The Effect of the COVID-19 Pandemic on Non-COVID-19 Deaths: Population-Wide Retrospective Cohort Study

BACKGROUND

Health care avoidance in the COVID-19 pandemic has been widely reported. Yet few studies have investigated the dynamics of hospital avoidance behavior during pandemic waves and inferred its impact on excess non-COVID-19 deaths.

OBJECTIVE

This study aimed to measure the impact of hospital avoidance on excess non-COVID-19 deaths in public hospitals in Hong Kong.

METHODS

This was a retrospective cohort study involving 11,966,786 patients examined between January 1, 2016, and December 31, 2021, in Hong Kong. All data were linked to service, treatment, and outcomes. To estimate excess mortality, the 2-stage least squares method was used with daily tallies of emergency department (ED) visits and 28-day mortality. Records for older people were categorized by long-term care (LTC) home status, and comorbidities were used to explain the demographic and clinical attributes of excess 28-day mortality. The primary outcome was actual excess death in 2020 and 2021. The 2-stage least squares method was used to estimate the daily excess 28-day mortality by daily reduced visits.

RESULTS

Compared with the prepandemic (2016-2019) average, there was a reduction in total ED visits in 2020 of 25.4% (548,116/2,142,609). During the same period, the 28-day mortality of non-COVID-19 ED deaths increased by 7.82% (2689/34,370) compared with 2016-2019. The actual excess deaths in 2020 and 2021 were 3143 and 4013, respectively. The estimated total excess non-COVID-19 28-day deaths among older people in 2020 to 2021 were 1958 (95% CI 1100-2820; no time lag). Deaths on arrival (DOAs) or deaths before arrival (DBAs) increased by 33.6% (1457/4336) in 2020, while non-DOA/DBAs increased only by a moderate 4.97% (1202/24,204). In both types of deaths, the increases were higher during wave periods than in nonwave periods. Moreover, non-LTC patients saw a greater reduction in ED visits than LTC patients across all waves, by more than 10% (non-LTC: 93,896/363,879, 25.8%; LTC: 7,956/67,090, 11.9%). Most of the comorbidity subsets demonstrated an annualized reduction in visits in 2020. Renal diseases and severe liver diseases saw notable increases in deaths.

CONCLUSIONS

We demonstrated a statistical method to estimate hospital avoidance behavior during a pandemic and quantified the consequent excess 28-day mortality with a focus on older people, who had high frequencies of ED visits and deaths. This study serves as an informed alert and possible investigational guideline for health care professionals for hospital avoidance behavior and its consequences.

Randomised feasibility study of prehospital recognition and antibiotics for emergency patients with sepsis (PhRASe)

Severe sepsis is a time critical condition which is known to have a high mortality rate. Evidence suggests that early diagnosis and early administration of antibiotics can reduce morbidity and mortality from sepsis. The prehospital phase of emergency medical care may provide the earliest opportunity for identification of sepsis and delivery of life-saving treatment for patients. We aimed to assess the feasibility of (1) paramedics recognising and screening patients for severe sepsis, collecting blood cultures and administering intravenous antibiotics; and (2) trial methods in order to decide whether a fully-powered trial should be undertaken to determine safety and effectiveness of this intervention. Paramedics were trained in using a sepsis screening tool, aseptic blood culture collection and administration of intravenous antibiotics. If sepsis was suspected, paramedics randomly allocated patients to intervention or usual care using scratchcards. Patients were followed up at 90 days using linked anonymised data to capture length of hospital admission and mortality. We collected self-reported health-related quality of life at 90 days. We pre-specified criteria for deciding whether to progress to a fully-powered trial based on: recruitment of paramedics and patients; delivery of the intervention; retrieval of outcome data; safety; acceptability; and success of anonymised follow-up. Seventy-four of the 104 (71.2%) eligible paramedics agreed to take part and 54 completed their training (51.9%). Of 159 eligible patients, 146 (92%) were recognised as eligible by study paramedics, and 118 were randomised (74% of eligible patients, or 81% of those recognised as eligible). Four patients subsequently dissented to be included in the trial (3%), leaving 114 patients recruited to follow-up. All recruited patients were matched to routine data outcomes in the Secure Anonymised Information Linkage Databank. Ninety of the 114 (79%) recruited patients had sepsis or a likely bacterial infection recorded in ED. There was no evidence of any difference between groups in patient satisfaction, and no adverse reactions reported. There were no statistically significant differences between intervention and control groups in Serious Adverse Events (ICU admissions; deaths). This feasibility study met its pre-determined progression criteria; an application will therefore be prepared and submitted for funding for a fully-powered multi-centre randomised trial.Trial registration: ISRCTN36856873 sought 16th May 2017; https://doi.org/10.1186/ISRCTN36856873.

Stable Automatic Envelope Estimation for Noisy Doppler Ultrasound

Doppler ultrasound technology is widespread in clinical applications and is principally used for blood flow measurements in the heart, arteries, and veins. A commonly extracted parameter is the maximum velocity envelope. However, current methods of extracting it cannot produce stable envelopes in high noise conditions. This can limit clinical and research applications using the technology. In this article, a new method of automatic envelope estimation is presented. The method can handle challenging signals with high levels of noise and variable envelope shapes. Envelopes are extracted from a Doppler spectrogram image generated directly from the Doppler audio signal, making it less device-dependent than existing image-processing methods. The method's performance is assessed using simulated pulsatile flow, a flow phantom, and in vivo ascending aortic flow measurements and is compared with three state-of-the-art methods. The proposed method is the most accurate in noisy conditions, achieving, on average, for phantom data with signal-to-noise ratios (SNRs) below 10 dB, bias and standard deviation of 0.7% and 3.3% lower than the next-best performing method. In addition, a new method for beat segmentation is proposed. When combined, the two proposed methods exhibited the best performance using in vivo data, producing the least number of incorrectly segmented beats and 8.2% more correctly segmented beats than the next best performing method. The ability of the proposed methods to reliably extract timing indices for cardiac cycles across a range of signal quality is of particular significance for research and monitoring applications.

Screening for Frailty in Older Emergency Patients and Association with Outcome

Older people have a high incidence of adverse outcomes after urgent care presentation. Identifying high-risk older patients early is key to targeting interventions at those patients most likely to benefit. This study used the Frailsafe three-point screening questions amongst older Emergency Department (ED) attendees. Consecutive unplanned ED attendances in patients aged ≥75 were assessed for Frailsafe status. The primary outcome was mortality at 180 days. A Frailsafe screen was completed in 356 patients, of whom 194/356 (54.5%) were Frailsafe positive. The mean age was 85.8 for Frailsafe screen positive and 82.2 for Frailsafe screen negative patients (p < 0.001). A positive Frailsafe screen was a predictor of death within 180 days of presentation to the ED and remained so after adjustment (AOR = 3.23, 95% CI 1.45–7.19, p = 0.004). A positive Frailsafe screen was an independent predictor of a new care home admission at 180 days (AOR = 8.95, 95% CI 2.01–39.83, p = 0.004). A positive Frailsafe screen was also predictive of a number of secondary outcomes, such as length of stay of >28 days (AOR 3.42, 95% CI 1.41–8.31, p = 0.007) and re-attendance within 30 days of discharge after admission (OR = 2.73, 95% CI 1.27–5.88, p = 0.01). Frailsafe screen results independently predict a range of outcomes amongst older ED attendees.

PP16 Prehospital recognition and antibiotics for 999 patients with sepsis: feasibility study results

Background

Sepsis is a common condition which kills approximately 44,000 people annually in the UK. Early recognition and management of sepsis has been shown to reduce mortality and improve outcomes. Paramedics frequently attend patients with sepsis, and are well placed to provide early diagnosis and treatment. We aimed to assess whether a multi-centre randomised trial to evaluate pre-hospital antibiotics was feasible.

Methods

Volunteer paramedics used scratchcards to allocate patients with ‘Red Flag’ Sepsis at random between experimental and control arms. The primary outcome was mortality at six months. We also measured: adverse events, costs, final diagnosis, length of stay in hospital, and quality of care; and collected qualitative data about acceptability to patients in interviews, and paramedics in focus groups. We pre-specified criteria for deciding whether to progress to a fully powered trial based on: recruitment of paramedics and patients; retrieval of outcome data; safety; acceptability; and diagnostic accuracy.

Results

Fifty-four paramedics completed their training and were issued scratchcards to randomly allocate patients to trial arms. Patients were recruited from 1.12.17 to 31.5.18. In total, 118 patients were randomly allocated to trial arms; four patients dissented to be included in the trial, leaving 114 patients to follow-up. Sixty-two patients (54%) were allocated to the intervention arm. The mean age of the control arm was 71.2 years (range 28–97); 33 (65%) control participants were female. In the intervention arm the mean age was 75.6 years (range 30–99) and 38 patients (61%) were female. Nine patients in the control group (18%) and 17 in the intervention group (28%) were already taking antibiotics at the time of their 999 call. Twenty-three questionnaires were received. No serious adverse events were reported.

Conclusions

Complete results will be presented at the time of the conference, when routine linked anonymised outcomes are available.

Adding a new dimension to the weekend effect: an analysis of a national data set of electronic AKI alerts

BACKGROUND

Increased mortality related to differences in delivery of weekend clinical care is the subject of much debate.

AIM

We compared mortality following detection of acute kidney injury (AKI) on week and weekend days across community and hospital settings.

DESIGN

A prospective national cohort study, with AKI identified using the Welsh National electronic AKI reporting system.

METHODS

Data were collected on outcome for all cases of adult AKI in Wales between 1 November 2013 and 31 January 2017.

RESULTS

There were a total of 107 298 episodes. Weekday detection of AKI was associated with 28.8% (26 439); 90-day mortality compared to 90-day mortality of 31.9% (4551) for AKI detected on weekdays (RR: 1.11, 95% CI: 1.08-1.14, P < 0.001, HR: 1.16 95% CI: 1.12-1.20, P < 0.001). There was no 'weekend effect' for mortality associated with hospital-acquired AKI. Weekday detection of community-acquired AKI (CA-AKI) was associated with a 22.6% (10 356) mortality compared with weekend detection of CA-AKI, which was associated with a 28.6% (1619) mortality (RR: 1.26, 95% CI: 1.21-1.32, P < 0.001, HR: 1.34, 95%CI: 1.28-1.42, P < 0.001). The excess mortality in weekend CA-AKI was driven by CA-AKI detected at the weekend that was not admitted to hospital compared with CA-AKI detected on weekdays which was admitted to hospital (34.5% vs. 19.1%, RR: 1.8, 95% CI: 1.69-1.91, P < 0.001, HR: 2.03, 95% CI: 1.88-2.19, P < 0.001).

CONCLUSION

'Weekend effect' in AKI relates to access to in-patient care for patients presenting predominantly to hospital emergency departments with AKI at the weekend.

Prehospital recognition and antibiotics for 999 patients with sepsis: protocol for a feasibility study

Background

Sepsis is a common condition which kills between 36,000 and 64,000 people every year in the UK. Early recognition and management of sepsis has been shown to reduce mortality and improve the health and well-being of people with sepsis. Paramedics frequently come into contact with patients with sepsis and are well placed to provide early diagnosis and treatment.

We aim to determine the feasibility of undertaking a fully powered randomised controlled trial (RCT) to test the clinical and cost-effectiveness of paramedics obtaining blood cultures from and administering IV antibiotics to patients with sepsis, so we can make a decision about whether to proceed to a fully powered randomised controlled trial, which will answer questions regarding safety and effectiveness for patients and benefit to the National Health Service (NHS).

Methods/design

This is an individually randomised, two-arm feasibility study for a randomised controlled trial with a 1:1 ratio. Sixty paramedics will receive training to assist them to recognise sepsis using a screening tool, obtain blood cultures, and provide IV antibiotics. If sepsis is suspected, paramedics will randomly allocate patients to intervention or usual care using their next sequential individually issued scratch card. Patients will be followed up at 90 days using linked anonymised data to capture length of hospital admission and mortality. We will also collect self-reported health-related quality of life (using SF-12) at this time. We will interview ten patients by telephone and hold a focus group with paramedics, to find out what they think about the intervention.

Discussion

At the end of this study, we will make a recommendation about whether a full randomised controlled trial of paramedics obtaining blood cultures and administering IV antibiotics for sepsis is warranted, and if so, we will develop a proposal for research funding in order to take the work forward.

Trial registration

ISRCTN, ISRCTN36856873

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0258-8) contains supplementary material, which is available to authorized users.

Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool

Background

older adults are frequent users of emergency services and demonstrate high rates of adverse outcomes following emergency care.

Objective

to perform a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool, to determine its predictive value in identifying adults ≥65 years at risk of functional decline, unplanned emergency department (ED) readmission, emergency hospitalisation or death within 180 days after index ED visit/hospitalisation.

Methods

a systematic literature search was conducted in PubMed, EMBASE, CINAHL, EBSCO and the Cochrane Library to identify validation and impact analysis studies of the ISAR tool. A pre-specified ISAR score of ≥2 (maximum score 6 points) was used to identify patients at high risk of adverse outcomes. A bivariate random effects model generated pooled estimates of sensitivity and specificity. Statistical heterogeneity was explored and methodological quality was assessed using validated criteria.

Results

thirty-two validation studies (n = 12,939) are included. At ≥2, the pooled sensitivity of the ISAR for predicting ED return, emergency hospitalisation and mortality at 6 months is 0.80 (95% confidence interval (CI) 0.70-0.87), 0.82 (95% CI 0.74-0.88) and 0.87 (95% CI 0.75-0.94), respectively, with a pooled specificity of 0.31 (95% CI 0.24-0.38), 0.32 (95% CI 0.24-0.41) and 0.35 (95% CI 0.26-0.44). Similar values are demonstrated at 30 and 90 days. Three heterogeneous impact analysis studies examined the clinical implementation of the ISAR and reported mixed findings across patient and process outcomes.

Conclusion

the ISAR has modest predictive accuracy and may serve as a decision-making adjunct when determining which older adults can be safely discharged.

Acute Kidney Injury in the Era of the AKI E-Alert

BACKGROUND AND OBJECTIVES

Our aim was to use a national electronic AKI alert to define the incidence and outcome of all episodes of community- and hospital-acquired adult AKI.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A prospective national cohort study was undertaken in a population of 3.06 million. Data were collected between March of 2015 and August of 2015. All patients with adult (≥18 years of age) AKI were identified to define the incidence and outcome of all episodes of community- and hospital-acquired AKI in adults. Mortality and renal outcomes were assessed at 90 days.

RESULTS

There was a total of 31,601 alerts representing 17,689 incident episodes, giving an incidence of AKI of 577 per 100,000 population. Community-acquired AKI accounted for 49.3% of all incident episodes, and 42% occurred in the context of preexisting CKD (Chronic Kidney Disease Epidemiology Collaboration eGFR); 90-day mortality rate was 25.6%, and 23.7% of episodes progressed to a higher AKI stage than the stage associated with the alert. AKI electronic alert stage and peak AKI stage were associated with mortality, and mortality was significantly higher for hospital-acquired AKI compared with alerts generated in a community setting. Among patients who survived to 90 days after the AKI electronic alert, those who were not hospitalized had a lower rate of renal recovery and a greater likelihood of developing an eGFR<60 ml/min per 1.73 m2 for the first time, which may be indicative of development of de novo CKD.

CONCLUSIONS

The reported incidence of AKI is far greater than the previously reported incidence in studies reliant on clinical identification of adult AKI or hospital coding data. Although an electronic alert system is Information Technology driven and therefore, lacks intelligence and clinical context, these data can be used to identify deficiencies in care, guide the development of appropriate intervention strategies, and provide a baseline against which the effectiveness of these interventions may be measured.

Assessment of functional outcome using GOSE over 3 years post-injury in patients with moderate and severe trauma

Background: The aim of this study was to evaluate post-injury functional recovery over three years in patients with moderate and major trauma in Hong Kong.

Methods: This is a multicentre prospective cohort study conducted in Hong Kong. The inclusion criteria were: trauma patients admitted to one of three trauma centres, with age ≥ 18 years, injury severity score (ISS) ≥ 9, meeting Trauma Registry criteria, and surviving to 48 hours. Functional outcome was measured by the extended Glasgow Outcome Scale (GOSE) at 3 years post-injury. Good outcomes were defined as an extended Glasgow Outcome Scale (GOSE) ≥ 7, i.e. trauma patients' status rated as lower good recovery or upper good recovery categories.

Results: From 1st January 2010 to 30th September 2010, 400 patients were included. Mean age was 53.3 years; range 18–106 years; and 70% were male. 139 (35%) patients had ISS 9–15; 261 (65%) patients had ISS ≥ 16. Among those included, 38 % required ICU admission; and 58% had healthy pre-existing comorbidity status. For the GOSE analysis, the number of surviving responders at 3 years post-injury reaching a GOSE ≥ 7 was 86, which represented 54.1% of the 159 surviving responders, and 21.5% (86/400) of the original cohort. As there were no statistically significant differences between surviving responders and non-responders at baseline, the assumption is made that 54.1% of the 167 non-responders (N = 90) also reached a GOSE ≥ 7. The total number of cases reaching a GOSE ≥ 7 is therefore estimated to be (86+90), or 176, which is 44.1% of the original 400 cases.

Conclusion: The proportion of cases reaching a GOSE ≥ 7 at 3 years post-injury is 44.1%.

International perspectives on emergency department crowding

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.

Traumatic intracerebral haemorrhage: is the CT pattern related to outcome?

It is believed by many neurosurgeons that in addition to age and neurological status, the CT patterns of traumatic intracerebral haemorrhages are related to outcome. The aim of this study was to find out whether this is the case. The study was conducted in a regional level I trauma centre in Hong Kong. We prospectively collected data of patients with traumatic intracerebral haematomas over a 4-year period. Of 464 patients with head injuries, traumatic intracerebral haematoma was significantly associated with inpatient mortality and one year unfavorable outcome after adjustment for age, sex, post-resuscitation GCS, and presence of acute subdural haematoma. One hundred-and-fourteen patients had traumatic intracerebral haematomas and were included for further analysis. The mean age was 49, the male to female ratio was 2 to 1, and the median Glasgow Coma Scale (GCS) score on admission was 12. Logistic regression analysis showed that age and GCS score/GCS motor component score were significant factors for inpatient mortality, one-year mortality and one-year outcome. There was an association between temporal haematomas and inpatient mortality, subdural haematomas and inpatient mortality, and bilateral haematomas and unfavourable one-year outcome. In patients with severe head injury, a traumatic haematoma of more than 50 ml was associated higher inpatient mortality. In addition to age and GCS score, the CT patterns of bilateral haematomas, temporal haematomas and associated subdural haematomas were suggestive of poor outcome or mortality.

Multiple acute cerebral infarcts on diffusion-weighted imaging and risk of recurrent stroke

Multiple acute cerebral infarcts (MACIs) detected by diffusion-weighted imaging (DWI) may indicate an unstable source of thromboembolism. The authors studied 119 consecutive acute ischemic stroke patients within 24 hours of onset with DWI. MACIs were present in 20 patients (16.8%). During the follow-up period, there were 15 recurrent strokes, 3 acute coronary syndromes, and 5 deaths. MACI was the only significant independent predictor for vascular events and death (odd ratio [OR]] = 4.34; p = 0.001) and stroke recurrence (OR = 5.93; p = 0.001).

B0 images obtained from diffusion-weighted echo planar sequences for the detection of intracerebral bleeds

BACKGROUND AND PURPOSE

To evaluate the accuracy of B0 echo planar imaging (EPI) sequences for the detection of intracerebral bleeds.

METHODS

One hundred patients with acute strokes had magnetic resonance imaging and computed tomography (CT) examinations performed within 48 hours after the onset of symptoms. The detectability of intracerebral bleeds by the B0 EPI sequences was assessed. The results were compared to the gradient echo (GRE) sequence and CT brain examinations. The results of the GRE sequences were used as the gold standard.

RESULTS

The B0 EPI sequences detected 11 out of 11 acute, intracerebral hematomas; 6 out of 8 acute hemorrhagic strokes; 2 out of 2 acute, intraventricular hemorrhages; 8 out of 8 old hemorrhagic infarcts; 1 out of 1 subarachnoid hemorrhages; and 11 out of 22 patients with microbleeds. For the detection of acute, intracerebral hematomas and acute, hemorrhagic infarcts, B0 EPI sequences had a sensitivity of 89.5%, a specificity of 100%, and an accuracy of 98%. CT had a sensitivity of 57.9%, a specificity of 100%, and an accuracy of 92%. B0 EPI sequences did not miss any acute or chronic hemorrhages detected by CT examinations.

CONCLUSIONS

B0 EPI sequences could not replace GRE images for the detection of both acute and chronic hemorrhages. Their sensitivity for the detection of acute and chronic blood products, however, was comparable, if not superior, to that of CT examinations.

Cardiopulmonary resuscitation following profound immersion hypothermia

A case is presented in which prolonged resuscitation and rewarming was performed following post-rescue cardiopulmonary arrest in severe immersion hypothermia. The rescue and resuscitation techniques necessary to optimise outcome in such cases are described.

Review of police inquiries to an accident and emergency department

OBJECTIVE

To assess the workload generated by police inquiries to an accident and emergency (A&E) department and the adherence of medical staff to departmental guidelines relating to these inquiries.

DESIGN

Prospective analysis of the number, nature, and timing of police inquiries and the information released by medical staff.

SETTING

A&E department of an inner city teaching hospital.

OUTCOME MEASURES

Number of personal and telephone requests for information from police; completion of a form of inquiry; record of patient consent for release of information.

RESULTS

A daily average of 8.7 police inquiries were made, but in only 10% of cases was a form of inquiry completed. The patient's consent for release of information to the police was recorded in 4% of cases.

CONCLUSIONS

Police inquiries generate a significant workload for an A&E department, often at clinically busy times. Medical staff need further education to ensure that patient confidentiality is respected while assisting the police with their investigations.

Radiotherapy in early glottic carcinoma

Radiotherapy is widely accepted as primary treatment in the T1 stage of glottic cancer, but controversy surrounds the proper approach to T2 lesions of the glottis. A retrospective review of 90 patients addresses treatment results for T1 and T2 lesions of glottic carcinoma managed by primary radiotherapy with 60 to 64 Gy from 1977 to 1989. Seventy-nine patients met the criteria for local control analysis with a minimum follow-up of 5 years. Radiotherapy alone controlled disease in 93% (43 of 46) of patients with T1 lesion and 18% (6 of 33) of those with T2 tumors (including 10 patients in whom radiotherapy was terminated at 40 Gy because of persistent tumor). Ultimate control of disease for T1 and T2 lesions, including surgical salvage, was 100% and 82%, respectively. Larynx preservation was achieved in 100% of T1 and in 45% of T2 lesions. Extension of tumor and impaired vocal cord mobility showed statistical significance for adverse prognosis (p < .001). This paper discusses how these results affect treatment of glottic carcinoma, particularly in the T2 stage.

Use of flutter VRP1 in the management of patients with steroid-dependent asthma

We have assessed a new positive expiratory pressure device, the Flutter VRP1, in 20 patients with moderately severe asthma. Patients were studied for an initial 1-week 'run-in' period, followed by 2 weeks of the flutter device in one of which the ball-bearing was removed from the bowl. Peak expiratory flow rates, salbutamol inhaler requirements and visual analogue scores were recorded daily. Ease of sputum expectoration showed a significant improvement after 6 days of the flutter device, but there were no differences in objective measurements of lung function nor in salbutamol use. The device may be a useful adjunct to asthma therapy.

Telephone advice in the accident and emergency department: a survey of current practice

The objective of this study was to assess the standard of advice given by telephone by accident and emergency (A&E) departments following patients' enquiries. In order to do this patient enquiries were simulated and a telephone questionnaire was carried out. The study was carried out in 18 major and 16 minor A&E departments in Wales. Results achieved were that overall, correct telephone advice was given to 72 of 97 simulated patients (74%). Sixty calls were dealt with by the nursing staff (62%) who gave correct advice on 41 (68%) occasions. No A&E department had a formal policy nor provided staff training for handling patients' enquiries by telephone. It is concluded that A&E departments should train designated members of staff, preferably the triage nurse, who would formally deal with telephone enquiries requiring medical advice. There should be formal documentation of the enquiry and advice proffered as part of a departmental policy.

[Ultrasound diagnosis of regional lymph node metastasis of the neck in patients with head-neck neoplasms: sono-morphologic criteria and diagnostic accuracy]

High resolution sonography is generally considered a diagnostic tool with high sensitivity but low specificity in the assessment of cervical lymph node metastases. This study shows, that excellent sonographic results regarding sensitivity and specificity can be achieved, if sonomorphologic parameters, such as size, shape, delineation and type of echo pattern are included in the evaluation. We compared sonomorphology and histology of 82 patients operated for head and neck malignancies. The sonomorphological and histological findings in the largest lymph nodes in all neck areas were compared, and if a definite identification was possible, also in the second largest ones. Virtually, all longitudinal nodes of any size and practically all oval nodes of an axial diameter of up to 20 mm were found to be free of metastases, whereas 80% of round nodes with an axial diameter of up to 20 mm and practically all round and oval nodes exceeding 20 mm in axial diameter as well as irregularly shaped, poorly delineated and structurally inhomogeneous nodes demonstrated metastatic disease. On the basis of these results we have established the following criteria for the assessment of cervical lymph node metastases: All findings demonstrating longitudinal nodes of any size and oval nodes less than 20 mm in axial diameter are to be considered sonographically negative, whereas findings in which oval nodes exceeding 20 mm in axial diameter, as well as round, irregularly shaped, poorly delineated or inhomogeneous lymph nodes are found to be classified malignant. Of 58 sonographically positive neck areas, 54 were found to be malignant on histological examination, while 23 of 24 sonographically negative areas corresponded with histologically benign findings.(ABSTRACT TRUNCATED AT 250 WORDS)