bluuebunny/crossref_metadata_2025_split huggingface dataset:
1695 Which clinical features best predict occult scaphoid fracture? A systematic review and meta-analysis
Authors: Coventry Laura , Oldrini Ilaria , Novak Alex , Dean Ben , Metcalfe David 
Published: December 2022

Aims, Objectives and BackgroundScaphoid fractures require early identification to avoid complications such as painful non-union, avascular necrosis, and chronic wrist pain. Unfortunately, plain radiographs are insufficiently sensitive and so patients may require immobilisation and further imaging (e.g. MRI) despite normal initial radiographs.The aim of this systematic review was to determine which clinical features best predict the presence of an occult scaphoid fracture that warrants immobilisation and further imaging.Method and DesignA systematic review of diagnostic test accuracy studies was undertaken. All study designs were included if they evaluated predictors of scaphoid fracture amongst patients with normal initial scaphoid radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Depending on the number of studies, data were presented as individual data points, ranges, or meta-analysed by fitting either univariate random effects or multi-level mixed effects logistic regression models.Results and ConclusionEight studies reported data on 1,685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 7.3%. The most accurate predictors of occult scaphoid fracture were pain with supination against resistance (sensitivity 100%, specificity 97.9%, LR 45.0 [95% CI 6.5–312.5], supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR 3.7 [95% CI 2.2–6.1]), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR 2.3 [95% CI 1.8–3.0]), and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR 2.0 [95% CI 1.2–3.2]). The absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1, specificity 48.4, LR- 0.2 [95% CI 0.4–0.7]).In conclusion, no single feature can satisfactorily exclude occult scaphoid fracture. However, a number of clinical findings significantly affect the pre-test likelihood of fracture. Future work should determine whether combinations of clinical findings can be used to guide which patients require immobilisation and further imaging despite normal initial radiographs.
1704 Feasibility of implementing a 0–2 troponin algorithm in routine clinical practice
Authors: Ford Sarah , Krishnanandan Sarah , Collinson Paul 
Published: December 2022

Aims, Objectives and BackgroundRecent guidelines for Acute Coronary Syndrome have recommended rapid diagnosis based on repeat sampling at 2 hours from admission. We investigated the feasibility and diagnostic equivalence of repeat measurement at 2 hours by comparing the diagnostic classification achieved by measurement at 0 and 2 hours with a delta value of <=3 between samples to measurement at 0 and 3 hours and a delta of <=7ng/L between samples.Method and DesignFrom August to November 2021 all patients with chest pain where a diagnosis of acute coronary syndrome (ACS) was considered had a diagnostic protocol of measurement of cardiac troponin T (cTnT) on admission and at 2 and 3 hours from admission. Requests and results were extracted from the laboratory information system including date and time of result. Data was transferred to a relational database (Access, Microsoft corp) for analysis. Non-parametric statistics were used throughout using the Analyse It.(www.analyse-it.com) add in for Excel.Cardiac troponin T (cTnT) was measured by the Roche high sensitivity cardiac troponin T assay hs-cTnT (Roche diagnostics), range 3 – 10,000ng/L, 10% CV 13ng/L, 99th percentile 14 ng/L.Results and Conclusion728 sets of serial samples where obtained on 711 patients, 40.1% female median age 61.8 years,(interquartile range 50.6–75). Comparison of classification is shown in table 1. Overall agreement was good but there were 6 cases where a positive 3 hour delta occurred with a 2 hour delta of 3 or less. 4 had values exceeding the 99th percentile on the admission sample so would have been retained for further investigation. The remaining 4 patients had co-existing clinical conditions that required further investigation.Abstract 1704 Table 1ClassificationDelta ≤3 at 2 hDelta >3 at 2 hDelta ≤7 at 3 hours55837Delta >7 at 3 hours635Abstract 1704 Figure 1ConclusionThe routine use of serial sampling at admission and 2 hours was clinically safe and resulted in the same clinical decisions in the context of the busy ED environment for the population served by the hospital.
1337 Evaluation of a trauma unit bypass tool in predicting major trauma
Authors: Freshwater Els 
Published: December 2022

Aims, Objectives and BackgroundIn order to direct patients to specialist Major Trauma Centres (MTCs), triage is performed at the scene of an incident to evaluate the extent of a patient’s injuries. The most severely injured patients are then transported directly to an MTC, even if there is a closer ED. This process is known as ‘Trauma Unit Bypass’ (TUB) and decision support tools are provided for use by ambulance service providers. This study aims to evaluate a tool in current operational use and suggest amendments which may improve its performance in clinical practice.Method and DesignData from a period of 12-months (1065 cases) were used to evaluate the performance of a TUB tool used in an English ambulance service. Data were sourced from the Trauma Audit and Research Network (TARN) and ED records and case reviews were performed to extract the required information. Statistical analysis was performed to evaluate the accuracy of the tool in identifying major trauma, defined as an Injury Severity Score (ISS) greater than 15. Further analysis was undertaken to make recommendations for alterations to the toolResults and ConclusionThe sensitivity of the Wessex TUB is 51.3% and the specificity is 71.3% which makes the tool a poor predictor of major trauma. The tool could be improved by altering thresholds for vital signs (blood pressure and Glasgow Coma Scale) and by providing clarity around the injury findings.This study provides the first full evaluation of this tool in clinical practice and makes some recommendations to improve performance. This could lead to more accurate identification of patients who have suffered major trauma and ensure they are transported to an appropriate specialist centre. However, it was identified that ISS>15 may not be the most useful outcome measure and it is recommended that a new definition is developed which more accurately describes need for MTC input.
1397 ’I don’t have time’: strategies for increasing research engagement in emergency department clinicians
Authors: Jarman Heather , Halter Mary , Moss Phil , Seel Claire 
Published: December 2022

Aims, Objectives and BackgroundClinicians who engage in generating research knowledge are more likely to implement findings in practice leading to better patient outcomes. Having an emergency department (ED) culture that gives significance to research is an important factor in supporting clinicians to develop the skill and ability to participate and perform research.In 2018 the ED at St George’s Hospital, London introduced an embedded research group with a dedicated leadership position, bringing together research delivery staff and clinical academics to increase the research culture in the department. This study aimed to investigate the impact of this model on research engagement amongst the ED clinical multi-disciplinary team.Method and DesignA case study design approach was used involving:A registry of the research-related initiatives undertaken in the departmentAnalysing the metrics of engagement in research activities by clinical staff, including number of publications and academic training uptakeData were collected between April 2018 and March 2022.Results and ConclusionRegistry data show 41 distinct initiatives established in the time period led or delivered by the research group. These included face-to-face teaching, publication writing support, a research internship program and small grant funding. Research outputs (publications or conference abstracts) showed a 23-fold increase from two in 2018 to 47 in 2021.The project to develop a research culture in ED has had a positive effect on both type and number of research-related activities across all clinical staff groups. This case study illustrates how research activities delivered close to clinical practice under visible, focused clinical research leadership can increase research engagement. Challenges of a clinically complex context were overcome by embedding a multidisciplinary clinical research unit, linking research delivery with clinical academic development. This model could be replicated in other settings.
1718 Another CT aortogram request? A 1 year retrospective case note review of all ED-requested CT aortograms
Authors: Manouchehri Shahab , Wilson Sarah , Ticehurst Francoise 
Published: December 2022

Aims, Objectives and BackgroundAcute aortic pathologies have a high mortality rate and can be difficult to diagnose in the Emergency Department (ED). We wanted to know what our local positive diagnosis rate was from ED-requested CT aortograms (CTA).Method and DesignThe radiology department provided a list of all CTA requested by ED during 2019. A retrospective notes review was conducted using the ED notes to identify diagnoses of acute aortic pathology and other positive diagnoses. Our ED saw approximately 90,000 adult patients in 2019.Results and Conclusion201 CTA were requested by ED in a single year (2019).5 (2.4%) scans diagnosed acute aortic syndrome (AAS), with an additional 3 scans that identified thoracic aortic aneurysm without AAS.13 (6.5%) abdominal aortic aneurysms were identified of which 2 had ruptured.In addition, 24 (11.9%) patients had non aortic pathologies identified from the scan (6 gallstones, 3 pneumonia, 3 renal colic, 2 metastatic disease, 2 pancreatitis, 2 pulmonary embolism, 6 ‘other’ diagnoses).Of those with confirmed AAS, only one had an ADD-RS (aortic dissection detection risk score) of 2 (>2 recommend straight to CTA), four had a score of 0 or 1 and none had a D-dimer recorded.It is sometimes perceived that CTA has a low diagnostic yield, but 23% of patients scanned in our cohort were able to have a positive diagnosis made after their scan, with approximately half of identified pathology being non-aortic.
1455 A 10-year review of insulin-related enquiries to the UK National Poisons Information Service (NPIS)
Authors: Moyns Emma , Ferner Robin , Euan Sandilands , Gray Laurence , Thanacoody Ruben , Bradberry Sally 
Published: December 2022

Aims, Objectives and BackgroundMore than 4.9 million people in the UK have diabetes, and sufferers are at increased risk of depression.1We reviewed enquiries to the NPIS about insulin overdose.Method and DesignRetrospective analysis of enquiries between 1 November 2011 and 31 October 2021.Results and ConclusionWe received 1195 enquiries involving insulin. Further analysis was limited to the 169 enquiries involving insulin only (90.5% via injection).Most enquiries (88%) concerned adults ≥ 18 years. There were 34 non-diabetic and 98 diabetic patients: 32 Type 1, 10 Type 2, and 56 type undocumented. Exposures were intentional (n=114, 68%), from therapeutic error (n=28), accidental (n=16) or circumstances unknown (n=11).Long-acting insulins were involved in 71 cases, and the highest dose was 20000 units (table 1). The lowest recorded blood glucose concentration (mmol/L) at the time of the enquiry was in the range 0–0.9 (n=7), 1.0–1.9 (n=29), 2.0–2.9 (n=25), 3.0–3.9 (n=12), >4.0 (n=14). Hypokalaemia (defined as K+<3.5 mmol/L) was noted in 26 (n=15%) enquiries. The maximum Poisoning Severity2(n=162) was graded: none (n=55), minor (n=29), moderate (n=44), and severe (n=34).Treatments given prior to contacting the NPIS were IV glucose (n=91, 54%), IV/IM glucagon (n=26, 15%), IV octreotide (n=6, 4%) and IV corticosteroids (n=2, 1%). No patient underwent surgical excision of the injection site. Long-acting insulins accounted for 5/6 cases where octreotide was given.Abstract 1455 Table 1Details of dose, insulin type, nadir blood glucose concentration, and Poisoning Severity Score in 169 cases of insulin poisoning reported to the UK National Poisons Information Service in the ten years to 31st October 2021. Ø = unrecordableInsulin type*Median dose Units (range)Lowestblood glucoseconcnmmol/L (mg/dL)Known diabeticpatientsMaximum poisoning severityModeraten% of all moderateSeveren% of all severeLong acting (N=71)600 (10–20000)Ø492352%1441%Medium acting (N=24)900 (60–4500)0.6 (11)11818%721%Short acting (N=14)75 (28–2000)1.6 (29)737%13%Ultrashort acting (N=35)180 (1.5–4800)1 (18)231023%515%Unknown (N=18)188 (45–400)Ø800%721%Canine (N=7)20 (7–1600)4.2 (76)000%00%*Where two or more insulin types or mixtures were involved (n=55, 32.5%), the longest-acting component was counted.ConclusionsHypoglycaemia following insulin overdose was mostly managed satisfactorily by intravenous glucose infusion, with glucagon used occasionally. The role of octreotide and corticosteroids was unclear. Approximately 20% of cases were severe, especially following overdose of medium- and long-acting insulins; we recorded no fatalities.Referenceshttps://www.diabetes.org.uk/professionals/position-statements-reports/statistics. Accessed February 2022.Persson HE, Sjöberg GK, Haines JA, De Garbino JP. Poisoning severity score. Grading of acute poisoning.J Toxicol Clin Toxicol1998;36: 205–213.
1632 Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies
Authors: Oldrini Ilaria , Coventry Laura , Novak Alex , Gwilym Steve , Metcalfe David 
Published: December 2022

Aims, Objectives and BackgroundPre-reduction radiographs are conventionally used to exclude important fracture before attempts to reduce a dislocated shoulder in the Emergency Department. However, this step increases cost, exposes patients to ionising radiation, and might delay closed reduction. Some studies have suggested that pre-reduction imaging may be omitted for a sub-group of patients with shoulder dislocations.The objective was to determine whether clinical predictors can identify patients that might safely undergo closed reduction of a dislocated shoulder without pre-reduction radiographs.Method and DesignA systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data were pooled and meta-analysed by fitting univariate random effects and multi-level mixed effects logistic regression models.Results and ConclusionEight studies reported data on 2,087 shoulder dislocations and 343 concomitant fractures. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (LR+ 1.8 [95% CI 1.5–2.1]; LR- 0.4 [0.2–0.6]), female sex (LR+ 2.0 [1.6–2.4], LR- 0.7 [0.6–0.8]), first time dislocation (LR+ 1.7 [1.4–2.0]; LR-0.2 [0.1–0.5]), and presence of humeral ecchymosis (LR+ 3.0–5.7; LR- 0.8–1.1). The most important mechanisms of injury were: high-energy mechanism fall (LR+ 2.0–9.8), fall >1 flight of stairs (LR+ 3.8 [95% CI 0.6–13.1]; LR- 1.0 [95% CI 0.9–1.0]), and motor vehicle collision (LR+ 2.3 [0.5–4.0]; LR- 0.9 [0.9–1.0]). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6–99.2%) and specificity (33.3%, 23.1–45.3%) but the Fresno-Quebec rule maintained 100% sensitivity across three studies that included 564 shoulder dislocations and 98 fractures.In conclusion, the Fresno-Quebec Rule has undergone both internal and external validation and may now have a role in clinical practice.
1412 Cervical spine immobilisation in ambulatory patients
Authors: Phillips Hannah , Savadia Krishna , Johnson Graham 
Published: December 2022

Aims, Objectives and BackgroundApproximately 2500 people suffer a traumatic cervical spinal fracture per year in the UK, of which 10–14% have an associated spinal cord injury. Emergency department practice was changed after Sundstrom et al (2014) found existing evidence for cervical spine collars to be weak. From April 2015 a new guideline was implemented in the Royal Derby Hospital removing the routine use of cervical collars for certain groups. This allowed patients who self-presented to the ED who met the Canadian C-spine criteria for radiographic imaging to remain free from immobilisation devices and undergo standing plain films or self-position for CT imaging.Method and DesignA retrospective case note review was carried out from April 2009 to September 2021. Patients with a confirmed diagnosis of cervical spine fracture were identified and those who did not arrive by ambulance were selected for analysis. Their case notes were reviewed for fracture site, time since injury, neurological symptoms and clinical management.Results and ConclusionCervical spine fracture was diagnosed in 30 patients each year on average over the study period. Fifteen per cent were not conveyed by ambulance. Over 70% of patients presented more than 4 hours after their injury. The most common site of injury was C6/7 (50%) followed by C2 (30%). Those patients who self-presented to the emergency department and were subsequently diagnosed with a cervical spine fracture suffered no adverse outcomes. Self-presentation to the emergency
1692 A multi-centre prospective observational study to evaluate healthcare impacts of e-scooters on emergency departments
Authors: Roberts Tom ,   Trainee Emergency Research Network Collaborators (TERN)
Published: December 2022

Aims, Objectives and BackgroundThis study aims to report the prevalence of E-scooter related injuries, delineate the impact of rental schemes on Emergency Departments (ED) and report associated ED resource use and cost.E-scooters have risen in popularity since the expansion of rental schemes and there is rising concern over the healthcare impact of faster illegal private E-scooters. Current literature is limited on the healthcare related impact of E-scooters by retrospective design and focus on specific injury patterns (e.g. orthopaedic or maxillofacial).This study presents prospective data on E-scooter related injury presenting to the ED, comparing sites with and without rental schemes.Method and DesignA prospective observational study for four weeks of recruitment across twenty EDs across the United Kingdom (12 with rental schemes and 8 without). All patients presenting to ED with an E-scooter associated injury were identified.A prospective observational design was chosen to more accurately collect data on E-scooter injury patterns and behaviours. Sites with and without rental schemes were chosen to compare the impact of rental schemes.Abstract 1692 Figure 1Results and ConclusionE-scooter related injury was found in 250 ED patients. Fractures were diagnosed in 30.4% of patients and 19.4% sustained a head injury (4.2% classified as severe traumatic brain injury). Only 6.4% of riders were helmeted and 19.8% were intoxicated with alcohol. Mean unadjusted ED costs per patient were £297.31. The mean Injury Severity Score (ISS) was 2.8 in rental E-scooter incidents and 3.0 in private E-scooter incidents. From multiple linear regression modelling, helmet use, alcohol use and private or rental E-scooters were not predictive of ISS.In conclusion, E-scooter riders are vulnerable to injuries of varying severity. Low rates of helmet use and high prevalence of alcohol intoxication suggest a need for targeted public health interventions, but improved data collection is required. Health service costs should be considered when reviewing the suitability of rental schemes.
1674 The KnifeSavers bleeding control campaign: an evaluation of the public education programme
Authors: Russell Nicole , Tattam Kristian , Callon Josh , Jackson Robert , Misra Nikhil 
Published: December 2022

Aims, Objectives and BackgroundPenetrating trauma remains a leading cause of mortality in the United Kingdom with major haemorrhage a potentially preventable cause of death.KnifeSavers, a not-for-profit healthcare professional led organisation based at a regional major trauma centre, launched in 2019 to educate and empower the public how to manage a bleeding wound. There are three pillars of the campaign; an education programme, distribution of bleeding control packs and a public awareness campaign all focused on stopping major bleeding at scene.The aim of this review is to evaluate the response to the education programme and improvement in confidence and ability of the attendees to control major bleeding.Method and DesignAdult public members attending KnifeSavers education sessions between July 2021 and March 2022 were recruited to partake in pre and post event surveys.Utilising a 5-point Likert scale participants willingness and preparedness to manage bleeding knife related wounds were assessed.The data was comparatively measured, without accounting for attrition, to evaluate a change in response.Abstract 1674 Figure 1Comparison of pre and post survey 5-point Likert scale dataResults and ConclusionThere were 137 responses to the pre survey and 74% retention rate for the post session survey (n=101).Despite a consistently high willingness in participants to intervene (93% pre session and 96% post), only 28% felt prepared to manage a bleeding wound prior to the education session, and 27% felt prepared to use a bleeding control kit.Following the session an increase to 98% of participants were prepared to deal with a bleeding wound, and 96% prepared use a bleeding control kit.Of note 97% of attendees stated it was important that training was delivered by health care professionals.This data suggests that the KnifeSavers education programme is an effective strategy in increasing public preparedness to manage life-threatening bleeding wounds and supports further expansion of the programme.A further mixed methods qualitative assessment including paired t-test statistical analysis is underway.