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Rahman LR, Melson E, Alousi SA, Sardar M, Levy MJ, Shafiq S, Rahman F, Coats T, Reddy NL. Point-of-care ultrasound is a useful adjunct tool to a clinician's assessment in the evaluation of severe hyponatraemia. Clin Endocrinol (Oxf) 2024; 100:595-601. [PMID: 38226504 DOI: 10.1111/cen.15024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/29/2023] [Accepted: 01/01/2024] [Indexed: 01/17/2024]
Abstract
INTRODUCTION Hyponatraemia is the most common electrolyte disorder in inpatients resulting mainly from an imbalance in water homeostasis. Intravascular fluid status assessment is pivotal but is often challenging given multimorbidity, polypharmacy and diuretics use. We evaluated the utility of point-of-care ultrasound (POCUS) as an adjunct tool to standard practice for fluid assessment in severe hyponatraemia patients. METHODS Patients presenting with severe hyponatremia (Serum Sodium [Na] < 120 mmol/L; Normal range: 135-145 mol/L), managed by standard care were included. Hyponatraemia biochemistry work-up and POCUS examination were undertaken. Both clinician and POCUS independently assigned one of the three fluid status groups of hypovolaemia, hypervolaemia or euvolaemia. The final diagnosis of three fluid status groups at admission was made at the time of discharge by retrospective case review. Clinician's (standard of care) and POCUS fluid assessments were compared to that of the final diagnosis at the time of discharge. RESULTS n = 19 patients were included. Median Na on admission was 113 mmol/L (109-116), improved to 129 ± 3 mmol/L on discharge. POCUS showed the higher degree of agreement with the final diagnosis (84%; n = 16/19), followed by the clinician (63%; n = 12/19). A trend towards higher accuracy of POCUS compared to clinician assessment of fluid status was noted (84% vs. 63%, p = 0.1611). Biochemistry was unreliable in 58% (n = 11/19) likely due to renal failure, polypharmacy or diuretic use. Inappropriate emergency fluid management was undertaken in 37% (n = 7/19) of cases based on initial clinician assessment. Thirst symptom correlated to hypovolaemia in 80% (4/5) cases. CONCLUSION As subjective clinical and biochemistry assessments of fluid status are often unreliable due to co-morbidities and concurrent use of medications, POCUS can be a rapid objective diagnostic tool to assess fluid status in patients with severe hyponatraemia, to guide accurate emergency fluid management.
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Affiliation(s)
- Latif R Rahman
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Eka Melson
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Endocrinology, University of Leicester, Leicester, UK
| | | | | | - Miles J Levy
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Endocrinology, University of Leicester, Leicester, UK
| | | | | | - Tim Coats
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Endocrinology, University of Leicester, Leicester, UK
| | - Narendra L Reddy
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Endocrinology, University of Leicester, Leicester, UK
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Pope I, Clark LV, Clark A, Ward E, Belderson P, Stirling S, Parrott S, Li J, Coats T, Bauld L, Holland R, Gentry S, Agrawal S, Bloom BM, Boyle AA, Gray AJ, Morris MG, Livingstone-Banks J, Notley C. Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial. Emerg Med J 2024; 41:276-282. [PMID: 38531658 DOI: 10.1136/emermed-2023-213824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/17/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Supporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention if it is sufficiently resourced. The objective of this trial was to determine whether an opportunistic ED-based smoking cessation intervention can help people to quit smoking. METHODS In this multicentre, parallel-group, randomised controlled superiority trial conducted between January and August 2022, adults who smoked daily and attended one of six UK EDs were randomised to intervention (brief advice, e-cigarette starter kit and referral to stop smoking services) or control (written information on stop smoking services). The primary outcome was biochemically validated abstinence at 6 months. RESULTS An intention-to-treat analysis included 972 of 1443 people screened for inclusion (484 in the intervention group, 488 in the control group). Of 975 participants randomised, 3 were subsequently excluded, 17 withdrew and 287 were lost to follow-up. The 6-month biochemically-verified abstinence rate was 7.2% in the intervention group and 4.1% in the control group (relative risk 1.76; 95% CI 1.03 to 3.01; p=0.038). Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (relative risk 1.80; 95% CI 1.36 to 2.38; p<0.001). No serious adverse events related to taking part in the trial were reported. CONCLUSIONS An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events. TRIAL REGISTRATION NUMBER NCT04854616.
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Affiliation(s)
- Ian Pope
- Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK
| | - Lucy V Clark
- Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK
| | - Emma Ward
- Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK
| | - Pippa Belderson
- Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK
| | - Susan Stirling
- Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Jinshuo Li
- Department of Health Sciences, University of York, York, UK
| | - Tim Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Linda Bauld
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Sarah Gentry
- Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK
| | | | | | - Adrian A Boyle
- Emergency Department, Addenbrooke's Hospital, Cambridge, UK
| | - Alasdair J Gray
- Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, Edinburgh, UK
| | - M Geraint Morris
- Emergency Department, Homerton University Hospital NHS Foundation Trust, London, UK
| | | | - Caitlin Notley
- Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK
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Marincowitz C, Bouamra O, Coats T, Kumar D, Lockey D, Mason L, Newcombe V, Thompson J, Edwards A, Lecky F. Major trauma presentations and patient outcomes in English hospitals during the COVID-19 pandemic: An observational cohort study. PLoS Med 2023; 20:e1004243. [PMID: 37315103 DOI: 10.1371/journal.pmed.1004243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/19/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Single-centre studies suggest that successive Coronavirus Disease 2019 (COVID-19)-related "lockdown" restrictions in England may have led to significant changes in the characteristics of major trauma patients. There is also evidence from other countries that diversion of intensive care capacity and other healthcare resources to treating patients with COVID-19 may have impacted on outcomes for major trauma patients. We aimed to assess the impact of the COVID-19 pandemic on the number, characteristics, care pathways, and outcomes of major trauma patients presenting to hospitals in England. METHODS AND FINDINGS We completed an observational cohort study and interrupted time series analysis including all patients eligible for inclusion in England in the national clinical audit for major trauma presenting between 1 January 2017 and 31 of August 2021 (354,202 patients). Demographic characteristics (age, sex, physiology, and injury severity) and clinical pathways of major trauma patients in the first lockdown (17,510 patients) and second lockdown (38,262 patients) were compared to pre-COVID-19 periods in 2018 to 2019 (comparator period 1: 22,243 patients; comparator period 2: 18,099 patients). Discontinuities in trends for weekly estimated excess survival rate were estimated when lockdown measures were introduced using segmented linear regression. The first lockdown had a larger associated reduction in numbers of major trauma patients (-4,733 (21%)) compared to the pre-COVID period than the second lockdown (-2,754 (6.7%)). The largest reductions observed were in numbers of people injured in road traffic collisions excepting cyclists where numbers increased. During the second lockdown, there were increases in the numbers of people injured aged 65 and over (665 (3%)) and 85 and over (828 (9.3%)). In the second week of March 2020, there was a reduction in level of major trauma excess survival rate (-1.71%; 95% CI: -2.76% to -0.66%) associated with the first lockdown. This was followed by a weekly trend of improving survival until the lifting of restrictions in July 2020 (0.25; 95% CI: 0.14 to 0.35). Limitations include eligibility criteria for inclusion to the audit and COVID status of patients not being recorded. CONCLUSIONS This national evaluation of the impact of COVID on major trauma presentations to English hospitals has observed important public health findings: The large reduction in overall numbers injured has been primarily driven by reductions in road traffic collisions, while numbers of older people injured at home increased over the second lockdown. Future research is needed to better understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first lockdown.
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Affiliation(s)
- Carl Marincowitz
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Omar Bouamra
- Trauma Audit Research Network, University of Manchester, Manchester, United Kingdom
| | - Tim Coats
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Dhushy Kumar
- Department of Critical Care, Anaesthesia and Pre-hospital Emergency Medicine, University Hospital Coventry, Coventry, United Kingdom
| | - David Lockey
- London's Air Ambulance, Royal London Hospital, London, United Kingdom
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Lyndon Mason
- Liverpool University Hospitals NHS Foundation Trust, University of Liverpool, Liverpool, United Kingdom
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Julian Thompson
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Antoinette Edwards
- Trauma Audit Research Network, University of Manchester, Manchester, United Kingdom
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
- Trauma Audit Research Network, University of Manchester, Manchester, United Kingdom
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Notley C, Clark L, Belderson P, Ward E, Clark AB, Parrott S, Agrawal S, Bloom BM, Boyle AA, Morris G, Gray A, Coats T, Man MS, Bauld L, Holland R, Pope I. Cessation of smoking trial in the emergency department (CoSTED): protocol for a multicentre randomised controlled trial. BMJ Open 2023; 13:e064585. [PMID: 36657751 PMCID: PMC9853266 DOI: 10.1136/bmjopen-2022-064585] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Attendees of emergency departments (EDs) have a higher than expected prevalence of smoking. ED attendance may be a good opportunity to prompt positive behaviour change, even for smokers not currently motivated to quit. This study aims to determine whether an opportunist smoking cessation intervention delivered in the ED can help daily smokers attending the ED quit smoking and is cost-effective. METHODS AND ANALYSIS A two-arm pragmatic, multicentred, parallel-group, individually randomised, controlled superiority trial with an internal pilot, economic evaluation and mixed methods process evaluation. The trial will compare ED-based brief smoking cessation advice, including provision of an e-cigarette and referral to local stop smoking services (intervention) with the provision of contact details for local stop smoking services (control). Target sample size is 972, recruiting across 6 National Health Service EDs in England and Scotland. Outcomes will be collected at 1, 3 and 6 months. The primary outcome at 6 months is carbon monoxide verified continuous smoking abstinence. ETHICS AND DISSEMINATION The trial was approved by the South Central-Oxford B Research Committee (21/SC/0288). Dissemination will include the publication of outcomes, and the process and economic evaluations in peer-reviewed journals. The findings will also be appropriately disseminated to relevant practice, policy and patient representative groups. TRIAL REGISTRATION NUMBER NCT04854616; protocol V.4.2.
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Affiliation(s)
- Caitlin Notley
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Lucy Clark
- Norwich Clincial Trials Unit, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Pippa Belderson
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Emma Ward
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Allan B Clark
- Norwich Clincial Trials Unit, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Sanjay Agrawal
- Institute of Lung Health, University of Leicester, Leicester, UK
| | - Ben M Bloom
- Emergency Department, Barts Health NHS Trust, London, UK
| | - Adrian A Boyle
- Emergency Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Geraint Morris
- Department of Emergency Medicine, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Alasdair Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tim Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Mei-See Man
- Norwich Clincial Trials Unit, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Linda Bauld
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, UK
| | | | - Ian Pope
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Emergency Medicine, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Ibrahim W, Wilde MJ, Cordell RL, Richardson M, Salman D, Free RC, Zhao B, Singapuri A, Hargadon B, Gaillard EA, Suzuki T, Ng LL, Coats T, Thomas P, Monks PS, Brightling CE, Greening NJ, Siddiqui S. Visualization of exhaled breath metabolites reveals distinct diagnostic signatures for acute cardiorespiratory breathlessness. Sci Transl Med 2022; 14:eabl5849. [PMID: 36383685 PMCID: PMC7613858 DOI: 10.1126/scitranslmed.abl5849] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acute cardiorespiratory breathlessness accounts for one in eight of all emergency hospitalizations. Early, noninvasive diagnostic testing is a clinical priority that allows rapid triage and treatment. Here, we sought to find and replicate diagnostic breath volatile organic compound (VOC) biomarkers of acute cardiorespiratory disease and understand breath metabolite network enrichment in acute disease, with a view to gaining mechanistic insight of breath biochemical derangements. We collected and analyzed exhaled breath samples from 277 participants presenting acute cardiorespiratory exacerbations and aged-matched healthy volunteers. Topological data analysis phenotypes differentiated acute disease from health and acute cardiorespiratory exacerbation subtypes (acute heart failure, acute asthma, acute chronic obstructive pulmonary disease, and community-acquired pneumonia). A multibiomarker score (101 breath biomarkers) demonstrated good diagnostic sensitivity and specificity (≥80%) in both discovery and replication sets and was associated with all-cause mortality at 2 years. In addition, VOC biomarker scores differentiated metabolic subgroups of cardiorespiratory exacerbation. Louvain clustering of VOCs coupled with metabolite enrichment and similarity assessment revealed highly specific enrichment patterns in all acute disease subgroups, for example, selective enrichment of correlated C5-7 hydrocarbons and C3-5 carbonyls in heart failure and selective depletion of correlated aldehydes in acute asthma. This study identified breath VOCs that differentiate acute cardiorespiratory exacerbations and associated subtypes and metabolic clusters of disease-associated VOCs.
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Affiliation(s)
- Wadah Ibrahim
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Michael J. Wilde
- School of Chemistry, University of Leicester, Leicester, LE1 7RH UK
- School of Geography, Earth and Environmental Sciences, University of Plymouth, Plymouth, PL4 8AA, UK
- joint corresponding authorship. (M.J.W.); (S.S.)
| | | | - Matthew Richardson
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Dahlia Salman
- Department of Chemistry, Loughborough University, Loughborough, LE11 3TT UK
| | - Robert C. Free
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Bo Zhao
- Leverhulme Centre for Demographic Science, University of Oxford, Oxford, OX1 1JD United Kingdom
- Nuffield College, University of Oxford, Oxford, OX1 1NF United Kingdom
| | - Amisha Singapuri
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Beverley Hargadon
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Erol A. Gaillard
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Toru Suzuki
- Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre, Glenfield General Hospital, Leicester, LE3 9QP UK
- Leicester NIHR Biomedical Research Centre (Cardiovascular theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
- The Institute of Medical Science, The University of Tokyo Shirokane-dai, Minato-ku 4-6-1, 108-8639 Tokyo, Japan
| | - Leong L. Ng
- Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre, Glenfield General Hospital, Leicester, LE3 9QP UK
- Leicester NIHR Biomedical Research Centre (Cardiovascular theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Tim Coats
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, University Road, Leicester LE1 7RH, UK
| | - Paul Thomas
- Department of Chemistry, Loughborough University, Loughborough, LE11 3TT UK
| | - Paul S. Monks
- School of Chemistry, University of Leicester, Leicester, LE1 7RH UK
| | - Christopher E. Brightling
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Neil J. Greening
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
| | - Salman Siddiqui
- Department of Respiratory Sciences, University of Leicester, Leicester, LE1 7RH UK
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Groby Road, Leicester LE3 9QP
- National Heart and Lung Institute, Imperial College, London, SW3 6LY UK
- joint corresponding authorship. (M.J.W.); (S.S.)
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Alshibani A, Coats T, Maynou L, Lecky F, Banerjee J, Conroy S. A comparison between the clinical frailty scale and the hospital frailty risk score to risk stratify older people with emergency care needs. BMC Emerg Med 2022; 22:171. [PMID: 36284266 PMCID: PMC9598033 DOI: 10.1186/s12873-022-00730-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Older adults living with frailty who require treatment in hospitals are increasingly seen in the Emergency Departments (EDs). One quick and simple frailty assessment tool-the Clinical Frailty Scale (CFS)-has been embedded in many EDs in the United Kingdom (UK). However, it carries time/training and cost burden and has significant missing data. The Hospital Frailty Risk Score (HFRS) can be automated and has the potential to reduce costs and increase data availability, but has not been tested for predictive accuracy in the ED. The aim of this study is to assess the correlation between and the ability of the CFS at the ED and HFRS to predict hospital-related outcomes. METHODS This is a retrospective cohort study using data from Leicester Royal Infirmary hospital during the period from 01/10/2017 to 30/09/2019. We included individuals aged + 75 years as the HFRS has been only validated for this population. We assessed the correlation between the CFS and HFRS using Pearson's correlation coefficient for the continuous scores and weighted kappa scores for the categorised scores. We developed logistic regression models (unadjusted and adjusted) to estimate Odds Ratios (ORs) and Confidence Intervals (CIs), so we can assess the ability of the CFS and HFRS to predict 30-day mortality, Length of Stay (LOS) > 10 days, and 30-day readmission. RESULTS Twelve thousand two hundred thirty seven individuals met the inclusion criteria. The mean age was 84.6 years (SD 5.9) and 7,074 (57.8%) were females. Between the CFS and HFRS, the Pearson correlation coefficient was 0.36 and weighted kappa score was 0.15. When comparing the highest frailty categories to the lowest frailty category within each frailty score, the ORs for 30-day mortality, LOS > 10 days, and 30-day readmission using the CFS were 2.26, 1.36, and 1.64 and for the HFRS 2.16, 7.68, and 1.19. CONCLUSION The CFS collected at the ED and the HFRS had low/slight agreement. Both frailty scores were shown to be predictors of adverse outcomes. More research is needed to assess the use of historic HFRS in the ED.
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Affiliation(s)
- Abdullah Alshibani
- grid.9918.90000 0004 1936 8411Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, LE1 7HA UK ,grid.412149.b0000 0004 0608 0662Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,grid.452607.20000 0004 0580 0891King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Tim Coats
- grid.269014.80000 0001 0435 9078University Hospitals of Leicester NHS Trust, Leicester, UK ,grid.9918.90000 0004 1936 8411Department of Cardiovascular Sciences, Emergency Medicine Academic Group, University of Leicester, Leicester, UK
| | - Laia Maynou
- grid.13063.370000 0001 0789 5319Department of Health Policy, London School of Economics and Political Science, London, UK ,grid.5841.80000 0004 1937 0247Department of Economics, Econometrics and Applied Economics, Universitat de Barcelona, Barcelona, Spain ,grid.5612.00000 0001 2172 2676Center for Research in Health and Economics (CRES), Universitat Pompeu Fabra, Barcelona, Spain
| | - Fiona Lecky
- grid.11835.3e0000 0004 1936 9262Centre for Urgent and Emergency Care Research, University of Sheffield, Sheffield, UK
| | - Jay Banerjee
- grid.9918.90000 0004 1936 8411Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, LE1 7HA UK ,grid.269014.80000 0001 0435 9078University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Simon Conroy
- grid.83440.3b0000000121901201MRC Unit for Lifelong Health and Ageing, University College London, London, UK
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Paranamana S, Roland D, Coats T. 947 The ‘silent video’ as a training aid for emergency department major incident management. J Accid Emerg Med 2022. [DOI: 10.1136/emermed-2022-rcem.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Aims/Objectives/BackgroundThere is a specific need to refresh knowledge of and update Major Incident Protocols (MIP) but a department may have less than one Major Incident (MI) every 5 years.As part of our department’s COVID-19 pandemic response, a ‘silent movie’ of PPE donning-and-doffing techniques was played on large screens in the background during clinical handovers. We theorised that this technique might be effective in training ED staff on the MIP.Methods/DesignWe created a seven-minute silent video about our MIP using volunteer actors from ED Doctors, Nurses, and Ancillary Healthcare Staff. Brief captions describing key aspects of the MIP were overlaid on video clips and images.The video was played on a continuous loop on wall mounted TVs for six continuous weeks, located within the handover room used by all ED staff members.A questionnaire was sent out to all staff in ED to assess how the video’s content improved understanding of the MIP. The design of the questionnaire was based on the Moore’s Expanded Education Outcome Model.Abstract 947 Table 1Moore’s Outcomes FrameworkMeasure/QuestionResponseLEVEL 1Participation Participation in questionnaire 95 responses out of 851 staff. Have you seen the ED major Incident video in the Handover Room? 67% of respondents had seen the training video (90% of these watched the whole video). LEVEL 2Satisfaction I was satisfied with the format, delivery and content of the video. 70% were satisfied with the format of the video I found the content of the video useful. 84% thought the content useful LEVEL 3ALearning: Declarative Knowledge I know how the ED is organised in a Major Incident. Before 25%, After 66%. LEVEL 3BLearning: Procedural Knowledge I know what to do in a major incident. Before 35%, After 67% I could locate the Major Incident tray in each area of the ED. Before 28%, After 53%. I would be able to perform well in a Major Incident. Before 40%, After increased to 69% Results/Conclusions64 of the respondents viewed the video. From the cohort, 70% were satisfied with the format of the video and 84% believed the content to be useful. Using the Moore’s outcome model there was an increase in 62.1% of the declarative knowledge post viewing, and a 47.8% increase in the confidence of knowing what to do in a MI. The confidence in being able to locate the MIP tray and perform well in a MI had also increased by 47.2% and 42.02% respectively.The repeated silent video format was an effective teaching tool, as reflected in all aspects of Moore’s model; majority of respondents showed improved confidence in all aspects of the MIP. Background training videos could form part of ED training, especially for topics which are not included in formal training programs.
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Holden K, Makinde M, Wilde M, Richardson M, Coats T, Monks P, Gaillard EA. Assessing the feasibility and acceptability of online measurements of exhaled volatile organic compounds (VOCs) in children with preschool wheeze: a pilot study. BMJ Paediatr Open 2021; 5:e001003. [PMID: 34568587 PMCID: PMC8438855 DOI: 10.1136/bmjpo-2020-001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/17/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Investigating airway inflammation and pathology in wheezy preschool children is both technically and ethically challenging. Identifying and validating non-invasive tests would be a huge clinical advance. Real-time analysis of exhaled volatile organic compounds (VOCs) in adults is established, however, the feasibility of this non-invasive method in young children remains undetermined. AIM To determine the feasibility and acceptability of obtaining breath samples from preschool children by means of real-time mass spectrometry analysis of exhaled VOCs. METHODS Breath samples from preschool children were collected and analysed in real time by proton transfer reaction-time of flight-mass spectrometry (PTR-TOF-MS) capturing unique breath profiles. Acetone (mass channel m/z 59) was used as a reference profile to investigate the breath cycle in more detail. Dynamic time warping (DTW) was used to compare VOC profiles from adult breath to those we obtained in preschool children. RESULTS 16 children were recruited in the study, of which eight had acute doctor-diagnosed wheeze (mean (range) age 3.2 (1.9-4.5) years) and eight had no history of wheezing (age 3.3 (2.2-4.1) years). Fully analysable samples were obtained in 11 (68%). DTW was used to ascertain the distance between the time series of mass channel m/z 59 (acetone) and the other 193 channels. Commonality of 12 channels (15, 31, 33, 41, 43, 51, 53, 55, 57, 60, 63 and 77) was established between adult and preschool child samples despite differences in the breathing patterns. CONCLUSION Real-time measurement of exhaled VOCs by means of PTR-MS is feasible and acceptable in preschool children. Commonality in VOC profiles was found between adult and preschool children.
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Affiliation(s)
- Karl Holden
- Leicester NIHR Biomedical Research Centre (Respiratory Theme), Glenfield Hospital, Leicester, UK.,Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Misty Makinde
- Leicester NIHR Biomedical Research Centre (Respiratory Theme), Glenfield Hospital, Leicester, UK.,Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Michael Wilde
- Department of Chemistry, University of Leicester, Leicester, UK
| | - Matthew Richardson
- Leicester NIHR Biomedical Research Centre (Respiratory Theme), Glenfield Hospital, Leicester, UK.,Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Tim Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Paul Monks
- Department of Chemistry, University of Leicester, Leicester, UK
| | - Erol A Gaillard
- Leicester NIHR Biomedical Research Centre (Respiratory Theme), Glenfield Hospital, Leicester, UK.,Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK
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9
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Kakarala SE, Roberts KE, Rogers M, Coats T, Falzarano F, Gang J, Chilov M, Avery J, Maciejewski PK, Lichtenthal WG, Prigerson HG. The neurobiological reward system in Prolonged Grief Disorder (PGD): A systematic review. Psychiatry Res Neuroimaging 2020; 303:111135. [PMID: 32629197 PMCID: PMC7442719 DOI: 10.1016/j.pscychresns.2020.111135] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 12/21/2022]
Abstract
Prolonged Grief Disorder (PGD) is a debilitating condition affecting between 7% and 10% of bereaved individuals. Past imaging and psychological studies have proposed links between PGD's characteristic symptoms - in particular, profound yearning - and the neural reward system. We conducted a systematic review to investigate this connection. On December 19, 2019, we searched six bibliographic databases for data on the neurobiology of grief and disordered grief. We excluded studies of the hypothalamic-pituitary-adrenal (HPA) axis, animal studies, and reviews. After abstract and full-text screening, twenty-four studies were included in the final review. We found diverse evidence for the activation of several reward-related regions of the brain in PGD. The data reviewed suggest that compared to normative grief, PGD involves a differential pattern of activity in the amygdala and orbitofrontal cortex (OFC); likely differential activity in the posterior cingulate cortex (PCC), rostral or subgenual anterior cingulate cortex (ACC), and basal ganglia overall, including the nucleus accumbens (NAc); and possible differential activity in the insula. It also appears that oxytocin signaling is altered in PGD, though the exact mechanism is unclear. Our findings appear to be consistent with, though not confirmative of, conceptualizing PGD as a disorder of reward, and identify directions for future research.
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Affiliation(s)
- S E Kakarala
- Cornell Center for Research on End-of-life Care, Weill Cornell Medicine, 420 E. 70th St., New York, NY 10021, USA
| | - K E Roberts
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - M Rogers
- Cornell Center for Research on End-of-life Care, Weill Cornell Medicine, 420 E. 70th St., New York, NY 10021, USA
| | - T Coats
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - F Falzarano
- Cornell Center for Research on End-of-life Care, Weill Cornell Medicine, 420 E. 70th St., New York, NY 10021, USA
| | - J Gang
- Cornell Center for Research on End-of-life Care, Weill Cornell Medicine, 420 E. 70th St., New York, NY 10021, USA
| | - M Chilov
- Medical Library, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - J Avery
- Department of Radiology, Weill Cornell Medicine, 1305 York Ave., New York, NY 10021, USA
| | - P K Maciejewski
- Cornell Center for Research on End-of-life Care, Weill Cornell Medicine, 420 E. 70th St., New York, NY 10021, USA; Department of Radiology, Weill Cornell Medicine, 1305 York Ave., New York, NY 10021, USA
| | - W G Lichtenthal
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA; Department of Psychiatry, Weill Cornell Medicine, 525 E. 68th St., New York, NY 10065, USA
| | - H G Prigerson
- Cornell Center for Research on End-of-life Care, Weill Cornell Medicine, 420 E. 70th St., New York, NY 10021, USA; Department of Medicine, Weill Cornell Medicine, 1320 York Ave., New York, NY 10021, USA.
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10
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Beaumont O, Lecky F, Bouamra O, Surendra Kumar D, Coats T, Lockey D, Willett K. Helicopter and ground emergency medical services transportation to hospital after major trauma in England: a comparative cohort study. Trauma Surg Acute Care Open 2020; 5:e000508. [PMID: 32704546 PMCID: PMC7368476 DOI: 10.1136/tsaco-2020-000508] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022] Open
Abstract
Background The utilization of helicopter emergency medical services (HEMS) in modern trauma systems has been a source of debate for many years. This study set to establish the true impact of HEMS in England on survival for patients with major trauma. Methods A comparative cohort design using prospectively recorded data from the UK Trauma Audit and Research Network registry. 279 107 patients were identified between January 2012 and March 2017. The primary outcome measure was risk adjusted in-hospital mortality within propensity score matched cohorts using logistic regression analysis. Subset analyses were performed for subjects with prehospital Glasgow Coma Scale <8, respiratory rate <10 or >29 and systolic blood pressure <90. Results The analysis was based on 61 733 adult patients directly admitted to major trauma centers: 54 185 ground emergency medical services (GEMS) and 7548 HEMS. HEMS patients were more likely male, younger, more severely injured, more likely to be victims of road traffic collisions and intubated at scene. Crude mortality was higher for HEMS patients. Logistic regression demonstrated a 15% reduction in the risk adjusted odds of death (OR=0.846; 95% CI 0.684 to 1.046) in favor of HEMS. When analyzed for patients previously noted to benefit most from HEMS, the odds of death were reduced further but remained statistically consistent with no effect. Sensitivity analysis on 5685 patients attended by a doctor on scene but transported by GEMS demonstrated a protective effect on mortality versus the standard GEMS response (OR 0.77; 95% CI 0.62 to 0.95). Discussion This prospective, level 3 cohort analysis demonstrates a non-significant survival advantage for patients transported by HEMS versus GEMS. Despite the large size of the cohort, the intrinsic mismatch in patient demographics limits the ability to statistically assess HEMS true benefit. It does, however, demonstrate an improved survival for patients attended by doctors on scene in addition to the GEMS response. Improvements in prehospital data and increased trauma unit reporting are required to accurately assess HEMS clinical and cost-effectiveness.
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Affiliation(s)
- Oliver Beaumont
- Clinical Academic Graduate School, Oxford University, Oxford, Oxfordshire, UK.,Department of Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, UK
| | - Fiona Lecky
- Trauma Audit Research Network, University of Manchester, Manchester, UK.,Care for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Omar Bouamra
- Trauma Audit Research Network, University of Manchester, Manchester, UK
| | - Dhushy Surendra Kumar
- Department of Critical Care, Anaesthesia and Pre-hospital Emergency Medicine, University Hospital Coventry, Coventry, UK
| | - Tim Coats
- Emergency Medicine Academic Group, University of Leicester, Leicester, UK
| | - David Lockey
- Department of Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Keith Willett
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
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11
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Reed MJ, Grubb NR, Lang CC, O'Brien R, Simpson K, Padarenga M, Grant A, Tuck S, Keating L, Coffey F, Jones L, Harris T, Lloyd G, Gagg J, Smith JE, Coats T. Multi-centre Randomised Controlled Trial of a Smartphone-based Event Recorder Alongside Standard Care Versus Standard Care for Patients Presenting to the Emergency Department with Palpitations and Pre-syncope: The IPED (Investigation of Palpitations in the ED) study. EClinicalMedicine 2019; 8:37-46. [PMID: 31193636 PMCID: PMC6537555 DOI: 10.1016/j.eclinm.2019.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 02/07/2019] [Accepted: 02/15/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Patients with palpitations and pre-syncope commonly present to Emergency Departments (EDs) but underlying rhythm diagnosis is often not possible during the initial presentation. This trial compares the symptomatic rhythm detection rate of a smartphone-based event recorder (AliveCor) alongside standard care versus standard care alone, for participants presenting to the ED with palpitations and pre-syncope with no obvious cause evident at initial consultation. METHODS Multi-centre open label, randomised controlled trial. Participants ≥ 16 years old presenting to 10 UK hospital EDs were included. Participants were randomised to either (a) intervention group; standard care plus the use of a smartphone-based event recorder or (b) control group; standard care alone. Primary endpoint was symptomatic rhythm detection rate at 90 days. Trial registration number NCT02783898 (ClinicalTrials.gov). FINDINGS Two hundred forty-three participants were recruited over an 18-month period. A symptomatic rhythm was detected at 90 days in 69 (n = 124; 55.6%; 95% CI 46.9-64.4%) participants in the intervention group versus 11 (n = 116; 9.5%; 95% CI 4.2-14.8) in the control group (RR 5.9, 95% CI 3.3-10.5; p < 0.0001). Mean time to symptomatic rhythm detection in the intervention group was 9.5 days (SD 16.1, range 0-83) versus 42.9 days (SD 16.0, range 12-66; p < 0.0001) in the control group. The commonest symptomatic rhythms detected were sinus rhythm, sinus tachycardia and ectopic beats. A symptomatic cardiac arrhythmia was detected at 90 days in 11 (n = 124; 8.9%; 95% CI 3.9-13.9%) participants in the intervention group versus 1 (n = 116; 0.9%; 95% CI 0.0-2.5%) in the control group (RR 10.3, 95% CI 1.3-78.5; p = 0.006). INTERPRETATION Use of a smartphone-based event recorder increased the number of patients in whom an ECG was captured during symptoms over five-fold to more than 55% at 90 days. This safe, non-invasive and easy to use device should be considered part of on-going care to all patients presenting acutely with unexplained palpitations or pre-syncope. FUNDING This study was funded by research awards from Chest, Heart and Stroke Scotland (CHSS) and British Heart Foundation (BHF) which included funding for purchasing the devices. MR was supported by an NHS Research Scotland Career Researcher Clinician award.
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Affiliation(s)
- Matthew J. Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
- Edinburgh Acute Care, Usher Institute of Population Health Sciences and Informatics, College of Medicine and Veterinary Medicine, University of Edinburgh, The Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
- Corresponding author at: Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
| | - Neil R. Grubb
- Department of Cardiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Christopher C. Lang
- Department of Cardiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Rachel O'Brien
- Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Kirsty Simpson
- Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Mia Padarenga
- Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Alison Grant
- Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Sharon Tuck
- Edinburgh Clinical Research Facility, Epidemiology and Statistics Core, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Liza Keating
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading RG1 5AN, UK
| | - Frank Coffey
- DREEAM - Department of Research and Education in Emergency medicine, Acute medicine and Major trauma, Nottingham University Hospitals NHS Trust, Queen's Medical Centre Derby Road, Nottingham, NG7 2UH, UK
| | - Lucy Jones
- Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield Rd, Calow, Chesterfield S44 5BL, UK
| | - Tim Harris
- Barts Health NHS Trust, Whitechapel, London E1 1BB, UK
| | - Gavin Lloyd
- Royal Devon and Exeter Hospital, Barrack Rd, Exeter EX2 5DW, UK
| | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton & Somerset NHS Foundation Trust, Taunton TA1 5DA, UK
| | - Jason E. Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, UK
| | - Tim Coats
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, University Road, Leicester LE1 7RH, UK
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12
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Rutty GN, Robinson C, Amoroso J, Coats T, Morgan B. Could post-mortem computed tomography angiography inform cardiopulmonary resuscitation research? Resuscitation 2017; 121:34-40. [DOI: 10.1016/j.resuscitation.2017.09.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
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Abstract
Objective The progressive rise in demand on NHS emergency care resources is partly attributable to increases in attendances of children and older people. A quality gap exists in the care provision for the old and the young. The Five Year Forward View suggested new models of care but that the "answer is not one-size-fits-all". This article discusses the urgent need for person-centred outcome measures to bridge the gap that exists between demand and provision. Design This review is based on evidence gathered from literature searching across several platforms using a variety of search terms to account for the obvious heterogeneity, drawing on key 'think-tank' evidence. Settings Qualitative and quantitative studies examining approaches to caring for individuals at the extremes of age. Participants Individuals at the extremes of age (infants and older people). Main Outcome Measures Understanding similarities and disparities in the care of individuals at the extremes of age in an emergency and non-emergency context. Results There exists several similarities and disparities in the care of individuals at the extremes of age. The increasing burden of health disease on the economy must acknowledge the challenges that exist in managing patients in emergency settings at the extremes of age and build systems to acknowledge the traits these individuals exhibit. Conclusion Commissioners of services must optimise the models of care delivery by appreciating the similarities and differences between care requirements in these two large groups seeking emergency care.
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Affiliation(s)
- J S Minhas
- 1 Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK
| | - D Minhas
- 2 Department of Paediatrics, University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK
| | - T Coats
- 3 Emergency Medicine Academic Group, Cardiovascular Sciences, University of Leicester, Leicester LE1 5WW, UK
| | - J Banerjee
- 3 Emergency Medicine Academic Group, Cardiovascular Sciences, University of Leicester, Leicester LE1 5WW, UK
| | - D Roland
- 4 Department of Health Sciences, Centre for Medicine, University of Leicester, Leicester LE1 7RH, UK.,5 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Royal Infirmary, Leicester LE1 5WW, UK
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14
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Roland D, Arshad F, Coats T, Davies F. Baseline Characteristics of the Paediatric Observation Priority Score in Emergency Departments outside Its Centre of Derivation. Biomed Res Int 2017; 2017:9060852. [PMID: 28812025 PMCID: PMC5546051 DOI: 10.1155/2017/9060852] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 05/16/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES AND BACKGROUND Scoring systems in Emergency Departments (EDs) are rarely validated. This study aimed to examine the Paediatric Observation Priority Score (POPS), a method of quantifying patient acuity, in EDs in the United Kingdom, and determine baseline performance characteristics. METHODS POPS was implemented in 4 EDs for children (ages of 0 to 16) with participants grouped into 3 categories: discharged from ED, discharged but with return within 7 days, and admitted for less or more than 24 hours. RESULTS 3323 participants with POPS scores ranging from 0 to 11 (mean = 2.33) were included. The proportion of each POPS score varied between sites with approximately 10-20% being POPS 0 and 12-25% POPS greater than 4. Odds ratio of readmission with POPS 5-9 against 0-4 was 2.05 (CI 1.20 to 3.52). POPS 0-4 showed no significant difference (p = 0.93) in relation to admission/discharge rates between sites with a significant difference found (p < 0.01) for POPS > 5. CONCLUSION It is feasible to implement POPS into EDs with similar performance characteristics to the original site of development. There is now evidence to support a wider health service evaluation to refine and improve the performance of POPS.
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Affiliation(s)
- Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Emergency Department, Infirmary Square, Leicester LE1 5WW, UK
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | - Fawaz Arshad
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Emergency Department, Infirmary Square, Leicester LE1 5WW, UK
| | - Tim Coats
- Emergency Medicine Academic Group, Cardiovascular Sciences, Leicester University, Leicester, UK
| | - Ffion Davies
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Emergency Department, Infirmary Square, Leicester LE1 5WW, UK
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15
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Roland D, Jones S, Coats T, Davies F. Are Increasing Volumes of Children and Young People Presenting to Emergency Departments Due to Increasing Severity of Illness? Acad Emerg Med 2017. [DOI: 10.1111/acem.13114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Damian Roland
- SAPPHIRE Group, Health Services; University of Leicester
- Paediatric Emergency Leicester Academic (PEMLA) Group; Leicester Royal Infirmary
| | - Sam Jones
- Paediatric Emergency Leicester Academic (PEMLA) Group; Leicester Royal Infirmary
| | - Tim Coats
- Emergency Medicine Academic Group (EMAG); Leicester UK
| | - Ffion Davies
- Paediatric Emergency Leicester Academic (PEMLA) Group; Leicester Royal Infirmary
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16
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Abstract
The microcirculation describes the smallest elements of the cardiovascular conducting system and is pivotal in the maintenance of homeostasis. Microcirculatory dysfunction is present early in the pathophysiology of sepsis, with the extent of microcirculatory derangement relating to disease severity and prognosis in ICU patients. However, at present microcirculatory function is not routinely monitored at the bedside. This article describes the pathophysiology of microcirculatory derangements in sepsis, methods of its measurement and evidence to support their clinical use.
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Affiliation(s)
- Matthew Charlton
- Anaesthetics and Critical Care, Diagnostic Development Unit, University of Leicester, Leicester, UK
| | - Mark Sims
- Astrobiology and Space Instrumentation, Diagnostic Development Unit, University of Leicester, Leicester, UK
| | - Tim Coats
- Emergency Medicine, Diagnostic Development Unit, University of Leicester, Leicester, UK
| | - Jonathan P Thompson
- Anaesthetics and Critical Care, Diagnostic Development Unit, University of Leicester, Leicester, UK
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17
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Mitchell AJ, Hussain S, Leaver J, Rajan C, Jones A, Malcolm N, Coats T. Is there a difference between hospital-verified and self-reported self-harm? Implications for repetition. Gen Hosp Psychiatry 2016; 43:12-16. [PMID: 27796251 DOI: 10.1016/j.genhosppsych.2016.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 07/20/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Repeated intentional self-harm (SH) is associated with economic costs and increased risk of suicide. Estimates of repetition vary according to method of data capture and are limited by short periods of follow-up observation. Some sources use hospital records and others self-reported SH (SRSH). Our aim was to examine the relationship between SRSH and hospital-verified SH (HVSH) and later repetition of SH (predictive validity). We also aimed to examine whether rates of SH repetition differ between first-time presenters and non-first-time presenters using either definition of SH. METHOD We conducted a large prospective study tracking SH attempts through an Accident and Emergency (A&E) department within the United Kingdom. We took a representative sample of 774 patients (30% of total who reported SH) and followed them for 5.6 years on average. The index episode of SH was recorded at the time of referral to staff in A&E. Prior episodes of SH were determined from an electronic search of A&E patient database, and in addition, recollection of prior SH as reported by the patient to their clinician at the time of index presentation was recorded. RESULTS Across the whole sample 32.0% of patients repeated SH within 1 year, which rose to 54.1% at completion of follow-up. Repetition rates were considerably higher in patients with a prior SH history than those presenting with a first SH episode after 1 year (47.9% vs. 19.6%) and by the end of follow-up (73.8% vs. 39.4%) (P<.001). Of 411 with self-reported first presentations, 45.2% repeated over the study period. In terms of predictive validity, 65.2% of those with previous SRSH repeated vs. 73.8% with previous HVSH (P<.001). There was low agreement between SRSH and HVSH (Kappa=0.353, 95% confidence interval 0.287-0.419, low). CONCLUSIONS We found relatively poor agreement between hospital-defined and self-reported SH. A total of 62.8% of those who denied SH actually had a hospital-verified previous episode. Patients with recorded prior SH and those who recall previous SH have significantly higher rates of repetition, but the two samples imprecisely overlap and predictive validity is stronger for HVSH.
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Affiliation(s)
| | | | | | | | | | | | - Tim Coats
- Leicester Royal Infirmary, Department of Emergency medicine
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18
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Coats T, Marks R, Mayor S. Clinical News. Br J Hosp Med (Lond) 2016; 77:556-559. [PMID: 27723403 DOI: 10.12968/hmed.2016.77.10.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tim Coats
- Professor of Emergency Medicine, University of Leicester, Leicester
| | - Richard Marks
- Chair of the Working Group and Council Member of the Royal College of Anaesthetists
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19
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Lecky F, Russell W, Fuller G, McClelland G, Pennington E, Goodacre S, Han K, Curran A, Holliman D, Freeman J, Chapman N, Stevenson M, Byers S, Mason S, Potter H, Coats T, Mackway-Jones K, Peters M, Shewan J, Strong M. The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study. Health Technol Assess 2016; 20:1-198. [PMID: 26753808 DOI: 10.3310/hta20010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Reconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence - with regard to 'early neurosurgery' in this cohort - which we sought to address. METHODS Pilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). PRIMARY OUTCOMES recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. 'Open-label' secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions. RESULTS Overall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%; p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury. CONCLUSIONS Current NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating 'early neurosurgery through bypass' and address the challenge of reliable TBI diagnosis at the scene of injury. TRIAL REGISTRATION Current Controlled Trials ISRCTN68087745. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fiona Lecky
- EMRiS Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK
| | - Wanda Russell
- Trauma Audit and Research Network, Center of Occupational and Environmental Health, Institute of Population, University of Manchester, Manchester, UK
| | - Gordon Fuller
- EMRiS Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK
| | - Graham McClelland
- Research and Development Department, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Elspeth Pennington
- Research and Development Department, North West Ambulance Service, Carlisle, UK
| | - Steve Goodacre
- EMRiS Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK
| | - Kyee Han
- Research and Development Department, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Curran
- Research and Development Department, North West Ambulance Service, Carlisle, UK
| | - Damien Holliman
- Department of Neurosurgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jennifer Freeman
- EMRiS Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK
| | - Nathan Chapman
- EMRiS Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- EMRiS Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK
| | - Sonia Byers
- Research and Development Department, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Suzanne Mason
- EMRiS Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK
| | - Hugh Potter
- Potter Rees Serious Injury Solicitors LLP, Manchester, UK
| | - Tim Coats
- Department of Cardiovascular Sciences, University of Leicester/University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Kevin Mackway-Jones
- Research and Development Department, North West Ambulance Service, Carlisle, UK
| | - Mary Peters
- Research and Development Department, North West Ambulance Service, Carlisle, UK
| | - Jane Shewan
- Research and Development Department, Yorkshire Ambulance Services NHS Trust, Wakefield, UK
| | - Mark Strong
- EMRiS Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK
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Green SJ, Hussain S, Hue J, Patel J, Coats T, Sims M. FEASIBILITY AND COMPARISON OF NON-INVASIVE HEMODYNAMIC DEVICES IN THE EMERGENCY DEPARTMENT; USCOM VS NICCOMO. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Davies F, Coats T, Lecky FE. A 10-YEAR DEMOGRAPHIC COMPARISON OF MAJOR TRAUMA AS A RESULT OF NON-ACCIDENTAL INJURY VERSUS ACCIDENTAL INJURY IN THE UK. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Coats T, Biggs M, Robinson C, Rutty G, Adnan A, Morgan B. END-TIDAL CO2 DETECTION DURING CADAVERIC VENTILATION. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ronald D, Martin G, Coats T, Matheson D. THE IMPORTANCE OF UNDERSTANDING JUNIOR DOCTOR PERCEPTIONS OF CONFIDENCE AND COMPETENCE IN RELATION TO THE FEBRILE CHILD. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Anderson K, Coats T, Monks P, White I, Pandya H, Beardsmore C, Skinner J. A COMPARISON OF TIDAL AND INCENTIVE BREATH COLLECTION METHODS FOR THE DETERMINATION OF BREATH VOLATILES CONCENTRATION. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Roland D, Matheson D, Taub N, Coats T, Lakhanpaul M. Is perception of quality more important than technical quality in patient video cases? BMC Med Educ 2015; 15:132. [PMID: 26268319 PMCID: PMC4542110 DOI: 10.1186/s12909-015-0419-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/29/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND The use of video cases to demonstrate key signs and symptoms in patients (patient video cases or PVCs) is a rapidly expanding field. The aims of this study were to evaluate whether the technical quality, or judgement of quality, of a video clip influences a paediatrician's judgment on acuity of the case and assess the relationship between perception of quality and the technical quality of a selection of video clips. METHODS Participants (12 senior consultant paediatricians attending an examination workshop) individually categorised 28 PVCs into one of 3 possible acuities and then described the quality of the image seen. The PVCs had been converted into four different technical qualities (differing bit rates ranging from excellent to low quality). RESULTS Participants' assessment of quality and the actual industry standard of the PVC were independent (333 distinct observations, spearmans rho = 0.0410, p = 0.4564). Agreement between actual acuity and participants' judgement was generally good at higher acuities but moderate at medium/low acuities of illness (overall correlation 0.664). Perception of the quality of the clip was related to correct assignment of acuity regardless of the technical quality of the clip (number of obs = 330, z = 2.07, p = 0.038). CONCLUSIONS It is important to benchmark PVCs prior to use in learning resources as experts may not agree on the information within, or quality of, the clip. It appears, although PVCs may be beneficial in a pedagogical context, the perception of quality of clip may be an important determinant of an expert's decision making.
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Affiliation(s)
- Damian Roland
- Department of Health Sciences, SAPPHIRE Group, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK.
- Paediatric Emergency Medicine Leicester Academic Group, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, LE1 5WW, UK.
| | - David Matheson
- Carnegie Faculty, Leeds Beckett University, Leeds, LS1 3HE, UK.
| | - Nick Taub
- Department of Health Sciences, SAPPHIRE Group, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK.
| | - Tim Coats
- Emergency Medicine Academic Group. Cardiovascular Sciences, Leicester University, Leicester, LE3 9QP, UK.
| | - Monica Lakhanpaul
- Emergency Medicine Academic Group. Cardiovascular Sciences, Leicester University, Leicester, LE3 9QP, UK.
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Stanworth SJ, Manno D, Shakur H, Coats T, Edwards P, Gilmore I, Jairath V, Veitch A, Roberts I. Extending evidence for the use of tranexamic acid from traumatic haemorrhage to other patients with major bleeding: do we need more than one haemorrhage protocol? The case of gastrointestinal bleeding. Transfus Med 2015; 25:198-200. [PMID: 26084425 DOI: 10.1111/tme.12215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/15/2015] [Indexed: 12/15/2022]
Affiliation(s)
- S J Stanworth
- Department of Haematology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust/NHSBT, Oxford, UK
| | - D Manno
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - H Shakur
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - T Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - P Edwards
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - I Gilmore
- Department of Medicine, University of Liverpool, Liverpool, UK
| | - V Jairath
- John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - A Veitch
- Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - I Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
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Goodacre S, Cohen J, Bradburn M, Stevens J, Gray A, Benger J, Coats T. The 3Mg trial: a randomised controlled trial of intravenous or nebulised magnesium sulphate versus placebo in adults with acute severe asthma. Health Technol Assess 2014; 18:1-168. [PMID: 24731521 DOI: 10.3310/hta18220] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Magnesium sulphate, administered by the intravenous (i.v.) or inhaled (nebulised) route, has been proposed as a treatment for adults with acute severe asthma. Existing trials show mixed results and uncertain evidence of benefit. OBJECTIVES We aimed to determine whether i.v. or nebulised magnesium sulphate improves symptoms of breathlessness and reduces the need for hospital admission in adults with acute severe asthma. DESIGN Multicentre, double-blind, placebo-controlled, three-arm, randomised trial. SETTING The emergency departments of 34 acute hospitals in the UK. PARTICIPANTS We recruited 1109 adults (age >16 years) with acute severe asthma [peak expiratory flow rate (PEFR) <50% of best/predicted, respiratory rate >25 breaths per minute, heart rate >110 beats per minute or inability to complete sentences in one breath]. Patients with life-threatening features or a contraindication to either nebulised or intravenous magnesium sulphate were excluded. INTERVENTIONS Participants were randomly allocated to i.v. magnesium sulphate (2 g over 20 minutes) or nebulised magnesium sulphate (3 × 500 mg over 1 hour) or standard therapy alone. MAIN OUTCOME MEASURES The primary outcome was the proportion of patients admitted to hospital (either after emergency department treatment or at any time over the subsequent 7 days) and breathlessness measured on a 100-mm visual analogue scale (VAS) over 2 hours after initiation of treatment. RESULTS We randomised 406 patients to i.v. magnesium sulphate, 339 to nebulised magnesium sulphate and 364 to placebo. Hospital admission was recorded for 394, 332 and 358 patients, respectively, and VAS breathlessness for 357, 296 and 323 patients respectively. Mean age was 36.1 years and 763 out of 1084 (70%) patients were female. Intravenous magnesium sulphate was associated with an odds ratio (OR) of 0.73 [95% confidence interval (CI) 0.51 to 1.04; p=0.083] for hospital admission, an improvement in VAS breathlessness that was 2.6 mm (95% CI -1.6 to 6.8 mm; p=0.231) greater than that associated with placebo and an improvement in PEFR that was 2.4 l/minute (95% CI -8.8 to 13.6 l/minute; p=0.680) greater than that associated with placebo. Nebulised magnesium sulphate was associated with an OR of 0.96 (95% CI 0.65 to 1.40; p=0.819) for hospital admission, an improvement in VAS breathlessness that was 2.6 mm (95% CI -1.8 mm to 7.0 mm; p=0.253) less than that associated with placebo and an improvement in PEFR that was 2.6 l/minute (95% CI -9.2 to 14.5 l/minute; p=0.644) less than that associated with placebo. There were no significant differences between i.v. or nebulised magnesium sulphate and placebo for any other outcomes. The number (%) of patients reporting any side effect was 61 (15.5%) in the i.v. group, 52 (15.7%) in the nebuliser group and 36 (10.1%) in the placebo group. The ORs for suffering any side effect were 1.68 (95% CI 1.07 to 2.63; p=0.025) for i.v. compared with placebo and 1.67 (95% CI 1.05 to 2.66; p=0.031) for nebuliser compared with placebo. CONCLUSIONS We were unable to demonstrate a clinically worthwhile benefit from magnesium sulphate in acute severe asthma. There was some weak evidence of an effect of i.v. magnesium sulphate on hospital admission, but no evidence of an effect on VAS breathlessness or PEFR compared with placebo. We found no evidence that nebulised magnesium sulphate was more effective than placebo. TRIAL REGISTRATION Current Controlled Trials ISRCTN04417063.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Judith Cohen
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alasdair Gray
- Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jonathan Benger
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Tim Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
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Gray A, Goodacre S, Cohen J, Braidburn M, Benger J, Coats T. THE 3MG TRIAL: A RANDOMISED CONTROLLED TRIAL OF INTRAVENOUS OR NEBULISED MAGNESIUM SULPHATE VERSUS PLACEBO IN ADULTS WITH SEVERE ACUTE ASTHMA. Arch Emerg Med 2013. [DOI: 10.1136/emermed-2013-203113.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Fuller GW, Woodford M, Lawrence T, Coats T, Lecky F. THE ACCURACY OF ALTERNATIVE TRIAGE RULES FOR IDENTIFICATION OF SIGNIFICANT TRAUMATIC BRAIN INJURY: A DIAGNOSTIC COHORT STUDY. Arch Emerg Med 2013. [DOI: 10.1136/emermed-2013-203113.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gray A, Goodacre S, Braidburn M, Cohen J, Benger J, Coats T. PREDICTION OF UNSUCCESSFUL TREATMENT IN PATIENTS WITH SEVERE ACUTE ASTHMA: AN ANALYSIS FROM THE 3MG TRIAL. Arch Emerg Med 2013. [DOI: 10.1136/emermed-2013-203113.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Roberts I, Shakur H, Coats T, Hunt B, Balogun E, Barnetson L, Cook L, Kawahara T, Perel P, Prieto-Merino D, Ramos M, Cairns J, Guerriero C. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013; 17:1-79. [PMID: 23477634 DOI: 10.3310/hta17100] [Citation(s) in RCA: 332] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Among trauma patients who survive to reach hospital, exsanguination is a common cause of death. A widely practicable treatment that reduces blood loss after trauma could prevent thousands of premature deaths each year. The CRASH-2 trial aimed to determine the effect of the early administration of tranexamic acid on death and transfusion requirement in bleeding trauma patients. In addition, the effort of tranexamic acid on the risk of vascular occlusive events was assessed. OBJECTIVE Tranexamic acid (TXA) reduces bleeding in patients undergoing elective surgery. We assessed the effects and cost-effectiveness of the early administration of a short course of TXA on death, vascular occlusive events and the receipt of blood transfusion in trauma patients. DESIGN Randomised placebo-controlled trial and economic evaluation. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial co-ordinating centre staff) were masked to treatment allocation. All analyses were by intention to treat. A Markov model was used to assess cost-effectiveness. The health outcome was the number of life-years (LYs) gained. Cost data were obtained from hospitals, the World Health Organization database and UK reference costs. Cost-effectiveness was measured in international dollars ($) per LY. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the results to model assumptions. SETTING Two hundred and seventy-four hospitals in 40 countries. PARTICIPANTS Adult trauma patients (n = 20,211) with, or at risk of, significant bleeding who were within 8 hours of injury. INTERVENTIONS Tranexamic acid (loading dose 1 g over 10 minutes then infusion of 1 g over 8 hours) or matching placebo. MAIN OUTCOME MEASURES The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury and other. RESULTS Patients were allocated to TXA (n = 10,096) and to placebo (n = 10,115), of whom 10,060 and 10,067 patients, respectively, were analysed. All-cause mortality at 28 days was significantly reduced by TXA [1463 patients (14.5%) in the TXA group vs 1613 patients (16.0%) in the placebo group; relative risk (RR) 0.91; 95% confidence interval (CI) 0.85 to 0.97; p = 0.0035]. The risk of death due to bleeding was significantly reduced [489 patients (4.9%) died in the TXA group vs 574 patients (5.7%) in the placebo group; RR 0.85; 95% CI 0.76 to 0.96; p = 0.0077]. We recorded strong evidence that the effect of TXA on death due to bleeding varied according to the time from injury to treatment (test for interaction p < 0.0001). Early treatment (≤ 1 hour from injury) significantly reduced the risk of death due to bleeding [198 out of 3747 patients (5.3%) died in the TXA group vs 286 out of 3704 patients (7.7%) in the placebo group; RR 0.68; 95% CI 0.57 to 0.82; p < 0.0001]. Treatment given between 1 and 3 hours also reduced the risk of death due to bleeding [147 out of 3037 patients (4.8%) died in the TXA group vs 184 out of 2996 patients (6.1%) in the placebo group; RR 0.79; 95% CI 0.64 to 0.97; p = 0.03]. Treatment given after 3 hours seemed to increase the risk of death due to bleeding [144 out of 3272 patients (4.4%) died in the TXA group vs 103 out of 3362 patients (3.1%) in the placebo group; RR 1.44; 95% CI1.12 to 1.84; p = 0.004]. We recorded no evidence that the effect of TXA on death due to bleeding varied by systolic blood pressure, Glasgow Coma Scale score or type of injury. Administering TXA to bleeding trauma patients within 3 hours of injury saved an estimated 755 LYs per 1000 trauma patients in the UK. The cost of giving TXA to 1000 patients was estimated at $30,830. The incremental cost of giving TXA compared with not giving TXA was $48,002. The incremental cost per LY gained of administering TXA was $64. CONCLUSIONS Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. Future work [the Clinical Randomisation of an Antifibrinolytic in Significant Head injury-3 (CRASH-3) trial] will evaluate the effectiveness and safety of TXA in the treatments of isolated traumatic brain injury (http://crash3.lshtm.ac.uk/). TRIAL REGISTRATION Current Controlled Trials ISRCTN86750102, ClinicalTrials.gov NCT00375258 and South African Clinical Trial Register DOH-27-0607-1919. FUNDING The project was funded by the Bupa Foundation, the J P Moulton Charitable Foundation and the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 10. See HTA programme website for further project information.
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Affiliation(s)
- I Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK.
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Abstract
BACKGROUND Clinical assessment can be used to identify which patients with acute asthma are at risk of unsuccessful initial treatment. OBJECTIVE To determine which elements of clinical assessment predict unsuccessful treatment, defined as needing critical care or any unplanned additional treatment. METHODS We analysed data from a large multicentre trial (the 3Mg trial). Adults with severe acute asthma underwent standardised clinical assessment, including peak expiratory flow rate (PEFR), up to 2 h after initiation of treatment. Standard care was provided other than blinded random allocation to trial treatment or placebo. Patients were followed up by record review up to 30 days. Unsuccessful treatment was defined as needing (1) critical care or (2) critical care or any unplanned additional treatment within 7 days of presentation. Logistic regression was used to identify predictors and derive a prediction model for each outcome. RESULTS Out of 1084 patients analysed, 81 (7%) received critical care and 157 (14%) received critical care or unplanned additional treatment. Baseline PEFR (p=0.017), baseline heart rate (p<0.001), other serious illness (p=0.019), PEFR change (p=0.015) and heart rate change (p<0.001) predicted need for critical care. Baseline PEFR (p=0.010), baseline heart rate (p<0.001), baseline respiratory rate (p=0.017), other serious illness (p=0.023), PEFR change (p=0.003) and heart rate change (p=0.001) predicted critical care or additional treatment. Models based on these characteristics had c-statistics of 0.77 and 0.69, respectively. CONCLUSIONS PEFR, heart rate and other serious illnesses are the best predictors of unsuccessful treatment, but models based on these variables provide modest predictive value.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Judith Cohen
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alasdair Gray
- Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jonathan Benger
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Tim Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
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Wilson R, Goodacre SW, Klingbajl M, Kelly AM, Rainer T, Coats T, Holloway V, Townend W, Crane S. Evaluation of the DAVROS (Development And Validation of Risk-adjusted Outcomes for Systems of emergency care) risk-adjustment model as a quality indicator for healthcare. Emerg Med J 2013; 31:471-5. [PMID: 23605036 PMCID: PMC4033152 DOI: 10.1136/emermed-2013-202359] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background and objective Risk-adjusted mortality rates can be used as a quality indicator if it is assumed that the discrepancy between predicted and actual mortality can be attributed to the quality of healthcare (ie, the model has attributional validity). The Development And Validation of Risk-adjusted Outcomes for Systems of emergency care (DAVROS) model predicts 7-day mortality in emergency medical admissions. We aimed to test this assumption by evaluating the attributional validity of the DAVROS risk-adjustment model. Methods We selected cases that had the greatest discrepancy between observed mortality and predicted probability of mortality from seven hospitals involved in validation of the DAVROS risk-adjustment model. Reviewers at each hospital assessed hospital records to determine whether the discrepancy between predicted and actual mortality could be explained by the healthcare provided. Results We received 232/280 (83%) completed review forms relating to 179 unexpected deaths and 53 unexpected survivors. The healthcare system was judged to have potentially contributed to 10/179 (8%) of the unexpected deaths and 26/53 (49%) of the unexpected survivors. Failure of the model to appropriately predict risk was judged to be responsible for 135/179 (75%) of the unexpected deaths and 2/53 (4%) of the unexpected survivors. Some 10/53 (19%) of the unexpected survivors died within a few months of the 7-day period of model prediction. Conclusions We found little evidence that deaths occurring in patients with a low predicted mortality from risk-adjustment could be attributed to the quality of healthcare provided.
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Affiliation(s)
- Richard Wilson
- Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steve W Goodacre
- Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Marcin Klingbajl
- Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anne-Maree Kelly
- Western Health and The University of Melbourne, Victoria, Australia
| | - Tim Rainer
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Tim Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | | | - Will Townend
- Department of Emergency Medicine, Hull Royal Infirmary, Hull, UK
| | - Steve Crane
- Department of Accident and Emergency, York District General Hospital, York, UK
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Roland D, Coats T, Matheson D. Towards a conceptual framework demonstrating the effectiveness of audiovisual patient descriptions (patient video cases): a review of the current literature. BMC Med Educ 2012; 12:125. [PMID: 23256787 PMCID: PMC3542158 DOI: 10.1186/1472-6920-12-125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 12/12/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Technological advances have enabled the widespread use of video cases via web-streaming and online download as an educational medium. The use of real subjects to demonstrate acute pathology should aid the education of health care professionals. However, the methodology by which this effect may be tested is not clear. METHODS We undertook a literature review of major databases, found relevant articles relevant to using patient video cases as educational interventions, extracted the methodologies used and assessed these methods for internal and construct validity. RESULTS A review of 2532 abstracts revealed 23 studies meeting the inclusion criteria and a final review of 18 of relevance. Medical students were the most commonly studied group (10 articles) with a spread of learner satisfaction, knowledge and behaviour tested. Only two of the studies fulfilled defined criteria on achieving internal and construct validity. The heterogeneity of articles meant it was not possible to perform any meta-analysis. CONCLUSIONS Previous studies have not well classified which facet of training or educational outcome the study is aiming to explore and had poor internal and construct validity. Future research should aim to validate a particular outcome measure, preferably by reproducing previous work rather than adopting new methods. In particular cognitive processing enhancement, demonstrated in a number of the medical student studies, should be tested at a postgraduate level.
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Affiliation(s)
- Damian Roland
- Emergency Medicine Academic Group, Emergency Department secretaries c/o Elizabeth Cadman-Moore, Leicester Royal Infirmary, Leicester, LE1 5WW, UK
| | - Tim Coats
- Emergency Medicine Academic Group, Emergency Department secretaries c/o Elizabeth Cadman-Moore, Leicester Royal Infirmary, Leicester, LE1 5WW, UK
| | - David Matheson
- Room B94C Medical School, Queens Medical Centre, Nottingham, NG7 2UH, UK
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Vorwerk C, Coats T. WITHDRAWN: Heliox for croup in children. Cochrane Database Syst Rev 2012; 10:CD006822. [PMID: 23076928 DOI: 10.1002/14651858.cd006822.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christiane Vorwerk
- Department of Emergency Medicine, Leicester Royal Infirmary, Leicester, UK.
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Oakley E, McD Taylor D, Coats T, Davidson A, Fry A, Babl FE. A primer for clinical researchers in the emergency department: Part IV: Multicentre research. Emerg Med Australas 2012; 24:482-91. [DOI: 10.1111/j.1742-6723.2012.01599.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Tim Coats
- Emergency Medicine Academic Group; University of Leicester; Leicester; UK
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Roberts I, Perel P, Prieto-Merino D, Shakur H, Coats T, Hunt BJ, Lecky F, Brohi K, Willett K. Effect of tranexamic acid on mortality in patients with traumatic bleeding: prespecified analysis of data from randomised controlled trial. BMJ 2012; 345:e5839. [PMID: 22968527 PMCID: PMC3439642 DOI: 10.1136/bmj.e5839] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To examine whether the effect of tranexamic acid on the risk of death and thrombotic events in patients with traumatic bleeding varies according to baseline risk of death. To assess the extent to which current protocols for treatment with tranexamic acid maximise benefits to patients. DESIGN Prespecified stratified analysis of data from an international multicentre randomised controlled trial (the CRASH-2 trial) with an estimation of the proportion of premature deaths that could potentially be averted through the administration of tranexamic acid. PARTICIPANTS 13,273 trauma patients in the CRASH-2 trial who were treated with tranexamic acid or placebo within three hours of injury and trauma patients enrolled in UK Trauma and Audit Research Network, stratified by risk of death at baseline (<6%, 6-20%, 21-50%, >50%). INTERVENTION Tranexamic acid (1 g over 10 minutes followed by 1 g over eight hours) or matching placebo. MAIN OUTCOME MEASURE Odds ratios and 95% confidence intervals for death in hospital within four weeks of injury, deaths from bleeding, and fatal and non-fatal thrombotic events associated with the use of tranexamic acid according to baseline risk of death. Unless there was strong evidence against the null hypothesis of homogeneity of effects (P<0.001), the overall odds ratio was used as the most reliable guide to the odds ratios in all strata. RESULTS Tranexamic acid was associated with a significant reduction in all cause mortality and deaths from bleeding. In each stratum of baseline risk, there were fewer deaths among patients treated with tranexamic acid. There was no evidence of heterogeneity in the effect of tranexamic acid on all cause mortality (P=0.96 for interaction) or deaths from bleeding (P=0.98) by baseline risk of death. In those treated with tranexamic acid there was a significant reduction in the odds of fatal and non-fatal thrombotic events (odds ratio 0.69, 95% confidence interval 0.53 to 0.89; P=0.005) and a significant reduction in arterial thrombotic events (0.58, 0.40 to 0.83; P=0.003) but no significant reduction in venous thrombotic events (0.83, 0.59 to 1.17; P=0.295). There was no evidence of heterogeneity in the effect of tranexamic acid on the risk of thrombotic events (P=0.74). If the effect of tranexamic acid is assumed to be the same in all risk strata (<6%, 6-20%, 21-50%, >50% risk of death at baseline), the percentage of deaths that could be averted by administration of tranexamic acid within three hours of injury in each group is 17%, 36%, 30%, and 17%, respectively. CONCLUSIONS Tranexamic acid can be administered safely to a wide spectrum of patients with traumatic bleeding and should not be restricted to the most severely injured. TRIAL REGISTRATION ISRCTN86750102.
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Affiliation(s)
- Ian Roberts
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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Fuller G, Lecky F, Woodford M, Bouamra O, Jenks T, Coats T, Hutchinson P. 015 Temporal trends in head injury outcomes from 2003 to 2010 in England and Wales, and the effect of specialist neurosciences care: a Cohort Study. Arch Emerg Med 2011. [DOI: 10.1136/emermed-2011-200617.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Bradburn M, Goodacre SW, Fitzgerald P, Coats T, Gray A, Hassan T, Humphrey J, Kendall J, Smith J, Collinson P. Interhospital variation in the RATPAC trial (Randomised Assessment of Treatment using Panel Assay of Cardiac markers). Emerg Med J 2011; 29:233-8. [PMID: 21617159 DOI: 10.1136/emj.2010.108522] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The RATPAC trial showed that using a point-of-care panel of CK-MB(mass), myoglobin and troponin at baseline and 90 min increased the proportion of patients successfully discharged home, leading to reduced median length of initial hospital stay. However, it did not change mean hospital stay and may have increased mean costs per patient. The aim of this study was to explore variation in outcome and costs between participating hospitals. METHODS RATPAC was a pragmatic multicentre randomised controlled trial (N=2243) and economic analysis comparing diagnostic assessment using the panel to standard care for patients with acute chest pain due to suspected myocardial infarction at six hospitals. The difference in the proportion of patients successfully discharged (primary outcome) and mean costs per patient between the participating hospitals was compared. RESULTS Point-of-care assessment led to a higher proportion of successful discharges in four hospitals, a lower proportion in one and was equivocal in another. The OR (95% CI) for the primary outcome varied from 0.12 (0.01 to 1.03) to 11.07 (6.23 to 19.66) with significant heterogeneity between the centres (p<0.001). The mean cost per patient for the intervention group ranged from being £214.49 less than the control group (-132.56 to 657.10) to £646.57 more expensive (73.12 to 1612.71), with weak evidence of heterogeneity between the centres (p=0.0803). CONCLUSION The effect of point-of-care panel assessment on successful discharge and costs per patient varied markedly between hospitals and may depend on local protocols, staff practices and available facilities.
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Affiliation(s)
- Mike Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Roberts I, Shakur H, Afolabi A, Brohi K, Coats T, Dewan Y, Gando S, Guyatt G, Hunt BJ, Morales C, Perel P, Prieto-Merino D, Woolley T. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 2011; 377:1096-101, 1101.e1-2. [PMID: 21439633 DOI: 10.1016/s0140-6736(11)60278-x] [Citation(s) in RCA: 640] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of the CRASH-2 trial was to assess the effects of early administration of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage. Tranexamic acid significantly reduced all-cause mortality. Because tranexamic acid is thought to exert its effect through inhibition of fibrinolysis, we undertook exploratory analyses of its effect on death due to bleeding. METHODS The CRASH-2 trial was undertaken in 274 hospitals in 40 countries. 20,211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min followed by infusion of 1 g over 8 h) or placebo. Patients were randomly assigned by selection of the lowest numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Both participants and study staff (site investigators and trial coordinating centre staff ) were masked to treatment allocation. We examined the effect of tranexamic acid on death due to bleeding according to time to treatment, severity of haemorrhage as assessed by systolic blood pressure, Glasgow coma score (GCS), and type of injury. All analyses were by intention to treat. The trial is registered as ISRCTN86750102, ClinicalTrials.gov NCT00375258, and South African Clinical Trial Register/Department of Health DOH-27-0607-1919. FINDINGS 10,096 patients were allocated to tranexamic acid and 10,115 to placebo, of whom 10,060 and 10,067, respectively, were analysed. 1063 deaths (35%) were due to bleeding. We recorded strong evidence that the effect of tranexamic acid on death due to bleeding varied according to the time from injury to treatment (test for interaction p<0.0001). Early treatment (≤1 h from injury) significantly reduced the risk of death due to bleeding (198/3747 [5.3%] events in tranexamic acid group vs 286/3704 [7.7%] in placebo group; relative risk [RR] 0.68, 95% CI 0.57-0.82; p<0.0001). Treatment given between 1 and 3 h also reduced the risk of death due to bleeding (147/3037 [4.8%] vs 184/2996 [6.1%]; RR 0.79, 0.64-0.97; p=0.03). Treatment given after 3 h seemed to increase the risk of death due to bleeding (144/3272 [4.4%] vs 103/3362 [3.1%]; RR 1.44, 1.12-1.84; p=0.004). We recorded no evidence that the effect of tranexamic acid on death due to bleeding varied by systolic blood pressure, Glasgow coma score, or type of injury. INTERPRETATION Tranexamic acid should be given as early as possible to bleeding trauma patients. For trauma patients admitted late after injury, tranexamic acid is less effective and could be harmful. FUNDING UK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation.
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Vorwerk C, Coats T. Predictive value of tissue oxygen saturation upon mortality in Emergency Department patients with sepsis. Crit Care 2011. [PMCID: PMC3061671 DOI: 10.1186/cc9461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
BACKGROUND Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be effective in reducing blood loss following trauma. OBJECTIVES To quantify the effect of antifibrinolytic drugs in reducing blood loss, transfusion requirement and mortality after acute traumatic injury. SEARCH STRATEGY We searched the Cochrane Injuries Group's Specialised Register, CENTRAL, MEDLINE, PubMed, EMBASE, Science Citation Index, National Research Register, Zetoc, SIGLE, Global Health, LILACS, and Current Controlled Trials. The Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE and EMBASE searches were updated in July 2010. SELECTION CRITERIA We included all randomised controlled trials of antifibrinolytic agents (aprotinin, tranexamic acid [TXA] and epsilon-aminocaproic acid) following acute traumatic injury. DATA COLLECTION AND ANALYSIS The titles and abstracts identified in the electronic searches were screened by two independent authors to identify studies that had the potential to meet the inclusion criteria. The full reports of all such studies were obtained. From the results of the screened electronic searches, bibliographic searches, and contacts with experts, two authors independently selected trials meeting the inclusion criteria, with any disagreements resolved by consensus. MAIN RESULTS Four trials met the inclusion criteria. Two trials with a combined total of 20,451 patients assessed the effects of TXA on mortality; TXA reduced the risk of death by 10% (RR=0.90, 95% CI 0.85 to 0.97; p=0.0035). Data from one trial involving 20,211 patients found that TXA reduced the risk of death due to bleeding by 15% (RR=0.85, 95% CI 0.76 to 0.96; p=0.0077). There was no evidence that TXA increased the risk of vascular occlusive events or need for surgical intervention. There was no substantial difference in the receipt of blood transfusion between the TXA and placebo groups. The two trials of aprotinin provided no reliable data. AUTHORS' CONCLUSIONS TXA safely reduces mortality in bleeding trauma patients without increasing the risk of adverse events. Further trials are needed to determine the effects of TXA in patients with isolated traumatic brain injury.
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Affiliation(s)
- Ian Roberts
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, North Courtyard, Keppel Street, London, UK, WC1E 7HT
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Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhogbe P, Izurieta M, Khamis H, Komolafe E, Marrero MA, Mejía-Mantilla J, Miranda J, Morales C, Olaomi O, Olldashi F, Perel P, Peto R, Ramana PV, Ravi RR, Yutthakasemsunt S. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376:23-32. [PMID: 20554319 DOI: 10.1016/s0140-6736(10)60835-5] [Citation(s) in RCA: 1767] [Impact Index Per Article: 126.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. METHODS This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.govNCT00375258, and South African Clinical Trial RegisterDOH-27-0607-1919. FINDINGS 10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%] tranexamic acid group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% CI 0.85-0.97; p=0.0035). The risk of death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76-0.96; p=0.0077). INTERPRETATION Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients. FUNDING UK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation.
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Abstract
BACKGROUND Croup, a common acute clinical syndrome in children up to the age of six, is thought to be triggered by a viral infection, and is characterised by a varying degree of respiratory distress due to upper airway inflammation and oedema of the subglottic mucosa. Corticosteroids, now part of the standard treatment for croup, improve symptoms but it takes time for their full effect to be achieved. Meanwhile, the child remains at risk of deterioration and developing respiratory failure necessitating emergency intubation and ventilation. Helium-oxygen (heliox) inhalation has been successful in the treatment of upper airway obstruction. Anecdotal evidence suggests that heliox relieves respiratory distress in children, but it remains unclear whether there is robust evidence to support the implementation of heliox for croup into clinical practice. OBJECTIVES To examine the effect of heliox on relieving symptoms and distress, determined by a croup score (a tool for measuring the severity of croup) or clinical assessment variables, through comparisons with placebo or active treatment(s) in children with croup. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2) which contains the Acute Respiratory Infections (ARI) Group's Specialised Register; MEDLINE (1950 to June week 3 2009); EMBASE (1974 to 2009 week 25) and CINAHL (1982 to June 2009). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of helium-oxygen mixtures with placebo or any active treatment in children with croup. DATA COLLECTION AND ANALYSIS Both authors independently identified and assessed citations for relevance. We assessed included trials for risk of bias using allocation concealment, blinding of intervention, completeness of outcome data, selective outcome reporting and other potential source of bias. We calculated mean differences for continuous data. We presented data not suitable for statistical analysis as descriptive data. MAIN RESULTS Two eligible RCTs were included (22 intervention, 22 controls). Neither trial compared heliox inhalation with placebo. One study compared heliox with 30% humidified oxygen whilst the other compared it to 100% oxygen with additional racaemic epinephrine nebulisation. There was no significant difference in change of croup score between intervention and control groups. AUTHORS' CONCLUSIONS At present there is a lack of evidence to establish the effect of heliox inhalation in the treatment of croup in children. A methodologically well-designed and adequately powered RCT is needed to assess whether there is a role for heliox therapy in the management of children with croup.
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Affiliation(s)
- Christiane Vorwerk
- Department of Emergency Medicine, Leicester Royal Infirmary, Infirmary Square, Leicester, UK, LE1 5WW
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Edwards A, Di Bartolomeo S, Chieregato A, Coats T, Della Corte F, Giannoudis P, Gomes E, Groenborg H, Lefering R, Leppaniemi A, Lossius HM, Ortenwal P, Roise O, Rusnak M, Sturms L, Smith M, Bondegaard Thomsen A, Willett K, Woodford M, Yates D, Lecky F. A comparison of European Trauma Registries. The first report from the EuroTARN Group. Resuscitation 2007; 75:286-97. [PMID: 17714850 DOI: 10.1016/j.resuscitation.2007.06.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Revised: 06/07/2007] [Accepted: 06/11/2007] [Indexed: 11/21/2022]
Abstract
UNLABELLED Trauma management systems have grown in response to regional variations in trauma population, geographical conditions and the provisions of care. National Trauma Registries are being established to improve patient outcomes. However international comparisons could provide the potential to record regional performance, identify and share examples of best practice. To assess whether it was possible to compare data currently being collected by a number of trauma services across Europe, a group was established to develop a common core dataset and to assess the feasibility of collecting anonymised data. METHOD A series of meetings with European collaborators led to the creation of a group entitled EuroTARN. A website was developed in 2002 and interested parties were invited to submit suggestions for a European dataset using an online version of the Delphi technique. A core dataset was created in 2003 and in 2004 participants were invited to submit a summary of past cases online via the EuroTARN Website. RESULTS Representatives from 14 countries met and corresponded to create the core dataset. During a trial data collection phase 14 institutions from 11 countries submitted unadjusted mortality data for over 21,500 cases with injury severity Scores of over 15 including information on multiply injured and head injured patients. The results demonstrated that there were observed differences in trauma outcome for similar groups of patients. CONCLUSION It is possible to collect and collate outcome data from established trauma registries across Europe with minimal additional infrastructure using a web-based system. Initial analysis of the results reveals significant international variations. The network has potential as a source of data for epidemiological and clinical research and for optimal trauma system design across Europe.
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Affiliation(s)
- Antoinette Edwards
- University of Manchester, Trauma Audit & Research Network, Clinical Sciences Building, Hope Hospital, Salford, Greater Manchester M6 8HD, United Kingdom.
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Au-Yong A, Coats T. C Reactive Protein and the diagnosis of intracranial infection. Arch Emerg Med 2007; 24:218-9. [PMID: 17351235 PMCID: PMC2660038 DOI: 10.1136/emj.2007.046839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A short cut review was carried out to determine whether measuring C Reactive Protein might help in the diagnosis of intracranial infection in a patient presenting to the Emergency department with an acute headache. 62 papers were found, but none answered the question. The clinical bottom line is that there doesn't appear to be any evidence for, or against, the use of C Reactive Protein in the diagnosis of intracranial infection in patients presenting to the Emergency department with an acute headache.
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Affiliation(s)
- Amy Au-Yong
- Emergency Department, Leicester Royal Infirmary
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