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Moreno-Blanco D, Alonso E, Sanz-García A, Aramendi E, López-Izquierdo R, Perez García R, Del Pozo Vegas C, Martín-Rodríguez F. Spanish vs USA cohort comparison of prehospital trauma scores to predict short-term mortality. Clin Med (Lond) 2024; 24:100208. [PMID: 38643832 PMCID: PMC11101846 DOI: 10.1016/j.clinme.2024.100208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/07/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND This study aimed to evaluate three prehospital early warning scores (EWSs): RTS, MGAP and MREMS, to predict short-term mortality in acute life-threatening trauma and injury/illness by comparing United States (US) and Spanish cohorts. METHODS A total of 8,854 patients, 8,598/256 survivors/nonsurvivors, comprised the unified cohort. Datasets were randomly divided into training and test sets. Training sets were used to analyse the discriminative power of the scores in terms of the area under the curve (AUC), and the score performance was assessed in the test set in terms of sensitivity (SE), specificity (SP), accuracy (ACC) and balanced accuracy (BAC). RESULTS The three scores showed great discriminative power with AUCs>0.90, and no significant differences between cohorts were found. In the test set, RTS/MREMS/MGAP showed SE/SP/ACC/BAC values of 86.0/89.9/89.6/87.1%, 91.0/86.9/87.5/88.5%, and 87.7/82.9/83.4/85.2%, respectively. CONCLUSIONS All EWSs showed excellent ability to predict the risk of short-term mortality, independent of the country.
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Affiliation(s)
- Diego Moreno-Blanco
- Department of Communications Engineering, University of the Basque Country (UPV/EHU), Bilbao, Spain; Biomedical Engineering and Telemedicine Centre, ETSI de Telecomunicación, Center for Biomedical Technology, Universidad Politécnica de Madrid, Madrid, Spain
| | - Erik Alonso
- Department of Applied Mathematics, University of the Basque Country (UPV/EHU), Bilbao, Spain
| | - Ancor Sanz-García
- Faculty of Health Sciences, University of Castilla - La Mancha (UCLM), Talavera, Spain.
| | - Elisabete Aramendi
- Department of Communications Engineering, University of the Basque Country (UPV/EHU), Bilbao, Spain
| | - Raúl López-Izquierdo
- Faculty of Medicine, University of Valladolid, Valladolid, Spain; CIBER of Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain; Emergency Department. Hospital Universitario Rio Hortega. Valladolid, Spain
| | - Rubén Perez García
- Emergency Department. Hospital Universitario Rio Hortega. Valladolid, Spain
| | - Carlos Del Pozo Vegas
- Faculty of Medicine, University of Valladolid, Valladolid, Spain; Emergency Department. Hospital Clínico Universitario. Valladolid, Spain
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, University of Valladolid, Valladolid, Spain; Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
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Lindskou TA, Ward LM, Søvsø MB, Mogensen ML, Christensen EF. Prehospital Early Warning Scores to Predict Mortality in Patients Using Ambulances. JAMA Netw Open 2023; 6:e2328128. [PMID: 37556138 PMCID: PMC10413164 DOI: 10.1001/jamanetworkopen.2023.28128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/29/2023] [Indexed: 08/10/2023] Open
Abstract
IMPORTANCE Early warning scores (EWSs) are designed for in-hospital use but are widely used in the prehospital field, especially in select groups of patients potentially at high risk. To be useful for paramedics in daily prehospital clinical practice, evaluations are needed of the predictive value of EWSs based on first measured vital signs on scene in large cohorts covering unselected patients using ambulance services. OBJECTIVE To validate EWSs' ability to predict mortality and intensive care unit (ICU) stay in an unselected cohort of adult patients who used ambulances. DESIGN, SETTING, AND PARTICIPANTS This prognostic study conducted a validation based on a cohort of adult patients (aged ≥18 years) who used ambulances in the North Denmark Region from July 1, 2016, to December 31, 2020. EWSs (National Early Warning Score 2 [NEWS2], modified NEWS score without temperature [mNEWS], Quick Sepsis Related Organ Failure Assessment [qSOFA], Rapid Emergency Triage and Treatment System [RETTS], and Danish Emergency Process Triage [DEPT]) were calculated using first vital signs measured by ambulance personnel. Data were analyzed from September 2022 through May 2023. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day-mortality. Secondary outcomes were 1-day-mortality and ICU admission. Discrimination was assessed using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC). RESULTS There were 107 569 unique patients (52 650 females [48.9%]; median [IQR] age, 65 [45-77] years) from the entire cohort of 219 323 patients who used ambulance services, among whom 119 992 patients (54.7%) had called the Danish national emergency number. NEWS2, mNEWS, RETTS, and DEPT performed similarly concerning 30-day mortality (AUROC range, 0.67 [95% CI, 0.66-0.68] for DEPT to 0.68 [95% CI, 0.68-0.69] for mNEWS), while qSOFA had lower performance (AUROC, 0.59 [95% CI, 0.59-0.60]; P vs other scores < .001). All EWSs had low AUPRCs, ranging from 0.09 (95% CI, 0.09-0.09) for qSOFA to 0.14 (95% CI, 0.13-0.14) for mNEWS.. Concerning 1-day mortality and ICU admission NEWS2, mNEWS, RETTS, and DEPT performed similarly, with AUROCs ranging from 0.72 (95% CI, 0.71-0.73) for RETTS to 0.75 (95% CI, 0.74-0.76) for DEPT in 1-day mortality and 0.66 (95% CI, 0.65-0.67) for RETTS to 0.68 (95% CI, 0.67-0.69) for mNEWS in ICU admission, and all EWSs had low AUPRCs. These ranged from 0.02 (95% CI, 0.02-0.03) for qSOFA to 0.04 (95% CI, 0.04-0.04) for DEPT in 1-day mortality and 0.03 (95% CI, 0.03-0.03) for qSOFA to 0.05 (95% CI, 0.04-0.05) for DEPT in ICU admission. CONCLUSIONS AND RELEVANCE This study found that EWSs in daily clinical use in emergency medical settings performed moderately in the prehospital field among unselected patients who used ambulances when assessed based on initial measurements of vital signs. These findings suggest the need of appropriate triage and early identification of patients at low and high risk with new and better EWSs also suitable for prehospital use.
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Affiliation(s)
- Tim Alex Lindskou
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Morten Breinholt Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Emergency Medical Services, North Denmark Region, Aalborg, Denmark
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Martín-Rodríguez F, Enriquez de Salamanca Gambara R, Sanz-García A, Castro Villamor MA, Del Pozo Vegas C, Sánchez Soberón I, Delgado Benito JF, Martín-Conty JL, López-Izquierdo R. Comparison of seven prehospital early warning scores to predict long-term mortality: a prospective, multicenter, ambulance-based study. Eur J Emerg Med 2023; 30:193-201. [PMID: 37040664 DOI: 10.1097/mej.0000000000001019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
The long-term predictive validity of early warning scores (EWS) has not been fully elucidated yet. The aim of the present study is to compare seven prehospital EWS to predict 1-year mortality. A prospective, multicenter, ambulance-based study of adult patients with an acute illness involving six advanced life support units and 38 basic life support units, referring to five emergency departments in Spain. The primary outcome was long-term mortality with a 1-year follow-up. The compared scores included: National Early Warning Score 2, VitalPAC early warning score, modified rapid emergency medicine score (MREMS), Sepsis-related Organ Failure Assessment, Cardiac Arrest Risk Triage Score, Rapid Acute Physiology Score, and Triage Early Warning Score. Discriminative power [area under the receiver operating characteristic curve (AUC)] and decision curve analysis (DCA) were used to compare the scores. Additionally, a Cox regression and Kaplan-Meier method were used. Between 8 October 2019, and 31 July 2021, a total of 2674 patients were selected. The MREMS presented the highest AUC of 0.77 (95% confidence interval, 0.75-0.79), significantly higher than those of the other EWS. It also exhibited the best performance in the DCA and the highest hazard ratio for 1-year mortality [3.56 (2.94-4.31) for MREMS between 9 and 18 points, and 11.71 (7.21-19.02) for MREMS > 18]. Among seven tested EWS, the use of the MREMS presented better characteristics to predict 1-year mortality; however, all these scores present moderate performances.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Clinical Simulation Center, Faculty of Medicine, Universidad de Valladolid
- Advanced Life Support, Emergency Medical Services (SACYL)
- Prehospital Early Warning Scoring-System Investigation Group
| | | | - Ancor Sanz-García
- Prehospital Early Warning Scoring-System Investigation Group
- Nursing, Physiotherapy and Occupational Therapy, Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina
| | - Miguel A Castro Villamor
- Advanced Clinical Simulation Center, Faculty of Medicine, Universidad de Valladolid
- Prehospital Early Warning Scoring-System Investigation Group
| | - Carlos Del Pozo Vegas
- Advanced Clinical Simulation Center, Faculty of Medicine, Universidad de Valladolid
- Prehospital Early Warning Scoring-System Investigation Group
- Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Juan F Delgado Benito
- Advanced Life Support, Emergency Medical Services (SACYL)
- Prehospital Early Warning Scoring-System Investigation Group
| | - José L Martín-Conty
- Nursing, Physiotherapy and Occupational Therapy, Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina
| | - Raúl López-Izquierdo
- Advanced Clinical Simulation Center, Faculty of Medicine, Universidad de Valladolid
- Prehospital Early Warning Scoring-System Investigation Group
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid
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Martín-Rodríguez F, Sanz-García A, Ortega GJ, Delgado Benito JF, Aparicio Obregon S, Martínez Fernández FT, González Crespo P, Otero de la Torre S, Castro Villamor MA, López-Izquierdo R. Tracking the National Early Warning Score 2 from Prehospital Care to the Emergency Department: A Prospective, Ambulance-Based, Observational Study. PREHOSP EMERG CARE 2023; 27:75-83. [PMID: 34846982 DOI: 10.1080/10903127.2021.2011995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Aim of the study: To assess the prognostic ability of the National Early Warning Score 2 (NEWS2) at three time points of care -at the emergency scene (NEWS2-1), just before starting the transfer by ambulance to the hospital (NEWS2- 2), and at the hospital triage box (NEWS2-3)- to estimate in-hospital mortality after two days since the index event.Methods: Prospective, multicenter, ambulance-based, cohort ongoing study in adults (>18 years) consecutively attended by advanced life support (ALS) and evacuated with high-priority to the emergency departments (ED) between October 2018 and May 2021. Vital sign measures were used to calculate the NEWS2 score at each time point, then this score was entered in a logistic regression model as the single predictor. Two outcomes were considered: first, all-cause mortality of the patients within 2 days of presentation to EMS, and second, unplanned ICU admission. The calibration and scores comparison was performed by representing the predicted vs the observed risk curves according to NEWS score value.Results: 4943 patients were enrolled. Median age was 69 years (interquartile range 53- 81). The NEWS2-3 presented the better performance for all-cause two-day in-hospital mortality with an AUC of 0.941 (95% CI: 0.917-0.964), showing statistical differences with both the NEWS2-1 (0.872 (95% CI: 0.833-0.911); p < 0.003) and with the NEWS2- 2 (0.895 (95% CI: 0.866-0.925; p < 0.05). The calibration and scores comparison results showed that the NEWS2-3 was the best predictive score followed by the NEWS2-2 and the NEWS2-1, respectively.Conclusions: The NEWS2 has an excellent predictive performance. The score showed a very consistent response over time with the difference between "at the emergency scene" and "pre-evacuation" presenting the sharpest change with decreased threshold values, thus displaying a drop in the risk of acute clinical impairment.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Centro de Simulación Clínica Avanzada, Departamento de Medicina, Dermatología y Toxicología, Universidad de Valladolid. Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Ancor Sanz-García
- Unidad de Análisis de Datos (UAD), del Instituto de Investigación Sanitaria del Hospital de la Princesa (IIS-IP), Madrid, Spain
| | - Guillermo J Ortega
- Unidad de Análisis de Datos (UAD), del Instituto de Investigación Sanitaria del Hospital de la Princesa (IIS-IP), Madrid, Spain.,Consejo Nacional de Investigaciones Científicas y Técnicas, CONICET, Argentina
| | - Juan F Delgado Benito
- Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Silvia Aparicio Obregon
- Parque Científico y Tecnológico de Cantabria, Universidad Europea del Atlántico, Santander, Spain
| | | | - Pilar González Crespo
- Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Santiago Otero de la Torre
- Gerencia de Emergencias Sanitarias, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Miguel A Castro Villamor
- Centro de Simulación Clínica Avanzada, Departamento de Medicina, Dermatología y Toxicología, Universidad de Valladolid, Spain
| | - Raúl López-Izquierdo
- Servicio de Urgencias, Hospital Universitario Rio Hortega de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
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Martín-Rodríguez F, López-Izquierdo R, Sanz-García A, Ortega GJ, Del Pozo Vegas C, Delgado-Benito JF, Castro Villamor MA, Soriano JB. Prehospital Respiratory Early Warning Score for airway management in-ambulance: A score comparison. Eur J Clin Invest 2023; 53:e13875. [PMID: 36121346 DOI: 10.1111/eci.13875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/30/2022] [Accepted: 09/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prehospital Respiratory Early Warning Scores to estimate the requirement for advanced respiratory support is needed. To develop a prehospital Respiratory Early Warning Score to estimate the requirement for advanced respiratory support. METHODS Multicentre, prospective, emergency medical services (EMS)-delivered, longitudinal cohort derivationvalidation study carried out in 59 ambulances and five hospitals across five Spanish provinces. Adults with acute diseases evaluated, supported and discharged to the Emergency Department with high priority were eligible. The primary outcome was the need for invasive or non-invasive respiratory support (NIRS or IRS) in the prehospital scope at the first contact with the patient. The measures included the following: epidemiological endpoints, prehospital vital signs (respiratory rate, pulse oximetry saturation, fraction of inspired oxygen, systolic and diastolic mean blood pressure, heart rate, tympanic temperature and consciousness level by the GCS). RESULTS Between 26 Oct 2018 and 26 Oct 2021, we enrolled 5793 cases. For NIRS prediction, the final model of the logistic regression included respiratory rate and pulse oximetry saturation/fraction of inspired oxygen ratio. For the IRS case, the motor response from the Glasgow Coma Scale was also included. The REWS showed an AUC of 0.938 (95% CI: 0.918-0.958), a calibration-in-large of 0.026 and a higher net benefit as compared with the other scores. CONCLUSIONS Our results showed that REWS is a remarkably aid for the decision-making process in the management of advanced respiratory support in prehospital care. Including this score in the prehospital scenario could improve patients' care and optimise the resources' management.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Faculty of Medicine, Valladolid University, Valladolid, Spain.,Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
| | - Raúl López-Izquierdo
- Faculty of Medicine, Valladolid University, Valladolid, Spain.,Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid, Spain
| | - Guillermo J Ortega
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid, Spain.,CONICET, Buenos Aires, Argentina
| | - Carlos Del Pozo Vegas
- Faculty of Medicine, Valladolid University, Valladolid, Spain.,Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | | | | | - Joan B Soriano
- Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain.,Servicio de Neumología, Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Todd VF, Moylan M, Howie G, Swain A, Brett A, Smith T, Dicker B. Predictive value of the New Zealand Early Warning Score for early mortality in low-acuity patients discharged at scene by paramedics: an observational study. BMJ Open 2022; 12:e058462. [PMID: 35835524 PMCID: PMC9289032 DOI: 10.1136/bmjopen-2021-058462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The utility of New Zealand Early Warning Score (NZEWS) for prediction of adversity in low-acuity patients discharged at scene by paramedics has not been investigated. The objective of this study was to evaluate the association between the NZEWS risk-assessment tool and adverse outcomes of early mortality or ambulance reattendance within 48 hours in low-acuity, prehospital patients not transported by ambulance. DESIGN A retrospective cohort study. SETTING Prehospital emergency medical service provided by St John New Zealand over a 2-year period (1 July 2016 through 30 June 2018). PARTICIPANTS 83 171 low-acuity, adult patients who were attended by an ambulance and discharged at scene. Of these, 41 406 had sufficient recorded data to calculate an NZEWS. PRIMARY AND SECONDARY OUTCOMES AND MEASURES Binary logistic regression modelling was used to investigate the association between the NZEWS and adverse outcomes of reattendance within 48 hours, mortality within 2 days, mortality within 7 days and mortality within 30 days. RESULTS An NZEWS greater than 0 was significantly associated with all adverse outcomes studied (p<0.01), compared with the reference group (NZEWS=0). There was a startling correlation between 2-day, 7-day and 30-day mortality and higher early warning scores; the odds of 2-day mortality in patients with an early warning score>10 was 70 times that of those scoring 0 (adjusted OR 70.64, 95% CI: 30.73 to 162.36). The best predictability for adverse outcome was observed for 2-day and 7-day mortality, with moderate area under the receiver operating characteristic curve scores of 0.78 (95% CI: 0.73 to 0.82) and 0.74 (95% CI: 0.71 to 0.77), respectively. CONCLUSIONS Adverse outcomes in low-acuity non-transported patients show a significant association with risk prediction by the NZEWS. There was a very high association between large early warning scores and 2-day mortality in this patient group. These findings suggest that NZEWS has significant utility for decision support and improving safety when determining the appropriateness of discharging low-acuity patients at the scene.
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Affiliation(s)
- Verity Frances Todd
- St John New Zealand (Hato Hone Aotearoa), Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
| | - Melanie Moylan
- Department of Biostatistics and Epidemiology, Auckland University of Technology, Auckland, New Zealand
| | - Graham Howie
- St John New Zealand (Hato Hone Aotearoa), Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
| | - Andy Swain
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
- Wellington Free Ambulance, Wellington, New Zealand
| | - Aroha Brett
- St John New Zealand (Hato Hone Aotearoa), Auckland, New Zealand
| | - Tony Smith
- St John New Zealand (Hato Hone Aotearoa), Auckland, New Zealand
| | - Bridget Dicker
- St John New Zealand (Hato Hone Aotearoa), Auckland, New Zealand
- Paramedicine Research Unit, Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
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Burgos-Esteban A, Gea-Caballero V, Marín-Maicas P, Santillán-García A, Cordón-Hurtado MDV, Marqués-Sule E, Giménez-Luzuriaga M, Juárez-Vela R, Sanchez-Gonzalez JL, García-Criado J, Santolalla-Arnedo I. Effectiveness of Early Warning Scores for Early Severity Assessment in Outpatient Emergency Care: A Systematic Review. Front Public Health 2022; 10:894906. [PMID: 35910902 PMCID: PMC9330632 DOI: 10.3389/fpubh.2022.894906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 06/22/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives Patient assessment and possible deterioration prediction are a healthcare priority. Increasing demand for outpatient emergency care services requires the implementation of simple, quick, and effective systems of patient evaluation and stratification. The purpose of this review is to identify the most effective Early Warning Score (EWS) for the early detection of the risk of complications when screening emergency outpatients for a potentially serious condition. Materials and Methods Systematic review of the bibliography made in 2022. Scientific articles in Spanish and English were collected from the databases and search engines of Pubmed, Cochrane, and Dialnet, which were published between 2017 and 2021 about EWSs and their capacity to predict complications. Results For analysis eleven articles were selected. Eight dealt with the application of different early warning scores in outpatient situations, concluding that all the scoring systems they studied were applicable. Three evaluated the predictive ability of various scoring systems and found no significant differences in their results. The eight articles evaluated the suitability of NEWS/NEWS2 to outpatient conditions and concluded it was the most suitable in pre-hospital emergency settings. Conclusions The early warning scores that were studied can be applied at the pre-hospital level, as they can predict patient mortality in the short term (24 or 48 h) and support clinical patient evaluation and medical decision making. Among them, NEWS2 is the most suitable for screening potentially deteriorating medical emergency outpatients.
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Affiliation(s)
- Amaya Burgos-Esteban
- Government of La Rioja, Rioja Health Service Servicio Riojano de Salud, La Rioja, Spain
- Department of Nursing, Research Group in Care Grupo de Investigación en Cuidados, University of La Rioja, Logroño, Spain
| | - Vicente Gea-Caballero
- Patient Blood Management Research Group, Madrid, Spain
- Community Health and Care Research Group, Faculty of Health Sciences, Valencian International University, Valencia, Spain
| | - Patricia Marín-Maicas
- Community Health and Care Research Group, Faculty of Health Sciences, Valencian International University, Valencia, Spain
| | - Azucena Santillán-García
- Community Health and Care Research Group, Faculty of Health Sciences, Valencian International University, Valencia, Spain
- Castilla-Leon Health Service, Sanidad Castilla y Leon, University Hospital of Burgos, Burgos, Spain
| | | | | | - Marta Giménez-Luzuriaga
- Government of La Rioja, Rioja Health Service Servicio Riojano de Salud, La Rioja, Spain
- Department of Nursing, Research Group in Care Grupo de Investigación en Cuidados, University of La Rioja, Logroño, Spain
| | - Raúl Juárez-Vela
- Department of Nursing, Research Group in Care Grupo de Investigación en Cuidados, University of La Rioja, Logroño, Spain
- *Correspondence: Raúl Juárez-Vela
| | | | - Jorge García-Criado
- Department of Physiology and Pharmacology, Faculty of Medicine, University of Salamanca, Salamanca, Spain
- Castilla-Leon Health Service, Sanidad Castilla y Leon, University Hospital of Salamanca, Salamanca, Spain
| | - Iván Santolalla-Arnedo
- Department of Nursing, Research Group in Care Grupo de Investigación en Cuidados, University of La Rioja, Logroño, Spain
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Saberian P, Abdollahi A, Hasani-Sharamin P, Modaber M, Karimialavijeh E. Comparing the prehospital NEWS with in-hospital ESI in predicting 30-day severe outcomes in emergency patients. BMC Emerg Med 2022; 22:42. [PMID: 35287593 PMCID: PMC8922925 DOI: 10.1186/s12873-022-00598-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Iran, the emergency departments (EDs) have largely adopted the emergency severity index (ESI) to prioritize the emergency patients, however emergency medical services (EMS) mainly triage the patients based on the paramedics' gestalt. The National Early Warning Score (NEWS) is a recommended prehospital triage in the UK. We aimed to compare prehospital NEWS and ED ESI for predicting severe outcomes in emergency patients. METHODS An observational study was conducted in a university-affiliated ED between January and April 2021. Adult patients who arrived in the ED by EMS were included. EMS providers calculated the patients' NEWS upon arriving on the scene using an Android NEWS application. In the ED, triage nurses utilized the ESI algorithm to prioritize patients with higher clinical risk. Then, Research nurses recorded patients' 30-day severe outcomes (death or ICU admission). Finally, The prognostic properties of ESI and NEWS were evaluated. RESULTS One thousand forty-eight cases were included in the final analysis, of which 29 (2.7%) patients experienced severe outcomes. The difference between the prehospital NEWS and ED ESI in predicting severe outcomes was not statistically significant (AUC = 0.825, 95% CI: 0.74-0.91 and 0.897, 95% CI, 0.83-0.95, for prehospital NEWS and ESI, respectively). CONCLUSION Our findings indicated that prehospital NEWS compares favorably with ED ESI in predicting 30-day severe outcomes in emergency patients.
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Affiliation(s)
- Peyman Saberian
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Anesthesiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Abdollahi
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Anesthesiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Ehsan Karimialavijeh
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Combination of Prehospital NT-proBNP with qSOFA and NEWS to Predict Sepsis and Sepsis-Related Mortality. DISEASE MARKERS 2022; 2022:5351137. [PMID: 35242244 PMCID: PMC8886755 DOI: 10.1155/2022/5351137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 12/18/2022]
Abstract
Background. The aim of this study was to assess the role of prehospital point-of-care N-terminal probrain natriuretic peptide to predict sepsis, septic shock, or in-hospital sepsis-related mortality. Methods. A prospective, emergency medical service-delivered, prognostic, cohort study of adults evacuated by ambulance and admitted to emergency department between January 2020 and May 2021. The discriminative power of the predictive variable was assessed through a prediction model trained using the derivation cohort and evaluated by the area under the curve of the receiver operating characteristic on the validation cohort. Results. A total of 1,360 patients were enrolled with medical disease in the study. The occurrence of sepsis, septic shock, and in-hospital sepsis-related mortality was 6.4% (67 cases), 4.2% (44 cases), and 6.1% (64 cases). Prehospital National Early Warning Score 2 had superior predictive validity than quick Sequential Organ Failure Assessment and N-terminal probrain natriuretic peptide for detecting sepsis and septic shock, but N-terminal probrain natriuretic peptide outperformed both scores in in-hospital sepsis-related mortality estimation. Application of N-terminal probrain natriuretic peptide to subgroups of the other two scores improved the identification of sepsis, septic shock, and sepsis-related mortality in the group of patients with low-risk scoring. Conclusions. The incorporation of N-terminal probrain natriuretic peptide in prehospital care combined with already existing scores could improve the identification of sepsis, septic shock, and sepsis-related mortality.
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Cash RE, Swor RA, Samuels-Kalow M, Eisenbrey D, Kaimal AJ, Camargo CA. Frequency and severity of prehospital obstetric events encountered by emergency medical services in the United States. BMC Pregnancy Childbirth 2021; 21:655. [PMID: 34560847 PMCID: PMC8464145 DOI: 10.1186/s12884-021-04129-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 09/15/2021] [Indexed: 03/21/2023] Open
Abstract
Background Prehospital obstetric events encountered by emergency medical services (EMS) can be high-risk patient presentations for which suboptimal care can cause substantial morbidity and mortality. The frequency of prehospital obstetric events is unclear because existing descriptions have reported obstetric and gynecological conditions together, without delineating specific patient presentations. Our objective was to identify the types, frequency, and acuity of prehospital obstetric events treated by EMS personnel in the US. Methods We conducted a cross-sectional analysis of EMS patient care records in the 2018 National EMS Information System dataset (n=22,532,890). We focused on EMS activations (i.e., calls for service) for an emergency scene response for patients aged 12-50 years with evidence of an obstetric event. Type of obstetric event was determined by examining patient symptoms, the treating EMS provider’s impression (i.e., field diagnosis), and procedures performed. High patient acuity was ascertained by EMS documentation of patient status and application of the modified early obstetric warning system (MEOWS) criteria, with concordance assessed using Cohen’s kappa. Descriptive statistics were calculated to describe the primary symptoms, impressions, and frequency of each type of obstetric event among these activations. Results A total of 107,771 (0.6%) of EMS emergency activations were identified as involving an obstetric event. The most common presentation was early or threatened labor (15%). Abdominal complaints, including pain and other digestive/abdomen signs and symptoms, was the most common primary symptom (29%) and primary impression (18%). We identified 3,489 (3%) out-of-hospital deliveries, of which 1,504 were preterm. Overall, EMS providers documented 34% of patients as being high acuity, similar to the MEOWS criteria (35%); however, there were high rates of missing data for EMS documented acuity (19%), poor concordance between the two measures (Cohen’s kappa=0.12), and acuity differences for specific conditions (e.g., high acuity of non-cephalic presentations, 77% in EMS documentation versus 53% identified by MEOWS). Conclusion Prehospital obstetric events were infrequently encountered by EMS personnel, and about one-third were high acuity. Additional work to understand the epidemiology and clinical care of these patients by EMS would help to optimize prehospital care and outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04129-1.
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Affiliation(s)
- Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Robert A Swor
- Department of Emergency Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Margaret Samuels-Kalow
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Eisenbrey
- Department of Emergency Medicine, McLaren Flint Hospital, Flint, MI, USA
| | - Anjali J Kaimal
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Bourn SS, Crowe RP, Fernandez AR, Matt SE, Brown AL, Hawthorn AB, Myers JB. Initial prehospital Rapid Emergency Medicine Score (REMS) to predict outcomes for COVID-19 patients. J Am Coll Emerg Physicians Open 2021; 2:e12483. [PMID: 34223444 PMCID: PMC8240529 DOI: 10.1002/emp2.12483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/20/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The Rapid Emergency Medicine Score (REMS) has not been widely studied for use in predicting outcomes of COVID-19 patients encountered in the prehospital setting. This study aimed to determine whether the first prehospital REMS could predict emergency department and hospital dispositions for COVID-19 patients transported by emergency medical services. METHODS This retrospective study used linked prehospital and hospital records from the ESO Data Collaborative for all 911-initiated transports of patients with hospital COVID-19 diagnoses from July 1 to December 31, 2020. We calculated REMS with the first recorded prehospital values for each component. We calculated area under the receiver operating curve (AUROC) for emergency department (ED) mortality, ED discharge, hospital mortality, and hospital length of stay (LOS). We determined optimal REMS cut-points using test characteristic curves. RESULTS Among 13,830 included COVID-19 patients, median REMS was 6 (interquartile range [IQR]: 5-9). ED mortality was <1% (n = 80). REMS ≥9 predicted ED death (AUROC 0.79). One-quarter of patients (n = 3,419) were discharged from the ED with an optimal REMS cut-point of ≤5 (AUROC 0.72). Eighteen percent (n = 1,742) of admitted patients died. REMS ≥8 optimally predicted hospital mortality (AUROC 0.72). Median hospital LOS was 8.3 days (IQR: 4.1-14.8 days). REMS ≥7 predicted hospitalizations ≥3 days (AUROC 0.62). CONCLUSION Initial prehospital REMS was modestly predictive of ED and hospital dispositions for patients with COVID-19. Prediction was stronger for outcomes more proximate to the first set of emergency medical services (EMS) vital signs. These findings highlight the potential value of first prehospital REMS for risk stratification of individual patients and system surveillance for resource planning related to COVID-19.
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Affiliation(s)
| | | | - Antonio R. Fernandez
- ESO, Inc.AustinTexasUSA
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillNorth CarolinaChapel HillUSA
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Early detection of intensive care needs and mortality risk by use of five early warning scores in patients with traumatic injuries: An observational study. Intensive Crit Care Nurs 2021; 67:103095. [PMID: 34244029 DOI: 10.1016/j.iccn.2021.103095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this research was to evaluate the predictive capacity of five Early Warning Scores in relation to the clinical evolution of adult patients with different types of trauma. RESEARCH METHODOLOGY We conducted a longitudinal, prospective, observational study, calculating the Early Warning Scores [Modified Early Warning Score (MEWS), National Early Warning Score 2 (NEWS-2), VitalPAC Early Warning Score (ViEWS), Modified Rapid Emergency Medicine Score (MREMS), and Rapid Acute Physiology Score (RAPS)] upon arrival of patients to the emergency department. SETTING In total, 445 cases of traumatic injuries were included in the study. MAIN OUTCOME MEASURES The predictive capacity was verified with the data on admission to intensive care units (ICU) and mortality at two, seven and 30 days. RESULTS 201 patients were hospitalized and 244 were discharged after being attended in the emergency department. 91 cases (20.4%) required ICU care and 4.7% of patients died (21 patients) within two days, 6.5% (29 patients) within seven days and 9.7% (43 patients) within 30 days. The highest area under the curve for predicting the need for ICU care was obtained by the National Early Warning Score 2 and the VitalPAC Early Warning Score. For predicting mortality, the Modified Rapid Emergency Medicine Score obtained the best scores for two-day mortality, seven-day mortality and 30-day mortality. CONCLUSIONS Every Early Warning Score analyzed in this study obtained good results in predicting adverse effects in adult patients with traumatic injuries, creating an opportunity for new clinical applications in the emergency department.
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Martín-Rodríguez F, López-Izquierdo R, del Pozo Vegas C, Delgado-Benito JF, Ortega GJ, Castro Villamor MA, Sanz-García A. Association of Prehospital Oxygen Saturation to Inspired Oxygen Ratio With 1-, 2-, and 7-Day Mortality. JAMA Netw Open 2021; 4:e215700. [PMID: 33847751 PMCID: PMC8044733 DOI: 10.1001/jamanetworkopen.2021.5700] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The early identification of patients at high risk of clinical deterioration represents one of the greatest challenges for emergency medical services (EMS). OBJECTIVE To assess whether use of the ratio of prehospital oxygen saturation measured by pulse oximetry (Spo2) to fraction of inspired oxygen (Fio2) measured during initial contact by EMS with the patient (ie, the first Spo2 to Fio2 ratio) and 5 minutes before the patient's arrival at the hospital (ie, the second Spo2 to Fio2 ratio) can predict the risk of early in-hospital deterioration. DESIGN, SETTING, AND PARTICIPANTS A prospective, derivation-validation prognostic cohort study of 3606 adults with acute diseases referred to 5 tertiary care hospitals in Spain was conducted between October 26, 2018, and June 30, 2020. Eligible patients were recruited from among all telephone requests for EMS assistance for adults who were later evacuated with priority in advanced life support units to the referral hospitals during the study period. MAIN OUTCOMES AND MEASURES The primary outcome was hospital mortality from any cause within the first, second, third, or seventh day after EMS transport to the hospital. The main measure was the Spo2 to Fio2 ratio. RESULTS A total of 3606 participants comprised 2 separate cohorts: the derivation cohort (3081 patients) and the validation cohort (525 patients). The median age was 69 years (interquartile range, 54-81 years), and 2122 patients (58.8%) were men. The overall mortality rate of the patients in the study cohort ranged from 3.6% for 1-day mortality (131 patients) to 7.1% for 7-day mortality (256 patients). The best model performance was for 2-day mortality with the second Spo2 to Fio2 ratio with an area under the curve of 0.890 (95% CI, 0.829-0.950; P < .001), although the other outcomes also presented good results. In addition, a risk-stratification model was generated. The optimal cutoff resulted in the following ranges of Spo2 to Fio2 ratios: 50 to 100 for high risk of mortality, 101 to 426 for intermediate risk, and 427 to 476 for low risk. CONCLUSIONS AND RELEVANCE This study suggests that use of the prehospital Spo2 to Fio2 ratio was associated with improved management of patients with acute disease because it accurately predicts short-term mortality.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Faculty of Medicine, Valladolid University, Valladolid, Spain
- Advanced Life Support, Emergency Medical Services, Valladolid, Spain
| | - Raúl López-Izquierdo
- Faculty of Medicine, Valladolid University, Valladolid, Spain
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carlos del Pozo Vegas
- Faculty of Medicine, Valladolid University, Valladolid, Spain
- Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Guillermo J. Ortega
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid, Spain
- Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | | | - Ancor Sanz-García
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid, Spain
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Crowe RP, Bourn SS, Fernandez AR, Myers JB. Initial Prehospital Rapid Emergency Medicine Score (REMS) as a Predictor of Patient Outcomes. PREHOSP EMERG CARE 2021:1-11. [PMID: 33320716 DOI: 10.1080/10903127.2020.1862944] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/05/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
Background: A standardized objective measure of prehospital patient risk of hospitalization or death is needed. The Rapid Emergency Medicine Score (REMS), a validated risk-stratification tool, has not been widely tested for prehospital use. This study's objective was to assess predictive characteristics of initial prehospital REMS for ED disposition and overall patient mortality. Methods: This retrospective analysis used linked prehospital and hospital data from the national ESO Data Collaborative. All 911 responses from 1/1/2019-12/31/2019 were included. REMS (0-26) was calculated using age and first prehospital values for: pulse rate, mean arterial pressure, respiratory rate, oxygen saturation, and Glasgow Coma Scale. Non-transports, patients <18 and cardiac arrests prior to EMS arrival were excluded. The primary outcome was ED disposition, dichotomized to discharge versus admission, transfer, or death. The secondary outcome was overall survival to discharge (ED or inpatient). Transfers and records without inpatient disposition were excluded from the secondary analysis. Predictive ability was assessed using area under the receiver operating curve (AUROC). Optimal REMS cut points were determined using test characteristic curves. Univariable logistic regression modeling was used to quantify the association between initial prehospital REMS and each outcome. Results: Of 579,505 eligible records, 94,640 (16%) were excluded due to missing data needed to calculate REMS. Overall, 62% (n = 298,223) of patients were discharged from the ED, 36% (n = 175,212) were admitted, 2% (n = 10,499) were transferred, and 0.2% (n = 931) died in the ED. A REMS of 5 or lower demonstrated optimal statistical prediction for ED discharge versus not discharged (admission/transfer/death) (AUROC: 0.68). Patients with initial prehospital REMS of 5 or lower showed a three-fold increase in odds of ED discharge (OR: 3.28, 95%CI: 3.24-3.32). Of the 457,226 patients included in overall mortality analysis, >98% (n = 450,112) survived. AUROC of initial prehospital REMS for overall mortality was 0.79. A score 7 or lower was statistically optimal for predicting survival. Initial prehospital REMS of 7 or lower was associated with a five-fold increase in odds of overall survival (OR:5.41, 95%CI:5.15-5.69). Conclusion: Initial prehospital REMS was predictive of ED disposition and overall patient mortality, suggesting value as a risk-stratification measure for EMS agencies, systems and researchers.
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Affiliation(s)
- Remle P Crowe
- ESO, Inc, Austin, Texas (RPC, SB, ARF, JBM); Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (ARF)
| | - Scott S Bourn
- ESO, Inc, Austin, Texas (RPC, SB, ARF, JBM); Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (ARF)
| | - Antonio R Fernandez
- ESO, Inc, Austin, Texas (RPC, SB, ARF, JBM); Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (ARF)
| | - J Brent Myers
- ESO, Inc, Austin, Texas (RPC, SB, ARF, JBM); Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (ARF)
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