bluuebunny/crossref_metadata_2025_split huggingface dataset:
THE ANTICOAGULATION OF CALF THROMBOSIS (ACT) PROJECT: RESULTS FROM THE RANDOMISED CONTROLLED EXTERNAL PILOT TRIAL
Authors: Horner D , Hogg K , Body R , Nash M J , Mackway-Jones K 
Published: September 2013

Objectives & BackgroundThere is currently little evidence defining the clinical importance of detecting and treating isolated distal deep vein thrombosis (IDDVT). Contemporary international guidelines vary regarding diagnostic and therapeutic advice. The potential benefits of anticoagulation remain poorly defined. We sought to evaluate the feasibility of a randomised controlled trial within a modern emergency department cohort.MethodsA pragmatic, open label, external pilot randomised controlled trial conducted from January 2011 to April 2012. Consecutive ambulatory symptomatic IDDVT patients were approached for inclusion. Participants were randomised to receive either conservative management (control) or phased therapeutic anticoagulation (intervention). All patients underwent assessor blinded color duplex imaging after 7 and 21 days, and clinical follow up at three months. Principal feasibility outcomes were recruitment rate and attrition. The primary clinical outcome was a composite of proximal propagation, pulmonary embolism, death attributable to venous thromboembolic disease or major bleeding. Analysis was by intention to treat.ResultsAcute IDDVT was detected in 93 cases. 79 were subsequently deemed eligible and 70 (88.6% of those eligible) recruited. 59/70 (84.3%, 95% CI 74.0–91.0%) patients completed the full protocol. All patients but 1 were followed up by direct contact after 90 days. Allocation crossover occurred in 15 (21.4%) cases. All predefined feasibility outcomes were achieved. The primary clinical outcome occurred in 4/35 (11.4%) controls and 0/35 in the intervention group (Absolute Risk Reduction [ARR] 11.4%, 95% Confidence Interval [CI] −1.5 to 26.7, p=0.11, number needed to treat [NNT] of 9). There were no cases of major bleeding in either group. Propagation to any site occurred in 11/35 (31.4%) of conservatively treated patients compared with 2/35 (5.7%) of those randomized to anticoagulation (ARR 25.7%, 95% CI 5.9 to 44.3%, P=0.001, NNT 4). Minor bleeding occurred in 3/35 (8.6%) controls and 7/35 (20.0%) anticoagulated patients (p=0.31).ConclusionWe have established feasibility for a definitive trial on the value of therapeutic anticoagulation for IDDVT. Our pilot study currently provides the largest prospective randomised clinical dataset on this topic and demonstrates a non-significant trend towards reduction in complications with anticoagulation.
FRACTURE PATHWAY REDESIGN IMPROVES EMERGENCY DEPARTMENT EFFICIENCY
Authors: Vardy J , Rymaszewski L , Begbie K , Anthony I , Chekroud M , Clark K , Ireland A J 
Published: September 2013

Objectives & BackgroundThe Redesigned Fracture Pathway has revolutionised fracture management, decreased orthopaedic workload and improved the patient journey. The Pathway consists of guideline driven treatment of patients with fractures. There is no follow up for many stable injuries, virtual review of other fractures and orthopaedic registrar referral for admission decisions. Many discharged patients never receive a clinic appointment necessitating the development of discharge information leaflets and a move from plaster casts to Velcro splints. Have orthopaedics simply passed their workload onto the Emergency Department?1) Patients with fractures are discharged with no follow up, does this necessitate longer consultations in ED?2) Without routine follow up do patients simply pitch back up to ED?3) Has the admissions process actually improved?MethodsWe examined length of consultations, unplanned reattendances to ED within 7 days, number of Orthopaedic admissions and time from first assessment to admission before and after Fracture Clinic Redesign.Results1) Length of consultation was unchanged for discharges without follow up, (p=0.316, 0.508, 0.571). Consultations were shorter when splints replaced casts, (p=0.046, 0.588, 0.032).2) Unplanned reattendances within 7 days did not increase as a proportion of ED attendances, (p=0.779).3) Orthopaedic admissions fell by 7.9% and time from first assessment to admission by 9.6% per annum (p=0.002, p=0.011). Orthopaedic breaches decreased significantly, (p<0.001).ConclusionDirect discharges from ED do not require longer consultations nor do they return to ED. Orthopaedic admission is increasingly efficient and breaches are down. Is Fracture Pathway Redesign good for the Emergency Department? Yes!
A STUDY TO ASSESS THE VALUE OF THORACIC COMPUTED TOMOGRAPHY IN PAEDIATRIC TRAUMA PATIENTS
Authors: Avanis M C , Liu Y M , McLeod K , Thorpe E , Masters J , Vaidya M 
Published: September 2013

Objectives & BackgroundComputed tomography (CT) is becoming increasingly popular as a primary imaging modality in adult trauma patients. This study aims to examine the added value of thoracic CT (TCT) in the context of paediatric trauma.MethodsRetrospective review of the case notes of 182 consecutive paediatric trauma patients aged 16 and younger who received a chest X-ray (CXR) prior to TCT between January 2010 and April 2012 at a large tertiary paediatric trauma centre in East London.ResultsThe main mechanisms of injury involved were road traffic accidents (50%), stab injuries (31%), and falls (14%). One hundred and twenty one patients (66%) underwent a TCT scan following a normal CXR. Of these, thirty four (28%) patients had new injuries detected. These included lung contusions (n=20), small pneumothoraces (n=5) and rib fractures (n=3). Of the 61 (34%) patients that had a TCT scan following an abnormal CXR, 26 (43%) had additional injuries detected. These included lung contusions (n=8), fractured ribs (n=6) and small pneumothoraces (n=6). The additional information from the TCT did not alter clinical management in any of the above cases.ConclusionThis study indicates a need for a comprehensive guideline for imaging in paediatric trauma, where the use of TCT is limited to specific patients, especially in view of the health implications that CT poses and source of financial burden for the NHS.
DELAYED ONSET OF SUBGALEAL HAEMATOMAS ASSOCIATED WITH SKULL FRACTURE FOLLOWING ACCIDENTAL HEAD TRAUMA
Authors: Melhem N Z , Abrahamson E L 
Published: September 2013

Objectives & BackgroundSubgaleal haematoma is associated with skull fracture in infants and young children. If the onset is reported to have appeared some time after the suggested mechanism, history may be placed in doubt raising safeguarding concerns. This can lead to social care intervention driven by medical opinion. We performed this study to evaluate our hypothesis that delay in haematoma is common in simple accidental head trauma.MethodsWe performed a 10 year retrospective review (2003–13) of all cases of skull fracture under 2 years of age presenting to our paediatric emergency department. We analysed the case records of those who had a delayed presentation with subgaleal haematoma, as defined as more than 24 hours after the injury, or where no injury was recalled.ResultsA total of 47 eligible patients were included. 12 (26%) presented more than 24 hours after reported injury (24 to 504 hours, mean 137) and a further 3 (6%) had no reported accident to explain a fracture. All of these cases presented with isolated subgaleal haematomas and no other clinical symptoms or signs. One case had intracranial abnormalities on CT scan whilst the remainder had simple linear skull fractures. In 8 of the 12 cases with a history of injury (67%), safeguarding concerns were carefully considered and excluded. No safeguarding considerations were documented in the 4 other cases. In the 3 cases with no history of injury, full child protection assessments occurred.ConclusionWhilst every case of skull fracture in infants and young children must be thoroughly assessed for safeguarding concerns, our findings suggest that delayed onset of a subgaleal haematoma can be consistent with accidental injury. It is important to take this into account when offering medical opinion on such cases, to avoid unnecessary social care and legal intervention.
HOW DOES CONFIDENCE IN PRACTICAL AND CLINICAL MANAGEMENT CHANGE FOLLOWING FOUR MONTHS WORKING IN THE EMERGENCY DEPARTMENT?
Authors: Everitt E , Whitehead A 
Published: September 2013

Objectives & BackgroundThere is a lack of information available about how the skills of Foundation Doctors develop over their time spent working in the Emergency Department (ED). Knowing this could better focus future training. We wanted to examine to what extent working in the ED influences confidence of Year 2 Foundation Doctors in managing common conditions seen in the ED and in performing practical procedures.MethodsQuestionnaires were given to F2 doctors at the beginning and end of their four month EM jobs at sites within the Pennine Acute Hospitals NHS Trust. These measured confidence in performing eleven practical skills and managing eleven common scenarios seen in the ED. Subjects scored confidence from 0 to 10.Results11 full sets of data were obtained. There was a global improvement in confidence. The greatest mean improvement in skills was in suturing (mean improvement of 5 points) and the smallest in arterial stab (mean improvement 0.9 points). The lowest confidence rating before and after the study period was removing a foreign body from an eye (Mean improvement 1.5 to 5/10). Confidence in patient management improved most in paediatric emergencies; managing a wheezy child and a febrile child with a rash (mean improvements 3.2 and 3.0 points respectively). The smallest improvement was in managing chest pain though initial scores for this were high (mean 7 improving to 9/10). Confidence managing a febrile child with a rash was initially the lowest (mean 5 increasing to 8/10).ConclusionThe ED provides good exposure for improving the skills of foundation doctors. The greatest improvement was in areas doctors had not experienced elsewhere (e.g. paediatrics, suturing, diagnosing fractures).
STREET DOCTORS ARE WE MAKING AN IMPACT?
Authors: McCartan N , Colclough J M , Crewe J P , Munn C J , Berry S A , Reeder C , Loster N 
Published: September 2013

Objectives & BackgroundStreet Doctors is an initiative set up by Liverpool medical students in 2008. The organisation aims to reduce the morbidity and mortality associated with violent crime by equipping ‘at risk' young people with basic life support and first aid skills. The high prevalence of violent crime is indicated by NHS data from 2011/12, showing that 4,490 people were admitted to hospitals across England due to assault with a sharp object. With over 120 student volunteers, Street Doctors is now established in 6 cities where knife crime is becoming a persistent and worrying concern.MethodsA survey was carried out to assess the impact that Street Doctors make during teaching sessions. For each group, there were two teaching sessions; covering basic management of haemorrhage, the recovery position and cardiopulmonary resuscitation. A questionnaire was created in which answers were quantified on a scale of 0–10 (with 10 representing the most positive score). These were given to the young offenders to be answered at the beginning and end of each session.ResultsThe results showed that 50% of the young people had seen someone be shot or stabbed. Of these, 93% felt comfortable speaking about their experiences within the sessions (scoring ≥5/10). 71% of the young offenders noted that they would feel more confident dealing with these situations after attending our teaching, associated with a mean improvement of 1.42 (p=0.04).ConclusionThese results show the positive impact that street doctors are making. The vast majority of attendees leave feeling more confident in their ability to deal with a knife or gunshot wound in the critical moments before an ambulance arrives. As an ever expanding organisation, Street Doctors has an increasing potential to pass on the valuable skills that may one day be used to save a person's life.
THE ACCURACY OF EXISTING PRE-HOSPITAL TRIAGE TOOLS FOR INJURED CHILDREN IN ENGLAND–AN ANALYSIS USING TRAUMA REGISTRY AND EMERGENCY DEPARTMENT DATA
Authors: Cheung R , Ardolino A , Lawrence T , Bouamra O , Lecky F E , Berry K , Chaudhury A , Issa S , Koralage N , Lyttle M D , Maconochie I K 
Published: September 2013

Objectives & BackgroundPre-hospital triage is becoming increasingly important as Regional Trauma Networks for children are implemented in England. The low incidence of trauma in children makes pre-hospital assessment of injury severity and where to send an injured child challenging. Currently there are few validated pre-hospital triage tools for children's trauma and no consensus on which to use. We investigate performance characteristics of pre-hospital paediatric triage tools currently in use in England for identifying injured children.MethodsWe identified a total of eight pre-hospital paediatric triage tools (six in current usage in England). Each tool was interrogated using 701 retrospective clinical episodes from the Trauma Audit and Research Network (TARN–representing severely injured children) and from 2934 patient records in four English Emergency Departments (representing moderate to minor injuries). Target rates for under– and over-triage were set as <5% and <25–50% respectively.ResultsFrom TARN data, two triage tools demonstrated acceptable under-triage rates (3% and 4%) for severe injuries but unacceptable over-triage of moderate injuries (83% and 72%). Two tools demonstrated acceptable over-triage (7% and 16%) with unacceptable under-triage (61% and 63%). Four tools demonstrated unacceptable under- and over-triage.For moderate and minor injuries, three tools demonstrated acceptable under- and over-triage rates (all 0%). The other five tools had unacceptable under-triage rates (25–100%). All eight tools had acceptable over-triage rates (1%–21%). (See tables 1 and 2)Abstract 004 Table 1Performance characteristics of pre-hospital paediatric trauma triage tools–TARN/severe injuriesToolnISS>15Undertriage rate (%)Overtriage rate (%)East Midlands701230383London472North West780Northern977South West London; Surrey1259Wessex3923Paediatric Trauma Score617Paediatric Triage Tape283946316Abstract 004 Table 2Performance characteristics of pre-hospital paediatric trauma triage tools–Moderate/minor injuriesToolnISS>15Undertriage (%)Overtriage (%)East Midlands29344018London2511North West021Northern019South West London; Surrey509Wessex507Paediatric Trauma Score1001Paediatric Triage Tape18114753ConclusionFor severe injuries, none of the pre-hospital triage tools for injured children currently used in England meet recommended criteria for over- and under-triage rates. For moderate to minor injuries, all tools achieved acceptable over-triage rates but tended to under-triage. There is an urgent need for development of triage tools to accurately risk-stratify injured children in the pre-hospital setting.
REDUCING ADVERSE EFFECTS FROM INTRAVENOUS N-ACETYLECYSTEINE TREATMENT OF PARACETOMOL POISONING: PRINCIPAL RESULTS OF THE SCOTTISH AND NEWCASTLE ANTEMETIC ORE_TREATMENT FOR PARACETAMOL POISONING (SNAP) RANDOMISED CONTROLLED TRIAL
Authors: Gray A , Dear J , Thanacoody R , Thomas S , Eddleston M , Sandilands E , Coyle J , Cooper J , Rodriguez A , Butcher I , Lewis S , Vliegenthart A , Veiraiah A , Webb D , Bateman N 
Published: September 2013

Objectives & BackgroundParacetamol poisoning is common worldwide. Standard intravenous N-acetylcysteine (NAC) therapy is complex, and commonly associated with concentration-related adverse effects and the potential for administration errors. We aimed to determine whether adverse effect incidence could be reduced by antiemetic pre-treatment and/or a simpler and shorter intravenous N-acetylcysteine regimen.MethodsWe delivered, in 3 centres, a randomised factorial trial comparing a modified 12 h (100 mg/kg over 2 h, 200 mg/kg over 10 h) with a standard 20.25 h NAC regimen (150 mg/kg 15 min, 50 mg/kg 4 h, 100 mg/kg 16 h) with and without pre-treatment with ondansetron (4 mg IV). The primary endpoint was absence of retching, vomiting or need for rescue antiemetic at 2 h; secondary endpoints included the incidence of anaphylactoid reactions, the need for medication or treatment interruption, and hepatic toxicity (ALT, INR).ResultsIn 217 participants, retching and vomiting were less common with ondansetron than placebo (OR 0.406, 97.5% CI 0.205–0.803, p=0.0031) and with the modified compared to the conventional acetylcysteine regimen (OR 0.260, 97.5% CI 0.130–0.518, p<0.0001). Frequency of anaphylactoid reactions was not affected by ondansetron, but less common with modified acetylcysteine; severe reactions 5/108 (4.6%) vs. 31/100 (31%) (p<0.0001). The proportion of patients with a 50% increase in ALT was not significantly different comparing conventional with modified regimens (OR 0.603, 97.5% CI 0.199–1.831), but more common with ondansetron than placebo (OR 3.295, 97.5% CI 1.013–10.723, p=0.0235).ConclusionIn patients with paracetamol poisoning requiring acetylcysteine, adverse effects were substantially reduced by ondansetron pre-treatment and by using a modified, shorter treatment regimen. Ondansetron, but not the modified regimen, increased the frequency of liver function abnormalities. If large effectiveness studies confirm the modified regimen is non-inferior to conventional then shorter and safer treatment would be possible for this common poisoning.
TOPICAL LIGNOCAINE TO IMPROVE ORAL INTAKE IN CHILDREN WITH PAINFUL INFECTIOUS MOUTH ULCERS: A BLINDED RANDOMISED PLACEBO-CONTROLLED TRIAL
Authors: Hopper S , Tancharoen C , McCarthy M , Lee K J , Davidson A , Babl F 
Published: September 2013

Objectives & BackgroundTo establish the efficacy of 2% viscous lignocaine in increasing oral intake in children with painful infectious mouth conditions compared with placebo.MethodsRandomised placebo–controlled trial of viscous lignocaine versus placebo at a single paediatric emergency department. Study staff, clinicians, nurses, care givers, and participants were blinded to the group assignment. Children with acute infectious ulcerative mouth conditions (gingivostomatitis, ulcerative pharyngitis or hand foot and mouth disease), and poor oral fluid intake were randomised to receive 0.15 ml/kg of either 2% viscous lignocaine or placebo with identical appearance and flavor. The primary outcome was the amount of fluid ingested in the 60 minutes following administration of the intervention. Secondary outcomes were specific ml/kg fluid targets and the incidence of adverse events.Results100 participants were recruited (50 per treatment group) all of whom completed the 60 minute fluid trial period. Oral intake one hour after drug administration was similar in both groups: lignocaine–mean (standard deviation) 9.48 ml/kg (7.02 ml/kg) vs. placebo 9.32 ml/kg (7.39 ml/kg); mean difference 0.15 ml/kg (95% confidence interval –2.7 ml/kg to 3.0 ml/kg; p=0.9). No evidence for difference between groups was found in secondary outcomes and there were no adverse events in either group.ConclusionViscous lignocaine is no better than a flavoured gel placebo in improving oral intake in children with painful infectious mouth ulcers.
Mental health status and gender as risk factors for onset of physical illness over 10 years
Authors: Matheson Flora I , Smith Katherine L W , Moineddin Rahim , Dunn James R , Glazier Richard H 
Published: September 2013

BackgroundThere is a growing interest in understanding the connection between mental illness (MI) and the onset of new physical illnesses among previously physically healthy individuals. Yet the role of gender is often forgotten in research focused on comorbidity of health problems. The objective of this study was to examine gender differences in the onset of physical illness in a cohort of respondents who met criteria for MI compared with a control cohort without mental health problems.MethodsThis cohort study, conducted in Ontario, Canada, used a unique linked dataset with information from the 2000–2001 Canadian Community Health Survey and medical records (n=15 902). We used adjusted Cox proportional survival analysis to examine risk of onset of four physical health problems (chronic obstructive pulmonary disorder, asthma, hypertension and diabetes) for those with and without baseline MI across a 10-year period (2002–2011) among respondents aged 18–74 years. We controlled for socioeconomic and health indicators associated with health.ResultsThe incidence of physical illness in the MI cohort was 28.5% among women and 29.9% among men (p=0.85) relative to controls (23.8% and 24%, respectively; p=0.48). Women in the MI cohort developed secondary physical health problems a year earlier than their male counterparts (p=0.002). Findings from the Cox proportional survival regression showed that women were at 14% reduced risk of developing physical illness, meaning that men were more disadvantaged (HR=0.89, CI 0.80 to 0.98). Those in the MI cohort were at 10 times greater risk of developing a secondary physical illness over the 10-year period (HR=1.10, CI 0.98 to 1.21). There was no significant interaction between gender and MI cohort (HR=1.05, CI 0.85 to 1.27).ConclusionsPolicy and clinical practice have to be sensitive to these complex-needs patients. Gender-specific treatment and prevention practices can be developed to target those at higher risk of multiple health conditions.
THE REGRESSION DISCONTINUITY DESIGN: A NOVEL APPROACH TO ASSESSING THE REAL-WORLD EFFECTIVENESS OF HUMAN PAPILLOMAVIRUS (HPV) VACCINATION ON ANOGENITAL WARTS
Authors: Smith Leah , Strumpf Erin , Levesque Linda , Kaufman Jay 
Published: September 2013

BackgroundThe human papillomavirus (HPV) vaccine and corresponding vaccination programs have been in Canada for over six years, yet there is no information on their effectiveness in reducing anogenital warts.ObjectivesTo assess the effect of the HPV vaccine (vaccine impact) and Ontario's Grade 8 HPV vaccination program (program impact) on anogenital warts using the Regression Discontinuity Design (RDD; a quasi-experimental, instrumental variable-based technique used to assess the causal effects of policy interventions).MethodsBy linking Ontario's 36 immunization databases with provincial health records, we will identify a population-based cohort of all girls in Grade 8 in 2003/04-2008/09. Girls will be followed from September 1 of Grade 8 until August 31 of Grade 11. Exposure will be categorized based on HPV vaccine program eligibility (2003/04-2006/07 vs. 2007/08-2008/09) and actual vaccine receipt (0-2 vs. 3 doses). Outcomes will be identified based on a new diagnosis of and treatment for anogenital warts. For the RDD analysis, a continuous instrument will be created using birth month and year, where December 1993 (end of ineligible birth cohort) and January 1994 (start of eligible birth cohort) define the program eligibility cut-off. To estimate the program impact, local linear regression will be employed at the cut-off; here, exposure will be based on program eligibility (intention-to-treat). To estimate vaccine impact, we will use two-stage local linear regression, which will account for actual vaccination status. Several strategies will be used to test and minimize potential confounding bias – e.g., comparison of baseline characteristics, use of triangular kernel, optimal bandwidth selection.ResultsBased on preliminary data (21 immunization databases), we identified a cohort of 155,999 ineligible and 75,508 eligible girls (N=231,507). Eligibility cohorts were similar across factors like age, urban/rural status, and vaccination history, suggesting they are balanced on factors other than program exposure. A graph of the probability of vaccination by instrument confirmed two additional RDD assumptions – there was discontinuity in exposure at the cut-off (4.6% vs. 45.8%) and no discontinuities at locations other than the cut-off.ConclusionsPreliminary results confirm the RDD is appropriate for use in this context. Complete, provincial-level results will be available by June 2013.