bluuebunny/crossref_metadata_2025_split huggingface dataset:
Introduction of a Venous Thromboembolism Prophylaxis Protocol for Older Adult Psychiatric Patients.
Authors: Croxford Anna , Clare Adam , McCurdy Kathleen 
Published: May 2015

AbstractHospital-Acquired venous thromboembolism (VTE) is a common cause of morbidity and mortality in older adults. In psychiatric patients these risks are increased due to multiple factors including poor mobility, restraint, catatonia, sedation, and conventional antipsychotic use. Diagnosis and treatment of psychiatric patients presenting with signs and symptoms of a VTE can be delayed due to a patient’s communication difficulties, non-compliance, or attribution of symptoms to a psychosomatic cause.However, despite the increased risk, approved VTE prophylaxis protocols are infrequently used on Psychiatric wards. On one Older Adult Psychiatric Ward, two patients presented with VTE (a fatal pulmonary embolism and a symptomatic deep vein thrombosis) over a 6 month period demonstrating the necessity for prophylactic assessment. A baseline audit over 3 months showed that 63-83% of patients on the ward had received no assessment of VTE risk, on any given week, although this improved slightly following the critical incidents.A VTE prophylaxis protocol, based on NICE guidance for VTE risk assessment in Medical and Surgical patients, was developed with consideration given to additional Psychiatric risk factors. This took the form of a pro-forma with a tick-box design that included mobility assessment, VTE risk factors, bleeding risk factors, and guidance on prescribing decisions. This was implemented on an Older Adult Psychiatric ward and prophylaxis was provided to those meeting the threshold.Weekly audit of all pro-formas (including assessments completed within 48 hours of admission and prophylaxis prescription) was conducted after the pro-forma introduction from 1st February 2013 to 24th May 2013. Frequency of assessments increased after protocol implementation with between 36% and 85% of all patients being assessed for VTE risk post intervention. Fluctuations in numbers assessed may have related to ward pressures, staff changes, and practicalities of pro-forma use.After completion of the PDSA cycles the initiative was handed over to a specialist registrar for implementation across the other trust Older Adult Psychiatry wards, and further audit was planned to be conducted via junior doctors and established Quality Assurance systems. Discussion of integration of a condensed pro-forma into the trust electronic notes system is ongoing.
Coagulation assessment with the new generation of oral anticoagulants
Authors: Pollack Charles V 
Published: May 2015

Long-term oral anticoagulant (OAC) therapy is used for the treatment and prevention of thrombosis and thromboembolism. As OAC use is so widespread, emergency physicians are likely to encounter patients on anticoagulant therapy in the emergency department (ED) on a regular basis, either for the same reasons as the population in general or as a result of the increased bleeding risk that OAC use entails.The vitamin K antagonist warfarin has been the standard OAC for several decades, but recently, the newer agents dabigatran etexilate, rivaroxaban and apixaban (collectively, novel OACs, non-vitamin K OACs, or simply ‘NOACs’) have become available for long-term use. Protocols for assessing and managing warfarin-treated patients in the ED are well established and include international normalised ratio (INR) testing, which helps guide patient management. However, the INR does not give an accurate evaluation of coagulation status with NOACs, and alternative tests are therefore needed for use in emergency settings. This paper discusses what information the INR provides for a patient taking warfarin and which coagulation tests can guide the physician when treating patients on one of the NOACs, as well as other differences in emergency anticoagulation management.
IDENTIFICATION OF TRAUMATIC BRAIN INJURY (TBI) IN THE PRE-HOSPITAL SETTING
Authors: Trebilcock Hannah 
Published: May 2015

BackgroundIdentification of TBI is extremely difficult and is often missed in the pre-hospital setting. Major trauma triage tool (MTTT) criteria specifies the suspicion of an open or depressed skull fracture as indicating a major trauma patient. However, it is often the case that patients with TBI recorded on the Trauma Audit and Research Network (TARN) data with an ISS>15, indicating major trauma, are not identified by the MTTT. This results in many patients with significant TBI being undertriaged and not receiving definitive care as rapidly as possible. Early intervention in patients suffering TBI is essential in ensuring the best possible outcome.A retrospective clinical record review is being conducted to establish whether there are clinical or behavioural indicators of TBI that could be incorporated into clinical guidance to improve identification.MethodThe sample consists of 193 patients on the trauma database who have sustained a head injury between January–March 2014. For each of these incidents the patient clinical record (PCR) has been reviewed to provide data on many different demographic, physiological and behavioural aspects. All data has now been entered ready for analysis. Using the TARN data, patients will be divided into 2 groups. The experimental group will consist of those patients who have significant head injuries recorded by TARN. The control group will include the patients who have been identified as suspected major trauma with a head injury but have no corresponding injuries recorded on TARN.ResultsIt is anticipated that at least one demographic, physiological or behavioural aspect will be a reliable indicator of TBI.ImplicationsThis retrospective clinical record review could greatly improve the identification of major trauma patients who have sustained a serious head injury. In turn this will mean more patients being appropriately conveyed to the MTC where specialised neurosurgeons are available.
SNAPSHOT OF INITIATIVES TO SUPPORT TIMELY PATIENT HANDOVER FROM AMBULANCES TO THE EMERGENCY DEPARTMENT
Authors: Wells Bridget , Evans Bridie Angela , Porter Alison , Gammon Becky , Mayes Robert Harris , Poulden Mark , Rees Nigel , Snooks Helen , Toghill Alun , Whitfield Richard 
Published: May 2015

BackgroundIncreasing pressure on the emergency care system contributes to delays in patient handover from ambulances to emergency departments. The impact of these delays includes ambulance queues, sub-optimal care for patients, staffing and operational challenges, and (in England) financial penalties.New models of care have the potential to reduce handover delay. We surveyed ambulance services across England and Wales to produce a snapshot of initiatives under development or being trialled in order to address problems associated with handover delay.MethodsDuring 2014, we carried out semi-structured telephone interviews with R&D leads in all 11 independent ambulance service trusts in England and Wales. We asked respondents about initiatives taking place within their area, what evaluation was taking place, and what they believed to be the challenges to evaluation. Interviews were recorded and transcribed, and analysed using the Framework approach.ResultsInitiatives fell into three groups: prehospital; at the ED; and whole system. Prehospital initiatives comprised clinical decision support tools (n=6); alternative pathways (n=6); hospital capacity monitoring (n=3); automated data transfer (n=3). Initiatives at ED included handover screens (n=8); rapid access models (n=7); hospital ambulance liaison officers (n=6); corridor care (n=3). Whole system approaches included new models of collaborative working (n=2); service review (n=2). Challenges to implementing and evaluating change included the lack of standardised approaches to handover across multiple hospital trusts within an ambulance service area; many of the reported initiatives took place only in a small part of the ambulance service's operational area. Only five respondents reported evaluation of handover initiatives, and of these two were described as informal evaluation only. The need to report and comply with performance targets was reported as a more immediate pressure than evaluation of new developments.ConclusionsWhile there is a range of activity taking place across England and Wales to address handover delays, there is little formal evaluation and there are missed opportunities for transferable learning.
THE IMPACT OF INCREASING THE RUNNING TIME TO THE MAJOR TRAUMA CENTRE (MTC) TO 60 MINUTES IN THE SOUTH WEST
Authors: Trebilcock Hannah 
Published: May 2015

BackgroundMajor trauma guidelines specify that if the patient can be safely managed and the MTC can be reached within 45 minutes of leaving scene then the patient should be conveyed to the MTC. However, there is no evidence that supports the 45 minute timeframe. Given the rurality of the South West, an increase in the running time to the MTC to 60 minutes has been discussed amongst major trauma experts.MethodAn audit was conducted to identify how many patients could benefit from an increase in running time to 60 minutes. The sample included all suspected major trauma patients identified between April 2013–March 2014 who were conveyed to the nearest trauma unit (TU). Travelling times to the TU and MTC were analysed. Patients were split into network areas to quantify the impact if any.ResultsA maximum of 354 patients were identified as potentially benefitting from an increase to 60 minutes based on the travelling times to the TU and MTC. A minimum of 90 patients could have benefitted from an increase to 60 minutes. This was quantified by the patients who triggered the major trauma triage tool but were unable to reach the MTC in 45 minutes, and those confirmed by the Trauma Audit and Research Network (TARN) as having an ISS>15. The biggest impact would be seen in the Peninsula area where a total of 205 extra patients would be able to reach the MTC if the running time was increased.ConclusionAn increase in running time to 60 minutes to the MTC for patients in the South West could significantly improve the level of care that many patients receive in the first few hours following major trauma injuries. With the information available it is not possible to quantify the operational impact such a change would have.
EMERGENCY MEDICAL DISPATCH EFFECTIVENESS: A NEW UTSTEIN TYPE ANALYTICAL TOOL FOR STUDYING THE SPECIFIC STAGES IN THE CALL TAKING PROCESS
Authors: Barron Tracey , Fivaz Conrad , Overton Jerry 
Published: May 2015

BackgroundWhether a cardiac arrest treated by the ambulance service results in return of spontaneous circulation (ROSC), is dependent on the actions of the emergency call handler and their ability to induce bystander CPR.The objective was to develop an Utstein style reporting tool as a stand-alone software reporting module that also allows users and researchers to enrich current data collection by integrating standardised call handling data from the software version of the Medical Priority Dispatch System protocol (ProQA) into current Utstein based reports, resulting in a more accurate and detailed analysis of the specific stages of call taking.MethodsA consensus group met on two occasions to review the existing Utstein literature. Drawing on the published research as the foundation of their evidence, and the accumulated experience of the group in relation to the call handling process, they developed a template of specific data elements generated by the software for the Utstein style reporting tool. The template was then reviewed by technical experts to confirm that a tool with these elements could be developed.ResultsA total of eight time measurements (e.g., time at which a cardiac arrest is recognised), and 13 demographic/processing measurements (e.g., whether Pre-Arrival Instructions were given) were identified. These measurements are consistent between users, regardless of how they organise their dispatch processes. Each case contains a unique identifying number that allows users to integrate the data into their current Utstein reporting.ConclusionsThe newly developed reporting tool makes analysis and comparison of Emergency Medical Dispatch resuscitation data possible and meaningful using universal measurements. It allows for more detailed evaluation between cardiac arrest variables, including comparison between individual staff and centres, with a view to identifying areas for performance and system improvements.
ENSURING AN APPROPRIATE PRE-HOSPITAL RESPONSE TO PATIENTS IN SICKLE CELL CRISIS
Authors: Shaw Joanna , Fothergill Rachael , Virdi Gurkamal 
Published: May 2015

IntroductionSome ambulance services in the UK use the Medical Priority Dispatch System (MPDS) to triage 999 calls and determine the response allocated to patients. When MPDS was developed in the 1970s Sickle Cell Disease (SCD) was not common in the UK and was therefore not included in the system. As ethnic diversity in the UK increased so did the prevalence of SCD, yet ambulance services were still unable to identify this group of patients and assess their specific needs.Patients with SCD usually contact the ambulance service when they experience a Sickle Cell Crisis (SCC), which is characterised by severe pain. It is important ambulances arrive quickly to allow patients' pain to be managed in a timely manner. However, not having a way to identify these patients at the time of the 999 call means that patients potentially receives variable responses.MethodTo determine the level of care provided, a retrospective clinical audit was undertaken for patients who reported SCC. A questionnaire was sent to patients with SCD which was used to inform the development of an override to MPDS allowing Emergency Medical Dispatchers to allocate a faster response to patients reporting SCC at the time of the 999 call. Following the introduction of the over-ride, a re-audit was conducted.ResultsThe re-audit showed the majority of patients (62%) received an equal or a faster response in line with the updated MPDS protocol. This increase resulted in reduced waiting time for patients; from 11 minutes and 20 seconds to 9 minutes, an average of 2 minutes and 20 seconds faster than before the over-ride.ConclusionThe over-ride resulted in a quicker ambulance response which reduced the chances of the patient's condition worsening before the arrival of an ambulance. This project also provided evidence and allowed for the SCC override to be adopted nationally.
Measurement of nucleated red blood cells in the peripheral blood as a marker of hypoxia in sudden unexpected death in infancy
Authors: Zapata Vazquez Rita E , Coetzee André , Harlock Edward , Simmerson Mark , Cohen Marta C 
Published: May 2015

AimsA recently proposed classification of sudden unexpected infant death incorporates consideration of possibly asphyxia. This depends on an adequate postmortem, scene investigation and history. A reliable marker of asphyxia has yet to be identified. Such a marker could assist in classifying these deaths. Our aim was to determine if the level of nucleated red blood cells (nRBCs) in the peripheral blood could help identify those possibly asphyxia-related deaths and if risk factors could influence this level in the peripheral blood.MethodsCases of sudden unexpected deaths in infancy and sudden infant death syndrome (SIDS) which occurred over a period of 6 years (2007–2013) and were autopsied at Sheffield Children's Hospital were reviewed and categorised according to a new classification proposed by Randallet al. The cases were then correlated with the blood level of nRBCs determined at the time of post mortem examination. The study was approved by the Clinical Governance Department, number SE331.Results139 deaths were classified into Group A (true SIDS, 67 cases), Group B (possible asphyxia related, 24 cases), Group C (non-asphyxia-related, 6 cases), Group D (no crime scene investigation, 0 cases) and Group E (identifiable cause, 42 cases). The levels were significantly increased in ex-premature babies, in infants with an underlying condition (Group C) and in deaths related to illness or trauma (Group E). There was a trend towards higher levels of nRBCs in younger age groups and in babies born to smoking mothers.ConclusionsSIDS remains a difficult diagnosis to make despite the current medical technological advances where no marker of hypoxia has yet been identified.
Tumor-Promoting Desmoplasia Is Disrupted by Depleting FAP-Expressing Stromal Cells
Authors: Lo Albert , Wang Liang-Chuan S. , Scholler John , Monslow James , Avery Diana , Newick Kheng , O'Brien Shaun , Evans Rebecca A. , Bajor David J. , Clendenin Cynthia , Durham Amy C. , Buza Elizabeth L. , Vonderheide Robert H. , June Carl H. , Albelda Steven M. , Puré Ellen 
Published: May 2015

Abstract
Malignant cells drive the generation of a desmoplastic and immunosuppressive tumor microenvironment. Cancer-associated stromal cells (CASC) are a heterogeneous population that provides both negative and positive signals for tumor cell growth and metastasis. Fibroblast activation protein (FAP) is a marker of a major subset of CASCs in virtually all carcinomas. Clinically, FAP expression serves as an independent negative prognostic factor for multiple types of human malignancies. Prior studies established that depletion of FAP+ cells inhibits tumor growth by augmenting antitumor immunity. However, the potential for immune-independent effects on tumor growth have not been defined. Herein, we demonstrate that FAP+ CASCs are required for maintenance of the provisional tumor stroma because depletion of these cells, by adoptive transfer of FAP-targeted chimeric antigen receptor (CAR) T cells, reduced extracellular matrix proteins and glycosaminoglycans. Adoptive transfer of FAP-CAR T cells also decreased tumor vascular density and restrained growth of desmoplastic human lung cancer xenografts and syngeneic murine pancreatic cancers in an immune-independent fashion. Adoptive transfer of FAP-CAR T cells also restrained autochthonous pancreatic cancer growth. These data distinguish the function of FAP+ CASCs from other CASC subsets and provide support for further development of FAP+ stromal cell-targeted therapies for the treatment of solid tumors. Cancer Res; 75(14); 2800–10. ©2015 AACR.
Evolving Information Needs among Colon, Breast, and Prostate Cancer Survivors: Results from a Longitudinal Mixed-Effects Analysis
Authors: Tan Andy S.L. , Nagler Rebekah H. , Hornik Robert C. , DeMichele Angela 
Published: May 2015

Abstract
Background: This study describes how cancer survivors' information needs about recurrence, late effects, and family risks of cancer evolve over the course of their survivorship period.
Methods: Three annual surveys were conducted from 2006 to 2008 in a cohort of Pennsylvania cancer survivors diagnosed with colon, breast, or prostate cancer in 2005 (round 1, N = 2,013; round 2, N = 1,293; round 3, N = 1,128). Outcomes were information seeking about five survivorship topics. Key predictors were survey round, cancer diagnosis, and the interaction between these variables. Mixed-effects logistic regression analyses were performed to predict information seeking about each topic, adjusting for demographic variables, clinical characteristics, and clustering of repeated observations within individuals.
Results: Information seeking about reducing risks of cancer recurrence was the most frequently reported topic across survivors and over time. Breast cancer survivors were more likely to seek about survivorship topics at round 1 compared with other survivors. In general, information seeking declined over time, but cancer-specific patterns emerged: the decline was sharpest for breast cancer survivors, whereas in later years female colon cancer survivors actually sought more information (about how to reduce the risk of family members getting colon cancer or a different cancer).
Conclusion: Cancer survivors' information needs varied over time depending on the topic, and these trends differed by cancer type.
Impact: Clinicians may need to intervene at distinct points during the survivorship period with information to address concerns about cancer recurrence, late effects, and family members' risks. Cancer Epidemiol Biomarkers Prev; 24(7); 1071–8. ©2015 AACR.
Subclonal Genomic Architectures of Primary and Metastatic Colorectal Cancer Based on Intratumoral Genetic Heterogeneity
Authors: Kim Tae-Min , Jung Seung-Hyun , An Chang Hyeok , Lee Sung Hak , Baek In-Pyo , Kim Min Sung , Park Sung-Won , Rhee Je-Keun , Lee Sug-Hyung , Chung Yeun-Jun 
Published: May 2015

Abstract
Purpose: The intratumoral heterogeneity (ITH) and the evolution of genomic architectures associated with the development of distant metastases are not well understood in colorectal cancers.
Experimental Design: We performed multiregion biopsies of primary and liver metastatic regions from five colorectal cancers with whole-exome sequencing and copy number profiling.
Results: In addition to a substantial level of genetic ITH, multiregion genetic profiling identifies the subclonal mutational architecture, leading to the region-based or spatial categorization of somatic mutations and the inference of intratumoral evolutionary history of cancers. The universal mutations (those observed in all the regional biopsies) are enriched in known cancer genes such as APC and TP53 with distinct mutational spectra compared with biopsy- or region-specific mutations, suggesting that major operative mutational mechanisms and their selective pressures are not constant across the metastatic progression. The phylogenies inferred from genomic data show branching evolutionary patterns where some primary biopsies are often segregated with metastastic lesions. Our analyses also revealed that copy number changes such as the chromosomal gains of c-MYC and chromothripsis can be region specific and the potential source of genetic ITH.
Conclusions: Our data show that the genetic ITH is prevalent in colorectal cancer serving as a potential driving force to generate metastasis-initiating clones and also as a means to infer the intratumoral evolutionary history of cancers. The paucity of recurrent metastasis-clonal events suggests that colorectal cancer distant metastases may not follow a uniform course of genomic evolution, which should be considered in the genetic diagnosis and the selection of therapeutic targets for the advanced colorectal cancer. Clin Cancer Res; 21(19); 4461–72. ©2015 AACR.