The prognostic value of emergency department measured hypertension: A systematic review and meta-analysis

OBJECTIVES

The objective was to assess the prognostic value of hypertension detected in the emergency department (ED).

METHODS

The ED presents a unique opportunity to predict long-term cardiovascular disease (CVD) outcomes with its potential for high-footfall, and large-scale routine data collection applied to underserved patient populations. A systematic review and meta-analyses were conducted to assess the prognostic performance and feasibility of ED-measured hypertension as a risk factor for long-term CVD outcomes. We searched MEDLINE and Embase databases and gray literature sources. The target populations were undifferentiated ED patients. The prognostic factor of interest was hypertension. Feasibility outcomes included prevalence, reliability, and follow-up attendance. Meta-analyses were performed for feasibility using a random effect and exact likelihood.

RESULTS

The searches identified 1072 studies after title and abstract review, 53 studies had their full text assessed for eligibility, and 26 studies were included. Significant heterogeneity was identified, likely due to the international populations and differing study design. The meta-analyses estimate of prevalence for ED-measured hypertension was 0.31 (95% confidence interval  0.25-0.37). ED hypertension was persistent outside the ED (FE estimate of 0.50). The proportion of patients attending follow-up was low with an exact likelihood estimate of 0.41. Three studies examined the prognostic performance of hypertension and demonstrated an increased risk of long-term CVD outcomes.

CONCLUSION

Hypertension can be measured feasibly in the ED and consequently used in a long-term cardiovascular risk prediction model. There is an opportunity to intervene in targeted individuals, using routinely collected data.

Association of multimorbidity and changes in health-related quality of life following myocardial infarction: a UK multicentre longitudinal patient-reported outcomes study

BACKGROUND

Multimorbidity is prevalent for people with myocardial infarction (MI), yet previous studies investigated single-health conditions in isolation. We identified patterns of multimorbidity in MI survivors and their associations with changes in HRQoL.

METHODS

In this national longitudinal cohort study, we analysed data from 9566 admissions with MI from 77 National Health Service hospitals in England between 2011 and 2015. HRQoL was measured using EuroQol 5 dimension (EQ5D) instrument and visual analogue scale (EQVAS) at hospitalisation, 6, and 12 months following MI. Latent class analysis (LCA) of pre-existing long-term health conditions at baseline was used to identify clusters of multimorbidity and associations with changes in HRQoL quantified using mixed effects regression analysis.

RESULTS

Of 9566 admissions with MI (mean age of 64.1 years [SD 11.9], 7154 [75%] men), over half (5119 [53.5%] had multimorbidities. LCA identified 3 multimorbidity clusters which were severe multimorbidity (591; 6.5%) with low HRQoL at baseline (EQVAS 59.39 and EQ5D 0.62) which did not improve significantly at 6 months (EQVAS 59.92, EQ5D 0.60); moderate multimorbidity (4301; 47.6%) with medium HRQoL at baseline (EQVAS 63.08, EQ5D 0.71) and who improved at 6 months (EQVAS 71.38, EQ5D 0.76); and mild multimorbidity (4147, 45.9%) at baseline (EQVAS 64.57, EQ5D 0.75) and improved at 6 months (EQVAS 76.39, EQ5D 0.82). Patients in the severe and moderate groups were more likely to be older, women, and presented with NSTEMI. Compared with the mild group, increased multimorbidity was associated with lower EQ-VAS scores (adjusted coefficient: -5.12 [95% CI -7.04 to -3.19] and -0.98 [-1.93 to -0.04] for severe and moderate multimorbidity, respectively. The severe class was more likely than the mild class to report problems in mobility, OR 9.62 (95% confidence interval: 6.44 to 14.36), self-care 7.87 (4.78 to 12.97), activities 2.41 (1.79 to 3.26), pain 2.04 (1.50 to 2.77), and anxiety/depression 1.97 (1.42 to 2.74).

CONCLUSIONS

Among MI survivors, multimorbidity clustered into three distinct patterns and was inversely associated with HRQoL. The identified multimorbidity patterns and HRQoL domains that are mostly affected may help to identify patients at risk of poor HRQoL for which clinical interventions could be beneficial to improve the HRQoL of MI survivors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01808027 and NCT01819103.

Systematic literature search, review and dissemination methodology for the COVID-19 pandemic

Purpose of the study

SARS-CoV-2 has caused healthcare systems globally to reorganise. A pandemic paradox emerged; while clinicians were desperate for information on a new disease, they had less time to find and evaluate the vast volume of publications at times of significant strain on healthcare systems.

A multidisciplinary team undertook a weekly literature search capturing all COVID-19 publications. We also monitored free open access medical education (FOAMed) sources for emerging themes. Title and abstract screening pooled the most relevant papers for emergency medicine. Three summary types were created, a ‘Top 5 Flash Update’, a journal club and a rapid response to emerging FOAMed themes. From these summaries, three modes of dissemination were used: short written summaries, blogs and podcasts. These were amplified through social media.

Study design

A retrospective review was conducted assessing the impact of this knowledge dissemination strategy for the period of March to September 2020.

Results

In total, 64 687 papers were identified and screened. Of the papers included in the ‘Top 5’, 28.3% were on epidemiology, 23.6% treatment, 16.7% diagnostics, 12% prognosis, 8.7% pathophysiology with the remaining 10.7% consisting of PPE, public health, well-being and ‘other’. We published 37 blogs, 17 podcasts and 18 Top 5 Flash Updates. The blogs were read 138 343 times, the Top 5 Flash Updates 68 610 times and the podcasts had 72 501 listens.

Conclusion

A combination of traditional academic and novel social media approaches can address the pandemic paradox clinicians are facing.

117 COVID-19 RCEM research summaries: taking the burden off busy clinicians

Aims/Objectives/Background

Entering lockdown on 23rd March 2020 due to the COVID-19 pandemic marked an unprecedented period for healthcare evidence. An exponential increase in published work, pre-prints, guidelines, online information portals and more, has been overwhelming especially when combined with the ever-changing local emergency department responses to COVID-19. Many research projects were either suspended in favour of clinical work or re-routed into pandemic-oriented studies. All the while, the gap between clinical providers and a mountain of information was growing. Our team developed a strategy to deliver the most pertinent evidence to those working in emergency medicine, taking some stress out this aspect of COVID-19 working.

Methods/Design

Each week a search was conducted using PubMed of everything produced in the previous 7 days. The number of titles varied from approximately 800 to 2500. A 3 to 5 person team distilled titles and then reviewed abstracts for papers of importance and relevance to emergency medicine. Relevant and high impact journals were individually searched over the same time period. Summaries of the short-listed papers were produced and the weekly editorial team selected 5 for inclusion in the weekly RCEM Top 5 and others were combined for extra reading as part of a 2–3 weekly ‘Director’s Cut’.

Results/Conclusions

The RCEM Top 5 (at time of writing) has been run for 13 weeks. The summaries themselves were accessed by between 3000 and 6000 RCEM members/fellows each week. The work has also fed into online journal clubs and blogs (combined views of over 30,000) and has attracted interest from wider colleagues nationally and internationally to both join and even replicate the approach to other relevant areas. The positive feedback is best summarised in the following quote: ‘when I’m too mentally overcooked to do any reading on my own this helps me feel I am doing some keeping up. Please continue!’

Sex differences in health-related quality of life among acute myocardial infarction survivors: an inverse weighted propensity score analysis

Background

Over 800,000 women in the UK are living with coronary heart disease, which is the main cause of acute myocardial infarction (AMI). Marked improvements have been noted in clinical outcomes following AMI due to improved use of evidence-based treatments. However, sex differences in outcomes following AMI persist, with limited evidence in the literature concerning patient reported outcomes such as health related quality of life (HRQoL).

Purpose

To investigate sex differences in HRQoL following AMI.

Methods

Data on HRQoL among 9,566 survivors of AMI were collected from 77 National Health Service hospitals in England between 1 November 2011 and 24 June 2015. HRQoL at time of hospitalisation with an AMI as well as at 1, 6 and 12 months post discharge were collected using the self-reported EuroQol five dimension questionnaire which contains a descriptive system (EQ-5D ranging from −0.5 “worse than death” to 1 “full health”) and a visual analogue scale (EQ-VAS ranging from 0 “worst imaginable health state” to 100 “best imaginable health state”). Multilevel regression modelling coupled with inverse probability weighting propensity score analysis was used to investigate longitudinal trajectories of sex differences in perceived HRQoL following AMI.

Results

Overall, there were 2,397 (25%) women in the study. HRQoL improved over time, however, women had a lower baseline HRQoL compared with men (EQ-VAS mean (SD) 59.8 (20.4) vs. 64.5 (20.9), and EQ-5D median (IQR) 0.73 (0.52 to 0.88) vs. 0.81 (0.62 to 1.00). Sex differences in HRQoL over time persisted, with women having a reduced HRQoL (EQ-VAS coefficient: −4.41, 95% CI: −5.16 to −3.66 and EQ-5D coefficient: −0.07, −0.08 to −0.06) and across the individual EQ-5D dimensions women were more likely to report problems with anxiety (odds ratio 2.03, 95% CI: 1.80 to 2.29), mobility (1.82, 1.58 to 2.09), self-care (1.75, 1.47 to 2.08), usual activities (1.70, 1.52 to 1.89) and pain (1.59, 1.45 to 1.75).

Conclusion

Although quality of life improves for AMI survivors, women have a lower baseline and worse recovery compared with men.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation, Wellcome Trust, Sir Henry Wellcome Postdoctoral Fellowship

Can Emergency Physician Gestalt "Rule In" or "Rule Out" Acute Coronary Syndrome: Validation in a Multicenter Prospective Diagnostic Cohort Study

BACKGROUND

Chest pain is a common problem presenting to the emergency department (ED). Many decision aids and accelerated diagnostic protocols have been developed to help clinicians differentiate those needing admission from those who can be safely discharged. Some early evidence has suggested that clinician judgment or gestalt alone could be sufficient.

OBJECTIVES

Our aim was to externally validate whether emergency physician's gestalt could "rule in" or "rule out" acute coronary syndromes (ACS).

METHODS

We performed a multicenter prospective diagnostic accuracy study including consenting patients presenting to the ED in whom the physician suspected ACS. At the time of arrival, clinicians recorded their perceived probability of ACS using a 5-point Likert scale. The primary outcome was a diagnosis of ACS, defined as acute myocardial infarction or major adverse cardiac events within 30 days.

RESULTS

A total of 1,391 patients were included; 240 (17.3%) had ACS. Overall, gestalt had fair diagnostic accuracy with a C-statistic of 0.75 (95% confidence interval = 0.72 to 0.79). If ACS was "ruled out" in the 60 (4.3%) patients where clinicians perceived that the diagnosis was "definitely not" ACS, a sensitivity of 98.0% and negative predictive value of 95.0% could have been achieved. If ACS was only ruled out in patients who also had no electrocardiographic (ECG) ischemia and a normal initial cardiac troponin (cTn) concentration, 100.0% sensitivity and NPV could be achieved. However, this strategy only applied to 4.1% of patients. If patients with "probably not" ACS who had normal ECG and cTn were also ruled out (n = 418, 30.8%), sensitivity fell to 86.2% with 99.2% NPV. Using gestalt "definitely" ACS to rule in ACS gave a specificity of 98.5% and positive predictive value of 71.2%.

CONCLUSION

Clinician gestalt is not sufficiently accurate or safe to either rule in or rule out ACS as a decision-making strategy. This study will enable emergency physicians to understand the limitations of our clinical judgment.

006 The inter-observer reliability of head injury assessment between clinicians and parents of head injured children

Background

Paediatric head injury is common, yet 80% are mild and require no investigation or treatment. Decision-making around neuroimaging is guided by clinical decision rules. Whether parents and clinicians interpret questions within these algorithms in the same way is not known. Understanding this is fundamental for public facing algorithms and parental guidance.

We aimed to determine the inter-observer reliability of Pediatric Emergency Care Applied Research Network (PECARN) head injury algorithm completion between clinicians and parents of head injured children.

We conducted a prospective, observational, feasibility study. Children over 2 years old, presenting to the Royal Manchester Children’s Hospital within 24 hours of a head injury, were recruited. Children were excluded if they required immediate resuscitation or non-accidental injury was suspected. Parents were given a questionnaire to complete whilst awaiting assessment, with the PECARN criteria in lay-man’s language. Following assessment, the treating clinician completed a similar questionnaire, blinded to the parent’s answers.

57 children were included. The mean age was 5.8 years (SD 4.07). The most common mechanism of injury was a fall from standing (46%), with only 6 parents reporting a dangerous mechanism. Arrival Glasgow Coma Scale (GCS) was 15/15 in 98% of children. The inter-rater reliability for individual PECARN criteria was highly variable, with kappa values ranging from −0.10 to 1.00. There was poor agreement on whether the child was alert and acting normally (K −0.10, SE 0.49) but perfect agreement on other features of altered mental state including agitation, repeated questioning and taking longer than normal to respond (all K 1.0).

The high variability in agreement between clinicians and parents when assessing PECARN criteria highlights differences in how these groups evaluate head injured children. This has significant implications for public facing algorithms, such as those used by NHS 111.

BET 2: Poor evidence on whether teaching cognitive debiasing, or cognitive forcing strategies, lead to a reduction in errors attributable to cognition in emergency medicine students or doctors

A short review was carried out to see if teaching cognitive forcing strategies reduces cognitive error in the practice of emergency medicine. Two relevant papers were found using the described search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. There is currently little evidence that teaching cognitive forcing strategies reduces cognitive error in the practice of emergency medicine.

Geographic variation in the treatment of non-ST-segment myocardial infarction in the English National Health Service: a cohort study

OBJECTIVES

To investigate geographic variation in guideline-indicated treatments for non-ST-elevation myocardial infarction (NSTEMI) in the English National Health Service (NHS).

DESIGN

Cohort study using registry data from the Myocardial Ischaemia National Audit Project.

SETTING

All Clinical Commissioning Groups (CCGs) (n=211) in the English NHS.

PARTICIPANTS

357 228 patients with NSTEMI between 1 January 2003 and 30 June 2013.

MAIN OUTCOME MEASURE

Proportion of eligible NSTEMI who received all eligible guideline-indicated treatments (optimal care) according to the date of guideline publication.

RESULTS

The proportion of NSTEMI who received optimal care was low (48 257/357 228; 13.5%) and varied between CCGs (median 12.8%, IQR 0.7-18.1%). The greatest geographic variation was for aldosterone antagonists (16.7%, 0.0-40.0%) and least for use of an ECG (96.7%, 92.5-98.7%). The highest rates of care were for acute aspirin (median 92.8%, IQR 88.6-97.1%), and aspirin (90.1%, 85.1-93.3%) and statins (86.4%, 82.3-91.2%) at hospital discharge. The lowest rates were for smoking cessation advice (median 11.6%, IQR 8.7-16.6%), dietary advice (32.4%, 23.9-41.7%) and the prescription of P2Y12 inhibitors (39.7%, 32.4-46.9%). After adjustment for case mix, nearly all (99.6%) of the variation was due to between-hospital differences (median 64.7%, IQR 57.4-70.0%; between-hospital variance: 1.92, 95% CI 1.51 to 2.44; interclass correlation 0.996, 95% CI 0.976 to 0.999).

CONCLUSIONS

Across the English NHS, the optimal use of guideline-indicated treatments for NSTEMI was low. Variation in the use of specific treatments for NSTEMI was mostly explained by between-hospital differences in care. Performance-based commissioning may increase the use of NSTEMI treatments and, therefore, reduce premature cardiovascular deaths.

TRIAL REGISTRATION NUMBER

NCT02436187.

Lesser trochanter fracture: the presenting feature of a more sinister pathology

We report the rare case of a 75-year-old man who was hospitalised following referral by his general practitioner with a 4-day history of worsening groin pain. Initial radiographs demonstrated an isolated avulsion fracture of the lesser trochanter. There were associated bony changes indicating pathological bone disease, likely secondary to bony metastasis. Further investigation revealed a renal mass almost certainly consistent with a renal cell carcinoma. This case emphasises the importance of having a high index of suspicion for neoplastic pathology when low impact injuries result in fractures.

Plantar fascia calcification a sequelae of corticosteroid injection in the treatment of recalcitrant plantar fasciitis

We report the case of a 72-year-old woman suffering with severe plantar fasciitis who received a therapeutic corticosteroid injection. Two-and-a-half years after the injection she developed a small calcified lump under the skin which subsequently caused ulceration and infection. She went on to develop a diabetic foot infection requiring an extended course of intravenous antibiotics.

Proteolytic activity of Lactobacillus strains isolated from dryfermented sausages on muscle sarcoplasmic proteins

The proteolytic activity of seven strains of Lactobacillus from two species isolated from dry cured sausages was assayed using a soluble muscle extract as a source of proteins, at a temperature of 30 °C. The results indicated that the strains of Lactobacillus plantarum tested had the more active proteolytic system, showing the highest amino acid release in the medium after 72 hr of incubation (L. plantarum CRL 681) when the microorganism was in the stationary phase of growth. The strains of L. casei showed a continued hydrolytic activity with a lower amino acids concentration along the studied period. The SDS-PAGE profiles showed that the major changes in sarcoplasmic proteins were produced in the 13 kDa and 36-40 kDa molecular weights region.

Over-expression of a cytosolic isoform of the HbCuZnSOD gene in Hevea brasiliensis changes its response to a water deficit

Hevea brasiliensis is the main commercial source of natural rubber. Reactive oxygen species (ROS) scavenging systems are involved in various biotic and abiotic stresses. Genetic engineering was undertaken to study the strengthening of plant defences by antioxidants. To that end, Hevea transgenic plant lines over-expressing a Hevea brasiliensis cytosolic HbCuZnSOD gene were successfully established and regenerated. Over-expression of the HbCuZnSOD gene was not clearly related to an increase in SOD activity in plant leaves. The impact of HbCuZnSOD gene over-expression in somatic embryogenesis and in plant development are presented and discussed. The water deficit tolerance of two HbCuZnSOD over-expressing lines was evaluated. The physiological parameters of transgenic plantlets subjected to a water deficit suggested that plants from line TS4T8An displayed lower stomatal conductance and a higher proline content. Over-expression of the HbCuZnSOD gene and activation of all ROS-scavenging enzymes also suggested that protection against ROS was more efficient in the TS4T8An transgenic line.

Restricted feed intake in lactating primiparous sows. II. Effects on subsequent litter sex ratio and embryonic gene expression

Expression of panels of candidate genes controlling myogenesis, angiogenesis and gender-specific imprinting of development were analysed in embryonic, placental and endometrial tissues recovered at Day 30 of gestation from a subset of primiparous sows that were either feed restricted (Restrict; n=17) or fed to appetite (Control; n=15) during the last week of the previous lactation. Embryos were also sex typed to investigate gender bias in response to treatments. Average embryonic weight was lower in the subset of Restrict compared with Control litters (1.38±0.07vs 1.59±0.08g, respectively) and the male:female sex ratio was higher (P<0.05) in embryos (litters) recovered from Restrict sows. Treatment affected (P≤0.05) the expression of embryonic and placental genes involved in insulin-like growth factor (IGF) 2 signalling, including IGF2, INSR and IGF2R. Embryonic expression of ESR1 was also affected by treatment (P<0.03) and sex×treatment interactions were observed for the expression of embryonic ESR1 (P<0.05) and placental ANGPT2 (P<0.03). At the molecular level, these results support the suggestion that changes in placental function are not the primary mechanism mediating detrimental effects of previous sow catabolism on early embryonic development in the feed-restricted lactational sow model. However, perturbations in the IGF2 system are implicated as mediators of these effects.

The green fluorescent protein as an efficient selection marker for Agrobacterium tumefaciens-mediated transformation in Hevea brasiliensis (Müll. Arg)

An efficient genetic transformation procedure using a recombinant green fluorescent protein (GFP) has been developed in Hevea brasiliensis clone PB260. Transformation experiments have been performed using an Agrobacterium tumefaciens binary vector harbouring both uidA and S65T-GFP reporter genes in order to compare selection methods using glucuronidase assay (GUS activity) and paromomycin resistance, GFP activity and paromomycin resistance, or GFP activity only. At transient level, the number of spots showing GUS or GFP activities was similar for 4 and 5 days after coculture. After selection, stable transformation events were observed and led to the establishment of transgenic callus lines. A higher number of lines were generated with GFP selection compared to the GUS one. GFP selection is less time-consuming in terms of callus subculturing, and offers the possibility of producing antibiotic resistance marker-free transgenic plants.

Influence of restraints on body-casted child ATDs in front and side sled tests

OBJECTIVE

The current study was designed to study hip spica casted and uncasted child dummies in front- and side-impact tests using a variety of restraints.

METHODS

Casted one- and three-year-old ATDs were restrained by a traditional child seat, a special hip spica child seat, and the vehicle seat belts. All tests positioned the child upright in either the rear-facing (one-year-old) or forward-facing (three-year-old) direction. One exception was vehicle seat belt tests for the one-year-old, which required the child to be positioned supine due to the position of the child's body imposed by the cast. The ATDs were tested in frontal impacts per FMVSS 213 (delta V of 30 mph) and in side impact using the pulse proposed for 213 (delta V of 20 mph). Corresponding control tests were performed with the uncasted ATDs. The FMVSS 213 mandated injury metrics (HIC36, 3 ms chest gs) and nonmandated due care metrics (HIC15, Nij) were evaluated.

RESULTS

For the one-year-old casted tests, 50 percent of the responses increased when compared to the uncasted control. A similar comparison for the three-year-old revealed an 80 percent increase when the dummy was fit with a body cast. HIC36 and chest gs were below the limits established in FMVSS 213 for all casted and uncasted tests. Frontal peak Nij values were in the tension-extension in nine out of ten cases and ranged from 0.8 to 0.83 (uncasted) and 1.02 to 1.92 (casted). Side-impact Nij was approximately 50 percent of the corresponding frontal tests.

CONCLUSIONS

The addition of a body cast increases head, neck, and chest responses in front- and side-impact tests. The increases are greatest for the three-year-old who was forward facing.