bluuebunny/crossref_metadata_2025_split huggingface dataset:
Maternal mortality in Colombia during the COVID-19 pandemic: time series and social inequities
Authors: Castañeda-Orjuela Carlos , Hilarion Gaitan Liliana , Diaz-Jimenez Diana , Cotes-Cantillo Karol , Garfield Richard 
Published: April 2023

ObjectiveThe impact of the COVID-19 pandemic goes beyond morbidity and mortality from that disease. Increases in maternal mortality have also been described but have not been extensively studied to date. This study aimed to examine changes in maternal mortality and identify correlates and predictors of excess maternal mortality in Colombia during the pandemic.SettingAnalysis of data from the national epidemiological surveillance databases of Colombia (Sivigila).ParticipantsDeaths among 6342 Colombian pregnant women who experienced complications associated with pregnancy, childbirth or the perperium during 2008–2020 were included in this study. For inequalities analysis, a subsample of 1055 women from this group who died in 2019 or 2020 years were analysed.MethodsWe collected data from the national surveillance system (Sivigila) on maternal mortality. Analysis was carried out in two stages, starting with a time series modelling using the Box-Jenkins approach. Data from Sivigila for 2008–2019 were used to establish a baseline of expected mortality levels. Both simple and complex inequality metrics, with the maternal mortality ratios (MMRs), were then calculated using the Multidimensional Poverty Index as a socioeconomic proxy.ResultsMaternal deaths in 2020 were 12.6% (95% CI −21.4% to 95.7%) higher than expected. These excess deaths were statistically significant in elevation for the months of July (97.4%, 95% CI 35.1% to 250.0%) and August (87.8%, 95% CI 30.5% to 220.8%). The MMR was nearly three times higher in the poorest municipalities compared with the most affluent communities in 2020.ConclusionsThe COVID-19 pandemic had considerable impact on maternal health, not only by leading to increased deaths, but also by increasing social health inequity. Barriers to access and usage of essential health services are a challenge to achieving health-related Sustainable Development Goals.
Revision of the Advanced Cancer Patients’ Distress Scale (ACPDS): a mixed-methods study among palliative patients and healthcare professionals in Germany
Authors: Züger Andrea , Fischbeck Sabine , Weber Martin , Mai Sandra 
Published: April 2023

ObjectivesTo revise the 37-item Advanced Cancer Patients’ Distress Scale (ACPDS) regarding its content, comprehensibility, applicability, and relevance by healthcare professionals (HCPs) and patients in order to enhance an existing instrument that is appropriate for the needs of patients with advanced cancer admitted to palliative care.DesignA preliminary revision of items regarding psychometric indices and relevance to initially shorten the scale, complemented by cognitive interviews with patients combining think-aloud and verbal-probe techniques and an HCP focus group on the detected remaining items. Interviews and the focus group were audio-recorded, transcribed verbatim and analysed using MAXQDA.SettingThe study took place at a German palliative care unit.Participants10 patients were interviewed (50% female) and 6 HCPs (3 physicians, 2 nurses and 1 psychologist) participated in the focus group.Outcome MeasuresComprehensibility, applicability, and relevance of the ACPDS were evaluated.ResultsBased on the psychometric revision, a reduced number of 17 items was discussed by the HCP focus group and within cognitive interviews with patients. For the rest of the analysis of the HCP focus group and the patient interview data, the introduction of the ACPDS was simplified and adapted to everyday language. As recommended by HCPs and patients, the example question was replaced. Nine items were reworded to boost clarity, openness, redundancy and mitigation. Three items were eliminated, and another three items were added.ConclusionWith this revised 17-item version of the ACPDS, we constructed an instrument that seems to be appropriate for the needs of patients with advanced cancer in a palliative care setting. In the next step, the shortened scale will be tested on psychometric data and validated by a large sample of inpatients on palliative care suffering from advanced cancer.Trial registration numberDRKS ID: DRKS00022425.
Hidden educational inequalities in high blood pressure and high blood glucose levels in Kerala: evidence from the National Family Health Survey (2019–2021)
Authors: Sharma Santosh Kumar , Nambiar Devaki , Joseph Jaison 
Published: April 2023

ObjectiveThis study assesses educational inequalities in measured as well as self-reported high blood pressure (BP) and high blood glucose (BG) in the southern Indian state of Kerala, which is known to have high chronic disease morbidity.DesignThe present findings are drawn from a large-scale, nationally representative cross-sectional study.Settings and participantsIndia’s Demographic and Health Survey (conducted in 2019–2021) had data on 36 526 individuals aged 15 years and above in the state of Kerala, India.Primary and secondary outcomes measuresMeasured high BP and BG; self-reported high BP and BG; as well as self-reported BP and BG testing. Descriptive statistics, bivariate analysis, along with multivariate statistics, were used. Educational inequalities were assessed through absolute and relative complex measures of inequality, namely the Slope Index of Inequality (SII) and Relative Concentration Index (RCI), respectively, with 95% CIs.ResultsThe largest margin of inequality in Kerala, between the least and the most educated groups, was observed for measured high BP (57.7% and 17.6%). Measured high BP (SII −45.4% (95% CI –47.3% to –43.4%); RCI −26.6% (95% CI –27.9% to –25.3%)), self-reported high BP (SII −34.5% (95% CI –36.3% to –32.7%); RCI −19.0% (95% CI –20.1% to –17.9%)). High BG levels were concentrated among those with lower educational attainment (SII −26.6% (95% CI –28.6% to –24.7%); RCI −15.7% (95% CI –16.9% to –14.5%)), represented by negative SII and RCI values.ConclusionsThe study findings suggest that research and programme efforts need to be redoubled to determine what is driving greater vulnerability to non-communicable diseases among population with lower educational attainment on the one hand and the possible role that improving education access can be on health outcomes, on the other hand. Further research should explore relevant intersections with low education.
Examining Indigenous emergency care equity projects: a scoping review protocol
Authors: Marchand Tyara , Daodu Oluwatomilayo , MacRobie Ali , Green-Dowden Stephen , Brindle Mary 
Published: April 2023

IntroductionIndigenous peoples across the globe face inequitable access to high-quality care. Emergency departments are the first point of access for many Indigenous peoples and are the interface between the individual and the healthcare system. There is a reliance on emergency services due to a lack of primary healthcare, a history of mistreatment from providers and increased disease complexity. As such, a potential place for health equity reform is within these departments and other acute care settings. It is the purpose of this review to determine what projects have occurred that address emergency care inequities in four countries such as Australia, Canada, New Zealand and the USA and explore their successes and failures.Methods and analysisUsing search strategies developed with a research librarian, publications will be identified from indexed databases including Medline, Embase, Web of Science, Cochrane Central, CINAHL and Scopus. Grey literature will also be searched and scanned for inclusion. To be included in the review, articles must describe interventions developed to address Indigenous health equity occurring within emergency care settings. Articles will include both programme descriptions and programme evaluations and be quality appraised by analysing study design and Indigenous research methodologies.Ethics and disseminationThis review does not require ethics approval. This protocol describes a review that attempts to map Indigenous health equity interventions taking place within emergency care settings. It will contribute to Indigenous health scholarship and equity research. Results will be made available in multiple dissemination methods to ensure accessibility by researchers and community members.
Rethinking standards on prison cell size in a (post)pandemic world: a scoping review
Authors: Dahiya Simran , Simpson Paul Leslie , Butler Tony 
Published: April 2023

ObjectiveTo describe the current international, regional and national standards on prison cell spatial density and the evidence for the association between COVID-19 transmission and prison crowding measures to provide recommendations on prison cell spatial density standards for a (post) pandemic world.DesignScoping review.Data sourcesPubMed, ProQuest, Informit, Criminal Justice Abstracts, Cochrane, Web of Science, Scopus, EMBASE, Google Scholar and Google were searched up to November 2021.Eligibility criteriaGuidelines were included provided they described standards of prison accommodation with respect to prison cells. Studies were included provided they examined an association between COVID-19 cases and a crowding measure.Data extraction and synthesisData were extracted by one reviewer and cross-checked by another. Quantitative and qualitative data on prison cell standards and characteristics of studies examining an association between COVID-19 and prison crowding were collected.Findings were synthesised qualitatively.ResultsSeventeen reports and six studies met eligibility criteria. International and regional standards on cell spatial density were mostly qualitative, with two quantifiable international standards located (3.4 m2and 3.5 m2per person for multiple occupancy cells), and two quantifiable regional standards located (4 m2per person (Europe) and 5.75 m2or 4 m2per person (Australia and New Zealand)). Country-based standards varied substantially, ranging from 1.25 m2per person (Pakistan) to 10 m2per person (Netherlands). Consideration of airborne transmission of disease in prisons were mostly overlooked or absent to rationalise standards. There was consistent evidence that prison crowding measures were associated with COVID-19 transmission/cases.ConclusionConsidering the physics of respiratory emissions, we recommend prison cell spatial density standards be updated to reflect graded levels of risk that consider other factors that combine to inform airborne transmission risk. Decarceration strategies should be considered and become vital if standards are not met.
Highlighting the importance of healthy sleep patterns in the risk of adult asthma under the combined effects of genetic susceptibility: a large-scale prospective cohort study of 455 405 participants
Authors: Xiang Bowen , Hu Mengxiao , Yu Haiyang , Zhang Yike , Wang Qing , Xue Fuzhong 
Published: April 2023

BackgroundIndividuals with asthma usually have comorbid sleep disturbances; however, whether sleep quality affects asthma risk is still unclear. We aimed to determine whether poor sleep patterns could increase the risk of asthma and whether healthy sleep patterns could mitigate the adverse effect of genetic susceptibility.MethodsA large-scale prospective study was performed in the UK Biobank cohort involving 455 405 participants aged 38–73 years. Polygenic risk scores (PRSs) and comprehensive sleep scores, including five sleep traits, were constructed. A multivariable Cox proportional hazards regression model was used to investigate the independent and combined effects of sleep pattern and genetic susceptibility (PRS) on asthma incidence. Subgroup analysis across sex and sensitivity analysis, including a 5-year lag, different covariate adjustments and repeat measurements were performed.ResultsA total of 17 836 individuals were diagnosed with asthma during over 10 years of follow-up. Compared with the low-risk group, the HRs and 95% CIs for the highest PRS group and the poor sleep pattern group were 1.47 (95% CI: 1.41 to 1.52) and 1.55 (95% CI: 1.45 to 1.65), respectively. A combination of poor sleep and high genetic susceptibility led to a twofold higher risk compared with the low-risk combination (HR (95% CI): 2.22 (1.97 to 2.49), p<0.001). Further analysis showed that a healthy sleep pattern was associated with a lower risk of asthma in the low, intermediate and high genetic susceptibility groups (HR (95% CI): 0.56 (0.50 to 0.64), 0.59 (0.53 to 0.67) and 0.63 (0.57 to 0.70), respectively). Population-attributable risk analysis indicated that 19% of asthma cases could be prevented when these sleep traits were improved.ConclusionsIndividuals with poor sleep patterns and higher genetic susceptibility have an additive higher asthma risk. A healthy sleep pattern reflected a lower risk of asthma in adult populations and could be beneficial to asthma prevention regardless of genetic conditions. Early detection and management of sleep disorders could be beneficial to reduce asthma incidence.
Curious CXR
Authors: Pluck Graham , Friedman Max , McGrath Henrietta 
Published: April 2023

A 98-year-old man with 2 days of headache, nausea, malaise and unsteadiness was referred to the ED by his GP with a suspicion of an intracranial bleed. His medical history included atrial fibrillation (AF) (taking warfarin). Observations were SpO2 95% on air, RR24, HR88, BP210/104, GCS14, Temp 34.3. On examination he had bilateral creps and was sleepy but not confused. A septic screen was undertaken and intravenous ceftriaxone given. His CTH was essentially normal. His CXR is shown in figure 1.Figure 1Anteropsterior(AP) CXR at presentation.QuestionWhat is the diagnosis?Acute collapse and consolidation secondary to pneumonia.Spontaneous haemothorax.Acute consolidation with underlying old TB.Traumatic lung contusions.
010 Diagnostic accuracy of pulmonary embolism (PE) rule-out strategies in pregnancy
Authors: Goodacre Steve , Nelson-Piercy Catherine , Hunt Beverley , Fuller Gordon 
Published: April 2023

Recent studies suggest that combinations of clinical probability assessment and D-dimer can safely rule out suspected PE in pregnant women. Van der Pol (NEJM 2019) reported that a pregnancy-modified YEARS algorithm and D-dimer ruled out PE in 195/498 (39%) and Righini (Ann Intern Med 2018) reported that the Geneva score and D-dimer ruled out PE in 46/395 (12%) without adverse outcome. We undertook a secondary analysis of pregnant women with suspected PE prospectively recruited to the DiPEP study to determine the diagnostic accuracy of these strategies.The DiPEP study collected data and blood samples from pregnant/postpartum women with suspected PE across 11 UK hospitals and with diagnosed PE from all UK hospitals over 18 months. We selected prospectively recruited pregnant women who had definitive diagnostic imaging for analysis. We used clinical data and D-dimer results to determine whether the van der Pol and Righini strategies would recommend further investigation and imaging results to determine whether this would detect or miss PE.We analysed 219 prospectively enrolled patients, including 12 (4.6%) with PE. The van der Pol strategy indicated no PE in 96/219 (43.8%), but this would have included 5/12 false negative cases with PE. Sensitivity for PE was 58.3% (95% CI 28.6–83.5%) and specificity 44.0% (37.1–51.0%). The Righini strategy indicated no PE in 46/219 (21.0%) but this would have missed 3/12 cases with PE. Sensitivity was 75.0% (21.9–98.7%) and specificity 20.8% (15.6–27.1%).Strategies using clinical probability and D-dimer do not accurately rule out PE in pregnancy. The absence of adverse events in the published management studies may reflect lack of statistical power to detect clinically important adverse event rates. We therefore recommend against using clinical probability assessment and D-dimer testing to rule out suspected PE in pregnancy.
011 High-sensitivity cardiac troponin on presentation to rule out myocardial infarction (HiSTORIC): a stepped-wedge cluster randomised controlled trial
Authors: Gray Alasdair 
Published: April 2023

BackgroundHigh-sensitivity troponin (hs-cTn) assays enable MI to be ruled out earlier, but the effectiveness and safety of this approach is uncertain. We compared a conventional pathway using the 99th centile and serial testing at presentation and at 6–12 hours, with a rapid rule out pathway that uses lower hs-cTn concentrations to risk stratify patients at presentation and earlier serial testing.Method and resultsA 6-centre stepped-wedge, cluster RCT was completed, evaluating the efficacy/safety of implementation of a rapid rule out pathway using a hs-cTnI assay. Consecutive patients were identified, with suspected ACS who had a hs-cTnI concentration within the normal range at presentation in 3 phases. During the validation phase, patients were assessed using the standard care pathway with serial hs-cTnI testing at presentation and 6–12 hours. All centres were randomized in a stepped-wedge fashion to the novel pathway, where MI is ruled out if hs-cTnI is <5 ng/L at presentation or between 5 ng/L and the 99th centile with a change <3 ng/L at 3 hours. Sequential hypothesis testing evaluated the superiority of the novel pathway for a primary efficacy endpoint of length of stay, and non-inferiority for a primary safety endpoint of MI or cardiac death 30 days following discharge.ConclusionsFrom Nov 2014 to Dec 2016, 36,322 patients with suspected ACS and hs-cTnI concentrations <99th centile at presentation were identified. All patients were followed up for at least one year. Median lengths of stay and the proportion with MI or cardiac death 30 days following discharge before and after implementation of the pathway will be reported. Non-inferiority for the primary safety endpoint will be concluded if the upper limit of the one-sided 95% CI is below the non-inferiority margin of 0.5%. The proportion of patients discharged directly from ED and proportion with MI or cardiac death one year following discharge will be reported.
014 Shared decision making: T-MACS choice for chest pain patients in the ED
Authors: Ward Abigail , Berg Patricia van den , Body Richard 
Published: April 2023

The concept of shared decision making (SDM) has gained increasing attention across healthcare fields including emergency care, with a focus shift towards patient-centred medicine.With cardiac chest pain accounting for approximately 6% of all emergency department (ED) attendances we aimed to co-design a personalised decision aid based on the established Troponin-only Manchester Acute Coronary Syndromes (T-MACS) prediction model to increase patient involvement in the decision making on serial troponin testing and follow up.The T-MACS Choice decision aid was co-designed with patient and physician involvement in 7 stages using a mixed-methods approach (figure 1) at the Manchester Royal Infirmary (MRI) from March to May 2017. The initial prototype was developed based on a) a literature review of SDM, b) the AHRQ health literacy toolkit and c) the International Patient Decision Aid Standards instrument.Abstract 014 Figure 1T-MACS choice development flowchartIn subsequent stages the prototype was improved based on feedback provided by the PRIMER patient and public involvement group, three SDM expert clinicians, focus groups interviews involving 26 members from patient groups with a history of cardiac problems, questionnaires from 29 emergency physicians and 14 patients presenting to MRI ED with chest pain and admitted for serial troponin testing.The final T-MACS Choice decision aid is personalised for the individual patient, reflecting their distinct risk group with the relevant choice options (figure 2).Abstract 014 Figure 2T-MACS choiceIn the initial development stages the most common themes identified were the importance of a personalised design and the use of clear, understandable language avoiding medical jargon. Both patients and physicians highlighted the importance of including information on heart health and prevention. In the final stages both sides agreed that T-MACS Choice had the right amount of information, was clear and engaging patients in the decision making.Further research on clinical implementation of T-MACS Choice is needed to determine its impact on patient choice and safety.
018 Clinician prediction of cardiac arrhythmia in patients presenting to the ED with palpitation or pre-syncope
Authors: Reed Matt , Grubb Neil , Lang Chris , O’Brien Rachel , Simpson Kirsty , Padarenga Mia , Grant Alison , Tuck Sharon , Keating Liza , Coffey Frank , Jones Lucy , Harris Tim , Lloyd Gavin , Gagg James , Smith Jason 
Published: April 2023

The IPED study showed that use of a smartphone-based event recorder in ED patients presenting with palpitation or pre-syncope, increased the number of patients in whom an ECG was captured during symptoms over five-fold to more than 55% at 90 days (Reed MJet al. Lancet eClinical Medicine 2019; 8: 37–46).This pre-planned analysis looked at the ability of ED clinicians to predict cardiac arrhythmia in patients presenting to the ED with palpitation or pre-syncope.Pre-planned sub study analysis of a randomised controlled multi-centre trial. Participants ≥16 years old presenting to 10 UK hospital EDs with palpitation or pre-syncope whose underlying ECG rhythm during these episodes remained undiagnosed after ED assessmentwere enrolled. The treating ED clinician was asked to rate the likelihood of underlying cardiac arrhythmia ranging from 1 (least likely) to 10 (most likely). Participants were then randomised to either an intervention group using a smartphone-based event recorder or a standard care control group. Primary endpoint of this sub study was symptomatic cardiac arrhythmia at 90 days.243 patients were enrolled. 6 patients had no ED clinician likelihood rating recorded and two further patients were lost to follow-up leaving 235 available for analysis. There were 12 patients recording a symptomatic cardiac arrhythmia at 90 days. These were atrial fibrillation (8), SVT (3), sinus bradycardia (<40 bpm; 1) and atrial flutter (1). One patient recorded 2 categories of arrhythmia. The AUC for prediction of cardiac arrhythmia was 0.81 (95% CI; 0.71–0.90). An ED clinician likelihood rating of 5 or more had 92% sensitivity and 59% specificity for predicting cardiac arrhythmia.Abstract 018 Figure 1ROC analysis of ED clinician likelihood rating for symptomatic cardiac dysrhythmia at 90 daysConclusionED clinicians are able to predict the liklihood of cardiac arrhythmia in patients presenting to the ED with palpitation or pre-syncope with reasonable accuracy.