bluuebunny/crossref_metadata_2025_split huggingface dataset:
027 The utilisation of urgent emergency care services by older care home residents in the UK and the subsequent impact on emergency departments
Authors: Brewster Molly , O’Keeffe Colin , Mason Suzanne 
Published: April 2023

BackgroundUrgent and Emergency Care Services (UECS) in the UK are under increasing pressure. Although accounting for a small proportion of Emergency Department (ED) attendances, there is a continually rising demand for the care of older people. Currently, there is limited data surrounding older care home (CH) residents and their use of UECS, thus this study aims to investigate the characteristics of older CH resident UECS utilisation and factors that influence ED transfer.Method and resultsInterviews were undertaken with healthcare and CH staff to elicit views around: the characteristics of ED attendances; demand placed upon UECS; alternative services; and interventions to reduce demand. Routine administrative data was collected for 21583 patients aged ≥75 from one large, urban type 1 ED in Yorkshire and Humber (Y&H) between April 2016 and March 2017. CH residents were identified to characterise attendances.ConclusionsCH residents were more likely to arrive by ambulance, OR of 3.810 (95% CI: 3.316–4.378, p<0.001); breach the four-hour target, OR of 1.321 (95% CI: 1.223–1.427, p<0.001); have an investigation, OR of 1.196 (95% CI: 1.035–1.381, p=0.015); receive resuscitation treatment, OR of 1.559 (95% CI: 1.409–1.725, p<0.001); and have a long inpatient admission (>2 days), OR of 2.083 (95% CI: 1.933–2.245, p<0.001) compared with non-care home residents (NCH) reflecting greater demand upon UECS. Interviews revealed ED transfer decisions were complex and reliant upon communication with the wider healthcare system and the risk averse attitudes of CH staff. Increased training of CH staff, advanced care planning and integrating healthcare services into the CH were suggestions to reduce the demands CH residents place upon UECS.This study reflects the demand CH residents place on UECS compared with NCH residents and highlights the importance of investigating factors influencing ED transfer. This will help to create targeted interventions to improve resident care and reduce UECS demand.
031 Bed block – a game to help understand patient flow
Authors: Edwards Sarah , Parkinson Leesa 
Published: April 2023

BackgroundPatient flow is crucial for patient safety, and for health services and the emergency departments(ED) within them to function. Poor patient flow is associated with increased mortality and morbidity. However, the concept of patient flow was not previously formally taught to all health care professionals (HCP) in our organisation. We developed a fun educational resource to be used with multidisciplinary groups to demonstrate the principles and pitfalls of patient flow in a hospital system.Method and resultsOur board game is a collaborative team game for 2–10 players and consists of a hospital with an ED, medical ward, surgical ward and intensive care. The game lasts around 45 minutes, during which the team aims to play through 24 hours in the hospital. The aim is to end the game with fewer patients in the hospital than at the start, without generating too many patient flow safety incidents. Pressure is added to the system by events such as bank holidays, norovirus outbreaks or failure of equipment. During play testing of the game, 90 different HCPs have provided written feedback.Abstract 031 Figure 1Abstract 031 Figure 2Abstract 031 Figure 3Conclusions95% of people found that they were more confident, and understood the importance of patient flow following the game. Common themes learnt from the game include the importance of team work, understanding the bigger picture and understanding the pressures in other parts of the hospital. Specific quotes include ‘would like to have played for longer’, ‘this game should be made available for the public, as it might help reduce ED attendances’, ‘great way of demonstrating the importance of team work’. This early testing of the game has shown how Bed Block can educate around patient flow. Further work is needed to explore the other educational opportunities from this work and if it impacts clinical practice.
032 Clinical frailty score as a decision-making tool in the emergency department – a step towards better outcomes for older patients
Authors: Mitchell Aine , Tahir Qurrat-Ul-Ain , Banerjee Jay 
Published: April 2023

BackgroundThe ≥65 year age group don’t always receive appropriate emergency care, occasionally due to ageism and as the ‘medical’ model of emergency care often does not benefit frail older patients.Over a six month period from December ’18 - June ’19, as part of a LeicGEM initiative, we aimed to:1. Improve accurate calculation and documentation of the CFS for patients ≥65 years.2. Increase utilisation of the CFS in providing individualised and holistic care for patients with frailty i.e. CFS ≥5.3. Improve consideration of end-of-life care (EOLC) if CFS ≥7.Through monthly PDSA cycles, our frailty QI team introduced interventions including: info-posters disseminated through email, handover sessions, ‘Champions’ on the shop-floor, targeted educational sessions and leaflets. We utilised rapid-cycle audit information and staff perceptions survey to measure improvements and focus initiatives. In the last 6 weeks, we looked for sustainability of improvements.CFS documentation improved and remained accurate, which was sustained. Discussions with patients and families, and ‘thought’ given to offer holistic, individualised care both showed improvement, though this was not definitely sustained. EOLC discussions did not show any definite improvement.Frailty is a clinically important entity that is recognisable and accurately measurable by emergency physicians. If appropriately used, the CFS can help guide clinical care plans for patients.Simple interventions in a local ED setting were able to improve documentation and utilisation of the CFS to provide patient-centred care for older patients.Changing to a culture more open to EOLC discussions in the emergency setting was noted to be difficult both from our staff survey and audit data. This will need a more focused approach to improve departmental culture to have, and staff comfort to start an EOLC conversation.We will continue to advocate for use of CFS, and for better care for all our older patients.Abstract 032 Figure 1CFS completion runchartAbstract 032 Figure 2EOLC runchartAbstract 032 Figure 3Individualised care runchart
035 Ensuring data adequacy in development of a major trauma clinical decision app
Authors: Mather Alexandra , Lowe David , Thomson Kevin , Whitelaw Alan , Beaumont Ben , Tulloch James 
Published: April 2023

BackgroundEmergency medicine clinicians from the QEUH research team EMQUIRE are working alongside design agency, Daysix, and the Scottish Trauma Network to develop a pioneering clinical decision support app to be used in major trauma.The development of the major trauma app will support clinicians to achieve three key aims:Robust data collectionCognitive aids to support and prompt cliniciansProvision of a reliable frameworkWhen creating a innovate, digital tool to be used in the medical setting, it is essential that it satisfies CE marking and MHRA regulations.Method and resultsA variety of methods have been used to ensure the trauma app provides reliable, valid and adequate data;A systematic review of existing paper trauma proformas within Scotland was performed and data points recorded. A review of 10 major trauma cases and documentation from each region was then taken place. This information was used to establish a minimum data setTARN and STAG data standards were reviewed, and the app data fields reflect thisCognitive aids and prompts within the app have a strong evidence base – literature from the ATLS manual and case–based evidenceThe Delphi method was used to establish clear data fields for the trauma app. This involved expert clinicians from MTCs and MTUs within ScotlandHigh fidelity trauma simulation was performedAbstract 035 Figure 1Abstract 035 Figure 2TraumaAbstract 035 Figure 3Trauma App-20_1ConclusionsThe comparison of current standards of paper documentation and data fields of the app has ensured granularity of data is increased.Clinicians have provided feedback throughout the design process which has led to further development and refinement. This expert input has ensured that the data fields within the app are adequate and valid.The overall result is an app that mirrors and supports the established clinical framework for trauma management and enables enhanced data visualisation of episodes of care.
041 Pre-hospital PEWS is not a useful predictor of the need for hospital admission from ED
Authors: Corfield Alasdair , Booth Kate , Clerihew Linda , Staines Harry , Stewart Elaine , Rooney Kevin 
Published: April 2023

ObjectivePhysiological derangement, as measured by Paediatric Early Warning Score (PEWS) is used to try and identify children with critical illness at an early point to identify and intervene in children at risk. PEWS have shown some utility as a track and trigger system in hospital and also as a predictor of adverse outcome both and and out of hospital. We wanted to examine whether a single pre-hospital PEWS, based on observations made by ambulance staff, was associated with the need for hospital admission.MethodsA retrospective analysis of all patients aged <16 transported to hospital by the Scottish Ambulance Survey between 2011 and 2015. Data was matched to outcome data regarding hospital admission or discharge, and length of stay.ResultsFull data was available for 21,202 paediatric patients, of whom 6340 (29.9%) were admitted to hospital, although this varied considerably by age (figure 1). Pre-hospital PEWS was associated with an odds ratio for admission of 1.173 (95% CI 1.160–1.187). Further analysis of PEWS shows Area Under ROC of 0.617 for PEWS, suggesting poor predictive ability. Gender does not significantly alter this (p=0.322) whereas addition of age increase the ROC to 0.630 (p<0.001) - see figure 2. There was no association between pre-hospital PEWS and length of hospital stay.Abstract 041 Figure 1Percent in-patient admission by gender and ageAbstract 041 Figure 2ROC Curves for comparisonsDiscussionThese data show that a single pre-hospital PEWS is a poor predictor of hospital admission for unselected patients in the Scottish Ambulance Service. The decision to admit a child to hospital is not only based on physiological derangement, and hence physiological based scoring systems such as PEWS cannot be used as the sole criteria for hospital admission, from an undifferentiated pre hospital population.
049 Development of a clinical decision rule for the early safe discharge of patients with mild traumatic brain injury and findings on CT brain scan: a retrospective cohort study
Authors: Marincowitz Carl , Lecky Fiona , Allgar Victoria , Hutchinson Peter , Elbeltagi Hadir , Johnson Faye , Quinn Eimhear , Tarantino Silvia , Townend Will , Kolias Angelos 
Published: April 2023

BackgroundInternational guidelines recommend routine hospital admission for all patients with mild traumatic brain injury (TBI) who have injuries on CT brain scan. Only a small proportion of these patients require neurosurgical or critical care intervention. We aimed to develop an accurate clinical decision rule to identify low risk patients safe for discharge from the emergency department (ED) and facilitate earlier referral of those requiring intervention.Method and resultsA retrospective cohort study of case-notes of patients admitted with initial GCS13-15 and injuries identified by CT was completed. Data on a primary outcome measure of clinically important deterioration (indicating need for hospital admission) and secondary outcome of neurosurgery, ICU admission or intubation (indicating need for neurosurgical admission) were collected. Multivariable logistic regression was used to derive models and a risk score predicting deterioration using routinely reported candidate variables identified in a systematic review. We compared the performance of this new risk score with the Brain Injury Guideline (BIG) criteria, derived in the USA.Abstract 049 Figure 1Population selectionAbstract 049 Table 1Model performanceAbstract 049 Table 2Performance of risk score and BIG criteriaConclusions1699 patients were included from 3 English Major Trauma Centres. 27.7% (95% CI: 25.5% to 29.9%) met the primary, and 13.1% (95% CI: 11.6% to 14.8%) met the secondary, outcome of deterioration. The derived clinical decision rule suggests that patients with simple skull fractures or intracranial bleeding less than 5 mm in diameter who are fully conscious could be safely discharged from the Emergency Department. The decision rule achieved a sensitivity of 99.5% (95% CI: 98.1% to 99.9%) and specificity of 7.4% (95% CI: 6% to 9.1%) to the primary outcome. The BIG criteria achieved the same sensitivity but lower specificity (5%).Our empirical models showed good predictive performance and outperformed the BIG criteria. This would potentially allow ED discharge of one in twenty patients currently admitted for observation. However prospective external validation and economic evaluation is required.
005 Rectal bleeding presenting to the paediatric emergency department
Authors: Evans Jordan , Metezai Huria , Roberts Zoe 
Published: April 2023

BackgroundBleeding per rectum in infants and children is often an alarming symptom for caregivers. The differential diagnosis is wide, from the benign to life-threatening. The current literature is limited on the description of this undifferentiated population in the UK. We aimed to describe the frequency of this presentation, the most common diagnoses and current management in the Paediatric Emergency Department (PED).Method and resultsRetrospective case note review of all patients presenting to a tertiary PED within a two year period from April 2017 to March 2019, with blood in stool/per rectum. Cases were identified by reviewing all presenting complaints including the words ‘blood’ or ‘bleed’. Data was collected using a standardised data collection form for the following variables; age, sex, diagnosis in PED, urgent intervention required, diagnosis on follow-up, diagnostic concordance between PED and follow-up diagnosis, investigation (stool, blood, imaging), admission, outpatient referral and reattendance during thestudy period.ConclusionsA total of 90 cases were identified, 10 were excluded as they did not meet inclusion criteria (n=80). This made up 0.14% of all presentations to the PED within the two year period. Mean age was 5 years (3 months - 15 years) with 51% female and 49% male. Collectively constipation and gastroenteritis accounted for 76% of diagnoses. 24% of patients were admitted the same day and 38% referred for outpatient follow up. There was agreement between PED diagnosis and outpatient diagnosis in 87% of cases. 5% of cases required urgent intervention.Bleeding per rectum is an infrequent presentation to the PED. The most common diagnoses are benign and many cases may be managed without need of admission or outpatient follow up. A high index of suspicion remains necessary to identify infrequent but serious pathology. There is currently limited evidence to guide practice and therefore further work is required.
Follow-on RifAximin for the Prevention of recurrence following standard treatment of Infection withClostridium Difficile(RAPID): a randomised placebo controlled trial
Authors: Major Giles , Bradshaw Lucy , Boota Nafisa , Sprange Kirsty , Diggle Mathew , Montgomery Alan , Jawhari Aida , Spiller Robin C 
Published: April 2023

BackgroundClostridium difficile infection (CDI) recurs after initial treatment in approximately one in four patients. A single-centre pilot study suggested that this could be reduced using ‘follow-on’ rifaximin treatment. We aimed to assess the efficacy of rifaximin treatment in preventing recurrence.MethodsA multisite, parallel group, randomised, placebo controlled trial recruiting patients aged ≥18 years immediately after resolution of CDI through treatment with metronidazole or vancomycin. Participants received either rifaximin 400 mg three times a day for 2 weeks, reduced to 200 mg three times a day for a further 2 weeks or identical placebo. The primary endpoint was recurrence of CDI within 12 weeks of trial entry.ResultsBetween December 2012 and March 2016, 151 participants were randomised to either rifaximin or placebo. Primary outcome data were available on 130. Mean age was 71.9 years (SD 15.3). Recurrence within 12 weeks was 29.5% (18/61) among participants allocated to placebo compared with 15.9% (11/69) among those allocated to rifaximin, a difference between groups of 13.7% (95% CI −28.1% to 0.7%, p=0.06). The risk ratio was 0.54 (95% CI 0.28 to 1.05, p=0.07). During 6-month safety follow-up, nine participants died in each group (12%). Adverse event rates were similar between groups.ConclusionWhile ‘follow-on’ rifaximin after CDI appeared to halve recurrence rate, we failed to reach our recruitment target in this group of frail elderly patients, so the estimated effect of rifaximin lacks precision. A meta-analysis including a previous trial suggests that rifaximin may be effective; however, further, larger confirmatory studies are needed.
Cancer cell genotype associated tumor immune microenvironment exhibits differential response to therapeutic STING pathway activation in high-grade serous ovarian cancer
Authors: Shakfa Noor , Li Deyang , Conseil Gwenaelle , Lightbody Elizabeth D , Wilson-Sanchez Juliette , Hamade Ali , Chenard Stephen , Jawa Natasha A. , Laight Brian J. , Afriyie-Asante Afrakoma , Tyryshkin Kathrin , Koebel Martin , Koti Madhuri 
Published: April 2023

BackgroundHigh-grade serous ovarian carcinoma (HGSC) is the most lethal gynecologic malignancy characterized by resistance to chemotherapy and high rates of recurrence. HGSC tumors display a high prevalence of tumor suppressor gene loss. Given the type 1 interferon regulatory function ofBRCA1andPTENgenes and their associated contrasting T-cell infiltrated and non-infiltrated tumor immune microenvironment (TIME) states, respectively, in this study we investigated the potential of stimulator of interferon genes (STING) pathway activation in improving overall survival via enhancing chemotherapy response, specifically in tumors with PTEN deficiency.MethodsExpression of PTEN protein was evaluated in tissue microarrays generated using pretreatment tumors collected from a cohort of 110 patients with HGSC. Multiplex immunofluorescence staining was performed to determine spatial profiles and density of selected lymphoid and myeloid cells. In vivo studies using the syngeneic murine HGSC cell lines, ID8-Trp53–/–;Pten–/–and ID8-Trp53–/–;Brca1–/–, were conducted to characterize the TIME and response to carboplatin chemotherapy in combination with exogenous STING activation therapy.ResultsPatient tumors with absence of PTEN protein exhibited a significantly decreased disease specific survival and intraepithelial CD68+ macrophage infiltration as compared with intact PTEN expression. In vivo studies demonstrated thatPten-deficient ovarian cancer cells establish an immunosuppressed TIME characterized by increased proportions of M2-like macrophages, GR1+MDSCs in the ascites, and reduced effector CD8+ cytotoxic T-cell function compared withBrca1-deficient cells; further, tumors from mice injected withPten-deficient ID8 cells exhibited an aggressive behavior due to suppressive macrophage dominance in the malignant ascites. In combination with chemotherapy, exogenous STING activation resulted in longer overall survival in mice injected withPten-deficient ID8 cells, reprogrammed intraperitoneal M2-like macrophages derived fromPten-deficient ascites to M1-like phenotype and rescued CD8+ cytotoxic T-cell activation.ConclusionsThis study reveals the importance of considering the influence of cancer cell intrinsic genetic alterations on the TIME for therapeutic selection. We establish the rationale for the optimal incorporation of interferon activating therapies as a novel combination strategy in PTEN-deficient HGSC.
Plasma phosphorylated tau 181 predicts amyloid status and conversion to dementia stage dependent on renal function
Authors: Lehmann Sylvain , Schraen-Maschke Susanna , Vidal Jean-Sébastien , Delaby Constance , Blanc Frédéric , Paquet Claire , Allinquant Bernadette , Bombois Stéphanie , Gabelle Audrey , Hanon Olivier 
Published: April 2023

ObjectivesPlasma P-tau181 is an increasingly established diagnostic marker for Alzheimer’s disease (AD). Further validation in prospective cohorts is still needed, as well as the study of confounding factors that could influence its blood level.MethodsThis study is ancillary to the prospective multicentre Biomarker of AmyLoid pepTide and AlZheimer’s diseAse Risk cohort that enrolled participants with mild cognitive impairment (MCI) who were examined for conversion to dementia for up to 3 years. Plasma Ptau-181 was measured using the ultrasensitive Quanterix HD-X assay.ResultsAmong 476 MCI participants, 67% were amyloid positive (Aβ+) at baseline and 30% developed dementia. Plasma P-tau181 was higher in the Aβ+ population (3.9 (SD 1.4) vs 2.6 (SD 1.4) pg/mL) and in MCI that converted to dementia (3.8 (SD 1.5) vs 2.9 (SD 1.4) pg/mL). The addition of plasma P-tau181 to a logistic regression model combining age, sex, APOEε4 status and Mini Mental State Examination improved predictive performance (areas under the curve 0.691–0.744 for conversion and 0.786–0.849 for Aβ+). The Kaplan-Meier curve of conversion to dementia, according to the tertiles of plasma P-tau181, revealed a significant predictive value (Log rank p<0.0001) with an HR of 3.8 (95% CI 2.5 to 5.8). In addition, patients with plasma P-Tau(181) ≤2.32 pg/mL had a conversion rate of less than 20% over a 3-year period. Using a linear regression approach, chronic kidney disease, creatinine and estimated glomerular filtration rate were independently associated with plasma P-tau181 concentrations.ConclusionsPlasma P-tau181 effectively detects Aβ+ status and conversion to dementia, confirming the value of this blood biomarker for the management of AD. However, renal function significantly modifies its levels and may thus induce diagnostic errors if not taken into account.