDUCATIONAL INTERVENTIONS IN PAEDIATRIC EMERGENCY CARE
Authors: Roland Damian , Charadva Creana , Coats Tim , Matheson David 
Published: August 2014

Objectives & BackgroundDemonstrating educational interventions improve patient care can been difficult. This study aimed to perform an extensive assessment of a bespoke e-learning package on the NICE Feverish illness in Children Guideline to aid the development of an evaluation model.MethodsAn e-learning package was designed featuring an interactive traffic light table page. For each of the 5 domains and the three risk categories there was a video describing the features within that domain. The e-learning package also contained a pre- and post- learning section consisting of a demographic questionnaire, an attitudinal survey and knowledge testing. The weblink to the e-learning package was distributed to 12 Emergency Departments throughout England in August 2012.ResultsA total of 202 junior doctors expressed an interest in undertaking the intervention, 115 (56.9%) commenced the package, 91 (45.3%) completed the pre-learning and 58 (28.7%) completed the post-learning.There was an average 1 point improvement (scale 1–10) in perceived safety, confidence and competence in relation to management of febrile children after the package had been completed (p<0.0001). The Knowledge Test scores improved significantly in MCQs (Z −3.942, p<0.001). ROLMA matrices, a previously published methodology of describing adherence to evidence based practice, were used to examine case-notes of children with undifferentiated febrile illness at the lead site (n=48 patient pre-intervention and n=20 patients post-learning). There was a trend to improved evidence based management in the post learning group but this was not significant (Chi-Square 2.776, p=0.096). Overall data in the lead department demonstrated a rise in admissions of children with undifferentiated fever compared to 2011 but less than the 5 previous years despite a rise in presentations over that time.In respect of satisfaction and success with the e-learning system 83.6% (56/67) participants agreed or strongly agreed.ConclusionIt is important any educational intervention is thoroughly examined as positive findings in respect of satisfaction or knowledge gain may not equate to behaviour change. The continued poor assessment of educational interventions results in potentially continued poor practice or educational technique. A new framework for evaluation (the 7Is) will be presented as a solution.
INTRANASAL KETAMINE FOR PROCEDURAL SEDATION
Authors: Hall Dani , Robinson Alison 
Published: August 2014

Objectives & BackgroundThe safety of intravenous ketamine in procedural sedation is well described.1 2Guidelines produced by NICE3and the College of Emergency Medicine4are used by Emergency Departments (ED) nationwide. To avoid cannulation, opioids are frequently administered to children intranasally5, avoiding first-pass metabolism.6Intranasal ketamine (INK) is an effective analgesic in children7and has been successfully utilised in prehospital and military settings.8 9However, a recent survey revealed that INK is not currently in use in UK paediatric EDs.10To determine the current level of evidence of the use of INK in procedural sedation in children we developed a clinical scenario and three part question.A 4 year old child presents with a lip laceration. Options for closure are under procedural sedation in the ED or general anaesthetic in theatre. You feel he would be suitable for procedural sedation. Your department's policy is intravenous ketamine. However the child is very upset and you feel the trauma of cannulation will adversely affect quality of sedation. Would INK be an alternative?MethodsIn [children undergoing procedural sedation] does [intranasal ketamine] result in [rapid onset, safe, effective sedation without prolonged recovery]?Using the search strategy outlined in table 1, seven relevant papers were identified.11–18ResultsEfficacyINK can be successfully used to sedate children for dental procedures at 3–6 mg/kg.11–135 mg/kg facilitates cannulation prior to induction of anaesthesia.14–16An ED based double-blinded RCT compared sedation with 3,6 and 9mg/kg INK17. The study was small and was terminated early due to high sedation failures.SafetyAll studies demonstrated 3–9 mg/kg INK is safe, with no serious adverse events.EfficiencyAt 3–9mg/kg, time to onset ranged from 3.6–9.4 minutes with recovery time between 30–69 minutes.11–17ConclusionAn ideal agent for procedural sedation in the Paediatric ED is safe, easily delivered with rapid onset and recovery. The limited but growing evidence supports the use of INK to achieve this, although ideal dose is still unclear. All published studies to date have varying flaws with strict protocols defining adequate sedation and a lack of validated dissociative sedation scale potentially limiting reported success. More studies are emerging with a recent proposal presented to the PERUKI group. INK may still make its way into Paediatric EDs in the not too distant future.
Abstract P1-07-06: Effect of biospecimen variables on proteomic biomarker assessment in breast cancer
Authors: Meric-Bernstam F , Akcakanat A , Chen H , Sahin A , Tarco E , Carkaci S , Adrada B , Singh G , Anh-Do K , Garces Z , Mittendorf EA , Babiera G , Wagner J , Bedrosian I , Krishnamurthy S , Symmans WF , Gonzalez-Angulo AM , Mills G 
Published: August 2014

Abstract
Background: PI3K/Akt/mTOR signaling is being actively pursued as a therapeutic target. We sought to determine how tumor heterogeneity and biospecimen variables affect assessment of PI3K/Akt/mTOR pathway activation.
Methods: Intraoperative image-guided core-needle biopsies (CNB) of primary breast tumors were prospectively collected in 53 patients with invasive breast cancer. After surgery, specimens were collected from the center and periphery of the excised tumor. CNB, central and peripheral surgical specimens were assessed with reverse phase proteomic arrays (RPPA), H&E and immunohistochemistry (IHC).
Results: The expression of standard of care markers ER, PR, and HER2 by RPPA correlated well between biospecimen types. Overall, there was a significant correlation between the expression of 132 (86%) of 154 different markers in the center and periphery; the correlation was significantly higher for smaller tumors, and with shorter cold ischemia time. Expression of many investigational prognostic markers and druggable targets on CNB correlated with expression in the surgical specimen (average of center and periphery), while others, such as EGFR and c-MET, had a weak correlation. Of 154 RPPA markers, 132 (86%) were not statistically different between the center and periphery, and 97 (67%) were not different between the CNB and the surgical specimen. On analysis of the PI3K/AKT/mTOR pathway, pAkt S473 and PTEN had a significant correlation between central and peripheral specimens, and between CNB and surgical specimens. However, pAkt S473, pS6 S235/236 and pS6 240/244 levels were higher in CNB than the central specimens both by RPPA and by IHC. When patients were classified by RPPA PI3K pathway activation score, there was a moderate agreement between classification on the CNB and central specimens (Cohen's Kappa 0.539). However 9 of 20 tumors classified as having PI3K activation on CNB were classified as not having pathway activation on central specimens.
Conclusions: There is remarkable homogeneity in expression of biomarkers within a tumor. However, proteomic markers are differentially expressed by biospecimen type and other preanalytic variables. PI3K pathway activation is greater in CNB compared to surgical samples.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-06.
Abstract P1-14-18: Overall survival results of a multicenter randomized phase II study in locally advanced breast cancer patients treated with or without celecoxib for HER2 negative tumor (Remagus 02 trial)
Authors: Giacchetti S , Pierga J-Y , Delaloge S , Asselain B , Brain E , Guinebretière JM , Che-Lehman J , Mathieu M-C , Sigal B , Marty M 
Published: August 2014

Abstract
Background: Cox 2 is frequently over expressed in breast cancers. Celecoxib is a COX-2 inhibitor with anti angiogenic and pro-apoptotic activities. There are few data of anti-COX2 treatment in breast cancers. and no data on the impact of neoadjuvant anti COX 2 agent on survival.
Patients and methods/: From May 2004 to October 2007, 340 stage II-III breast cancer patients were included in a phase II randomized trial and received 4 cycles (c) of epirubicin (75 mg/m2)–cyclophosphamide (750 mg/m2) q 3 w followed by 4 (c) of docetaxel (100 mg/m2) q 3 w. Pts with HER2 negative tumors (220 pts) were randomized to receive or not neoadjuvant celecoxib (200 mg bid) combined with docetaxel. All pts with hormone receptors positive tumor received hormonal treatment according to menopausal status (Pierga et al BCRT 2010). We report here overall survival (OS) and disease free survival (DFS) data and prognostic factors analyses at 5 years.
Results/: At a median follow up of 49 months, the median DFS and OS are not reached for the whole population and none of them is significantly different between pts who received celecoxib or who did not (p = respectively 0.62 and 0.36). Celecoxib had no impact either on clinical and pathological complete response rate (pCR). DFS is significantly higher in patients who achieved pCR as compared to those who did not (p = 0.017; RR = 0.21 [0.051–0.88], whereas OS is borderline significant [p = 0.07; RR = 0.19 (0.026–1.4)]. Patients with triple negative (TN) tumors (78 pts) achieved worst DFS (p = 0.02) and OS (p &lt;0.001) than non triple negative ones despite their higher pCR rate, 29.5 % [95 % CI 19;7-40;9 %] vs 11.4 % in all the other subgroups. At multivariate analysis including 7 factors [tumor size, clinical lymph node, grade (1 vs. 2and 3), pCR, ER, PR, TN], factors which influenced OS and DFS were pCR (p = 0.034 & 0.013 and PgR expression (p = 0.046 & 0.01).
Conclusion/: Celecoxib had no influence on pCR, DFS or OS. Despite higher pCR rate triple negative breast cancer patients' subgroup remains with the poorest outcome.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-18.
Abstract P1-14-19: Breast-Conserving Surgery after Neoadjuvant Chemotherapy is Oncologically Safe for Stage III Breast Cancer Patients
Authors: Shin H-C , Han W , Moon H-G , Im S-A , Park S-J , Noh D-Y 
Published: August 2014

Abstract
Background The use of breast-conserving surgery (BCS) in patients with large breast tumors downstaged by neoadjuvant chemotherapy (NCT) remains controversial in clinical stage III breast cancer patients because of the possibility of residual tumor and resistance to NCT. The aims of this study were 1) to evaluate the local recurrence (LR) rate depending on the use of NCT and 2) to determine the oncologic safety of BCS after NCT by comparing LR between patients treated with preplanned/downstaged BCS and patients treated with NCT and mastectomy in clinical stage III breast cancer patients.
Patients and Methods Between 2000 and 2007, 166 patients with clinical stage III breast cancer received BCS or mastectomy after NCT (NCT group) and 193 patients with clinical stage III breast cancer who underwent surgery first (Surgery group). Among 166 patients of the NCT group, 94 patients (56.6%) received mastectomy after NCT (mastectomy after NCT group), 39 patients (23.5%) received preplanned BCS (preplanned BCS group) and 33 patients (19.9%) received downstaged BCS (downstaged BCS group). The LR rates between the groups were compared.
Results At a median follow-up period of 66.9 months (range, 6.5 to 104.1 months), 11 patients in the NCT group and 7 patients in the Surgery group had developed LR. The 5-year LR-free survival rates were 93.6% in the NCT group and 95.9% in the Surgery group and the LR rates were not significantly different between the groups (p = 0.196). In the NCT group, LRs were observed in 6 patients in the mastectomy after NCT group, 3 patients in the preplanned BCS group and 2 patients in the downstaged BCS group. The 5-year LR-free survival rates were 94.4% in the mastectomy after NCT group, 92.0% in the preplanned BCS group and 93.9% in the downstaged BCS group, respectively (p = 0.953).
Conclusions Our study demonstrated that the LR was not different depending on the use of NCT in the clinical stage III breast cancer patients. Also, clinical stage III breast cancer patients who received preplanned or downstaged BCS after NCT showed similar LR-free survival rates compared to patients who received mastectomy after NCT. This result supports that BCS after NCT in clinical stage III patients is oncologically safe in terms of LR if primary breast tumor size has became 5cm or less after NCT.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-19.