Casemix and performance of Australian emergency departments: A comparison of major city, regional and remote locations

OBJECTIVE

EDs are an essential service, and higher rates of presentations per population are seen in regional and remote areas compared to major cities. Australia-wide differences in utilisation and performance remain largely unknown.

METHODS

This was a descriptive, retrospective epidemiological study analysing data collected via the National Non-Admitted Patient Emergency Department Care Database managed by the Australian Institute of Health and Welfare. Data from all reporting public hospitals in Australia for the period between 1 July 2018 and 30 June 2019 were analysed. Reporting EDs were geographically categorised using the 2016 Australian Statistical Geography Standard - Remoteness Area.

RESULTS

ED presentations for the 293 reporting EDs were 8 352 192 (median 17 904, range 8-113 929), one-third (33.09%, 95% CI 33.06-33.12) were outside major cities. Remote ED presentations were less likely to arrive by ambulance (12.13% [12.01-12.26]; major cites 28.07% [28.03-28.10]; regional 22.55% [22.50-22.60]) but more likely by police/correctional services vehicle (major cities 0.59% [0.58-0.60]; regional 0.71% [0.70-0.72]; remote 1.71% [1.66-1.76]). Presentations to remote EDs were more likely to leave without being attended by a health professional (5.29% [5.21-5.38]; major cities 3.93% [3.92-3.95]; regional 3.53% [3.51-3.55]). A larger proportion of admitted patients stayed at least 8 h in remote (21.83% [21.46-22.20]) and regional (21.52% [21.41-21.62]) EDs compared to major cities (19.82% [19.76-19.88]).

CONCLUSIONS

Our study highlights ED utilisation, casemix and performance by location. The differences observed, especially areas of inequity and need for interventions, reiterate that imperative regional and remote EDs are appropriately resourced to support the communities they serve.

Non-Ventilated Patients with Spontaneous Pneumothorax or Pneumomediastinum Associated with COVID-19: Three-Year Debriefing across Five Pandemic Waves

Spontaneous pneumothorax and pneumomediastinum (SP-SPM) are relatively rare medical conditions that can occur with or independently of COVID-19. We conducted a retrospective analysis of SP-SPM cases presented to the emergency departments (EDs) of two University-affiliated tertiary hospitals from 1 March 2020 to 31 October 2022. A total of 190 patients were identified: 52 were COVID-19 cases, and 138 were non-COVID-19 cases. The primary outcome we were looking for was in-hospital mortality. The secondary outcomes concerned the disease severity assessed by (a) days of hospitalization; (b) required mechanical ventilation (MV); and (c) required intensive care (IC). All were investigated in the context of the five pandemic waves and the patients' age and comorbidities. The pandemic waves had no significant effect on the outcomes of these patients. Logistic regression found age (OR = 1.043; 95%CI 1.002-1.085), COVID-19 (OR = 6.032; 95%CI 1.757-20.712), number of comorbidities (OR = 1.772; 95%CI 1.046-3.001), and ground-glass opacities over 50% (OR = 5.694; 95%CI 1.169-27.746) as significant risk predictors of in-hospital death while controlling for gender, smoking, the pandemic wave, and the extension of SP-SPM. The model proved good prediction performance (Nagelkerke R-square = 0.524) and would hold the same significant predictors for MV and IC.

Retrospective evaluation of the incidence of presumed feline urethral obstruction during a prepandemic year compared to a pandemic year

OBJECTIVE

To investigate the influence of the coronavirus disease 2019 (COVID-19) pandemic on the incidence of urethral obstruction (UO) in male cats.

DESIGN

Retrospective study.

SETTING

One veterinary university teaching hospital and 6 private practice veterinary specialty and emergency centers.

ANIMALS

A total of 24,937 total feline cases presenting to the emergency room (ER) between March 2019 and March 2021.

MEASUREMENTS AND MAIN RESULTS

Out of 24,937 total cases, 1793 male cats met the inclusion criteria for diagnosis of UO. Of those, 327 cases were identified in which an additional diagnosis of either urolithiasis or neoplasia was made and were therefore excluded. The remaining 1466 UO cases were presumed to be idiopathic urethral obstruction (iUO) caused by feline interstitial cystitis (FIC) alone. Of those, 637 cats presented during the prepandemic year and 829 cats presented during the pandemic year.

KEY FINDINGS

Incidence of presumptive iUO increased by 30% during the COVID-19 pandemic. Total feline emergency caseload increased by 38%. iUO accounted for 6.08% and 5.73% of total feline emergency cases during the prepandemic and pandemic years, respectively.

CLINICAL SIGNIFICANCE

The reported increase in incidence of feline UO is likely due to the increase in overall emergency feline caseload.

Time intervals in the pathway to emergency cancer diagnosis

Aim: Evidence on time-based metrics for cancers diagnosed through emergency presentation is lacking. We examined the duration of intervals from first symptoms to cancer diagnosis in the emergency versus primary care (PC) presentation route. Methods: Retrospective study of outpatients diagnosed with 15 solid cancers over 5 years. The outcome was the length of prediagnostic intervals by diagnostic route. Results: Median intervals in emergency presenters (n = 3167) were shorter than in PC presenters (n = 2215). However, intervals in emergency presenters with three or more prior PC consultations were similar to PC but remarkably longer than in those with one or two and no consultations. Conclusion: As we provide new interval measures for the emergency diagnostic pathway, results highlight the contribution of prior consultations to interval lengths.

A retrospective study of 333 emergency presentations and survival to discharge of backyard chickens in Australia from 2019 to 2022

This retrospective study assessed the diagnoses of emergency presentations and the survival to discharge of backyard chickens in five veterinary clinics within Australia. A total of 333 cases were reviewed from September 2019 to March 2022. October to December was the busiest period in both 2021 and 2020, with cases steadily increasing in the warmer months. Discharge following emergency presentation occurred in 57.4% of reviewed cases. Female chickens represented 92.7% of total cases, with an average age at presentation of 2.2 years (ranging from 1 day to 10 years). The most frequent diagnoses were of reproductive disease (n = 94/333), open diagnosis (n = 55/333), respiratory disease (n = 42/333), predator attack (n = 28/333), musculoskeletal disease (n = 22/333) and parasitism (n = 22/333).

Diagnosis of cancer in the Emergency Department: A scoping review

BACKGROUND

The Emergency Department (ED) plays a key role in the identification and care of acute medical conditions, including cancer. In this scoping review, we aimed to determine the role of the ED in the acute diagnosis of cancer.

METHODS

We conducted a scoping review of articles according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) using PubMed and Google Scholar. We screened studies of adults with a new diagnosis of cancer in the ED. We included randomized control trials, prospective, retrospective, and cross-sectional observational studies, and case reports published in English since 2000. We grouped the articles into categories based on their objectives and findings.

RESULTS

Of the 4459 articles, we included 47 in the review. The identified studies fell into three major categories: (1) studies describing the incidental diagnosis of cancer in the ED (n = 11, 23%), (2) studies characterizing the acute initial presentation of cancer in the ED (n = 19, 41%), and (3) studies describing the ED as a pathway to cancer diagnosis in the healthcare system (n = 17, 36%). Across the studies, cancer diagnoses in the ED were more likely in patients with higher comorbidities, occurred at later stages, and resulted in worse survival rates.

CONCLUSIONS

The ED plays a prominent role in the initial diagnosis of cancer. Efforts must be made to integrate the ED within the cancer care continuum.

Who Presents Where? A Population-Based Analysis of Socio-Demographic Inequalities in Head and Neck Cancer Patients' Referral Routes

Head and neck cancers (HNC) are often late stage at diagnosis; stage is a major determinant of prognosis. The urgent cancer referral pathway (two week wait; 2WW) within England's National Health Service aims to reduce time to diagnosis. We investigated factors associated with HNC route to diagnosis. Data were obtained from the English population-based cancer registry on 66,411 primary invasive HNCs (ICD C01-14 and C31-32) diagnosed 2006-2014. Multivariable logistic regression determined the likelihood of different diagnosis routes by patients' demographic and clinical characteristics. Significant socio-demographic inequalities were observed. Emergency presentations declined over time and 2WW increased. Significant socio-demographic inequalities were observed. Non-white patients, aged over 65, residing in urban areas with advanced disease, were more likely to have emergency presentations. White males aged 55 and older with an oropharynx cancer were more likely to be diagnosed via 2WW. Higher levels of deprivation were associated with both emergency and 2WW routes. Dental referral was more likely in women, with oral cancers and lower stage disease. Despite the decline over time in emergency presentation and the increased use of 2WW, socio-demographic variation is evident in routes to diagnosis. Further work exploring the reasons for these inequalities, and the consequences for patients' care and outcomes, is urgently required.

Impact of COVID-19 on the Mode of Presentation and Stage at Diagnosis of Colorectal Cancer

AIM

This study compares the stage at the presentation of patients with colorectal cancer (CRC) before and after introducing COVID-19 restrictions and the mode of presentation.

METHODS

This is a retrospective cohort study comparing the incidence of CRC, TNM stage and mode of presentation in the pre-COVID and COVID cohorts at a single UK Trust. All patients discussed at the CRC multidisciplinary team (MDT) from March 2017 to March 2021 were included and split into two cohorts; the pre-COVID group from 01/03/2017 to 29/02/2020 and the COVID group from 01/03/2020 to 28/02/2021. Percentages were used for descriptive statistics. Student's t-test was used for the comparison of demographic variables. Chi-squared test was used for the difference analysis for the categorical data, such as TNM and mode of presentation. P value ≤0.05 was significant.

RESULTS

In total, 1373 patients were diagnosed with CRC during the period from March 2017 to March 2021. The pre-COVID group (2017-2020) included 1104 CRC patients, compared to 269 patients in the COVID one (2020-2021). The mean age was higher in the pre-COVID group (p = 0.001). There was a statistically significant increase in the proportion of cases presenting with T4 disease (p = 0.023) and metastatic disease (p = 0.032) in the COVID group compared to the pre-COVID group. There was also a significant increase in the rate of emergency presentations (p < 0.0001).

CONCLUSION

We observed a statistically significant increase in rates of locally advanced (T4) and metastatic (distant) CRC in patients presenting after introducing the COVID-19 lockdown. There was also an increase in emergency presentations. There was no observed difference in nodal status. This may reflect disruption to cancer diagnostic services and the reluctance of patients to access medical care during a pandemic, particularly the elderly.

Neuroendocrine Carcinoma of the Colon: Emergency Presentation of a Rare Disease With Poor Biology

Neuroendocrine tumors (NETs) are rare entities. Most common among them are gastroenteropancreatic neuroendocrine tumors (GEP-NETs) and pulmonary NETs. Most of them are indolent in nature. Colonic NETs are rare among GEP-NETs and mostly present with large size and with metastasis. Emergency presentation with hematochezia is rare in colonic NETs. This case report discusses a rare emergency presentation of colonic NETs and highlights their poor biological nature.

Post-acute care for asthma patients presenting to an Australian hospital network

We evaluated post-acute care in 1273 asthma patients presenting to our hospital network. Patients with respiratory unit admission (n = 413) or consultation from the respiratory service (n = 45) were more likely to have guideline adherent care compared with patients without respiratory input (n = 153). Patients aged greater than 60 years had higher rates of representation within 90 days and lower rates of asthma action plans. Post-acute care of asthma at our centre falls short of guideline recommendations, and subspecialist involvement should be expanded.

The Socioeconomic Characteristics of Childhood Injuries in Regional Victoria, Australia: What the Missing Data Tells Us

Background: Injury is the leading cause of death among those between 1–16 years of age in Australia. Studies have found that injury rates increase with socioeconomic disadvantage. Rural Urgent Care Centres (UCC) represent a key point of entry into the Victorian healthcare system for people living in smaller rural communities, often categorised as lower socio-economic groups. Emergency presentation data from UCCs is not routinely collated in government datasets. This study seeks to compare socioeconomic characteristics of children aged 0–14 attending a UCC to those who attend a 24-h Emergency Departments with an injury-related emergency presentation. This will inform gaps in our current understanding of the links between socioeconomic status and childhood injury in regional Victoria. Methods: A network of rural hospitals in South West Victoria, Australia provide ongoing detailed de-identified emergency presentation data as part of the Rural Acute Hospital Data Register (RAHDaR). Data from nine of these facilities was extracted and analysed for children (aged 0–14 years) with any principal injury-related diagnosis presenting between 1 February 2017 and 31 January 2020. Results: There were 10,137 injury-related emergency presentations of children aged between 0–14 years to a participating hospital. The relationship between socioeconomic status and injury was confirmed, with overall higher rates of child injury presentations from those residing in areas of Disadvantage. A large proportion (74.3%) of the children attending rural UCCs were also Disadvantaged. Contrary to previous research, the rate of injury amongst children from urban areas was significantly higher than their more rural counterparts. Conclusions: Findings support the notion that injury in Victoria differs according to socioeconomic status and suggest that targeted interventions for the reduction of injury should consider socioeconomic as well as geographical differences in the design of their programs.

Where are children seen in Australian emergency departments? Implications for research efforts

OBJECTIVE

With most paediatric emergency research in Australia conducted at tertiary EDs, it is important to understand how presentations differ between those at tertiary paediatric EDs and all other EDs.

METHODS

Retrospective epidemiological study assessing paediatric case-mix and time-based performance metrics (aged 0-14 years) obtained from a national health service minimum dataset for the 2017-2018 financial year, comparing tertiary paediatric EDs and all other EDs. We defined a 'major tertiary paediatric hospital' as one which was accredited for training in both paediatric emergency medicine and paediatric intensive care.

RESULTS

Of the 1 695 854 paediatric ED presentations, 23.8% were seen in nine major metropolitan tertiary paediatric hospitals. Reasons for presentations were more distinctive between cohorts among children aged 10-14 years, where psychiatric illness (5.2% vs 2.5%) and neurological illness (4.5% vs 2.5%) were more commonly seen in major tertiary paediatric EDs. Australian Indigenous children were significantly less likely to present to tertiary paediatric EDs (3.0%), compared with other EDs (9.7%) (odds ratio 0.27, 95% confidence interval 0.26-0.27). While median waiting times were longer in major tertiary paediatric EDs (28 min [interquartile range 11-65]) than in other EDs (20 min [interquartile range 8-48], P < 0.001), patients were also less likely to leave without being seen (5.5% in tertiary paediatric EDs vs 6.9% in other EDs; odds ratio 0.80, 95% confidence interval 0.78-0.81).

CONCLUSIONS

The present study identified key areas of difference in paediatric presentations between tertiary paediatric EDs and other EDs. It is vital to broaden paediatric ED research beyond tertiary paediatric centres, to ensure relevance and generalisability.

Characteristics of Aboriginal and Torres Strait Islander peoples attending Australian emergency departments

OBJECTIVE

Aboriginal and Torres Strait Islander patients are overrepresented in Australian EDs. The present study aimed to assess their characteristics in utilising ED services at a national level.

METHODS

This exploratory, quantitative study used 2016-2017 de-identified data from the National Non-admitted Patient Emergency Department Care Database to assess the proportions (with 95% confidence interval) of Indigenous and non-Indigenous Australians across various aspects of ED presentations, including mode of arrival, triage scale, diagnosis information, episode end status and ED length of stay. Episode level ED data were compared by Indigenous status and geographical remoteness of EDs.

RESULTS

Of 7.4 million presentations, 6.58% were Indigenous presentations, with over two-thirds occurring in regional and remote EDs. Indigenous patients were more likely than non-Indigenous patients to arrive to EDs by ambulance and police/correctional services vehicle across all remoteness areas. Additionally, they were more likely to present with respiratory system illness, illness of the skin/subcutaneous tissue/breast and mental/behavioural disorders. Indigenous Australians were more likely to leave EDs before being seen or care complete (odds ratio 1.73, 95% confidence interval 1.71-1.74), and this was observed for patients classified across all levels of triage scale.

CONCLUSIONS

This is the first national study looking at the characteristics of and reasons for presenting to Australian EDs for Indigenous and non-Indigenous patients. Our findings provide important insight into the potential factors affecting Indigenous patient care, and an impetus for ongoing research and advocacy work to improve the quality of emergency care provided to Indigenous Australians.

Pediatric emergency asthma presentations in Southwest Victoria: a retrospective cross-sectional study 2017 to 2020

OBJECTIVES

Australia has one of the highest prevalence of asthma globally, and accessible emergency asthma presentation data remains vital, however, is currently underreported in regional and rural areas. Utilizing the Rural Acute Hospital Data Register (RAHDaR) which includes previously non-reported data, the aim of the study is to provide a more accurate understanding of asthma emergency presentation events, while investigating the factors associated with these presentations.

METHODS

A retrospective cross-sectional study collected de-identified emergency asthma presentation data from nine health services in regional Victoria for children aged 0 to 14 years between 2017 and 2020. Demographic and presentation data were collated along with government datasets. Asthma emergency presentations incidence rates and predictor variables were analyzed using hierarchical multiple regression after adjusting for smoking and sex. Significance was determined at p < 0.05.

RESULTS

Of the 1090 emergency asthma presentations, n = 369 occurred at health services who did not previously report data. This represents a 33.86% increase in our understanding of emergency asthma presentations and demonstrating a rate of 16.06 presentations per 1000 children per year. Key factors such as age, population density, and private health insurance were associated with asthma emergency presentation events among both sexes, while socioeconomic status and rurality were not predictive.

CONCLUSIONS

Although some findings are consistent with current research, the study highlights previously unrecognized specific factors that are predictive of asthma among 0-14-year-old children. These findings provide more accurate insights for healthcare workers and policymakers as they seek to support people with asthma and accurately address health inequities.

The data deficit for asthma emergency presentations might surprise you: how RAHDaR addresses the data chasm

INTRODUCTION

National and state-based minimum data sets remain inadequate in providing a complete representation of emergency presentations, especially among paediatric asthma presentations. Thus, the aim of the study was to identify if a deficit exists in current emergency paediatric asthma hospital presentation datasets and how this may inform an understanding of childhood asthma in Victoria Methods: This retrospective cross-sectional study examined emergency hospital presentation data between 1 February 2017 and 31 January 2019. All paediatric (0-14 years) emergency asthma presentation data were collected from nine hospitals in south-western Victoria, Australia, using the Rural Acute Hospital Data Register (RAHDaR), which gathers both Victorian Emergency Minimum Dataset (VEMD) data from larger government hospitals, and non-VEMD data from smaller, more rural institutions.

RESULTS

Of the 854 emergency presentations identified for children with asthma aged 0-14 years, 540 (63.2%) were managed initially at larger government-reporting hospitals. A total of 314 (36.8%) emergency presentations were initially managed at emergency facilities, such as urgent care centres. Overall, it was found that a total 278 (32.5%) of all emergency presentations did not appear in current government datasets.

CONCLUSION

The RAHDaR database, a complete register of data, captures all emergency presentations in south-western Victoria and highlights as much as a 33% deficit in the data currently available to inform asthma resource initiatives including policy development, funding allocation, prevention and management initiatives in Victoria. More accurate data from sources such as RAHDaR are essential to fill the now-evident data chasm.

The Value of Local Heatwave Impact Assessment: A Case-Crossover Analysis of Hospital Emergency Department Presentations in Tasmania, Australia

Heatwaves have been identified as a threat to human health, with this impact projected to rise in a warming climate. Gaps in local knowledge can potentially undermine appropriate policy and preparedness actions. Using a case-crossover methodology, we examined the impact of heatwave events on hospital emergency department (ED) presentations in the two most populous regions of Tasmania, Australia, from 2008–2016. Using conditional logistic regression, we analyzed the relationship between ED presentations and severe/extreme heatwaves for the whole population, specific demographics including age, gender and socio-economic advantage, and diagnostic conditions that are known to be impacted in high temperatures. ED presentations increased by 5% (OR 1.05, 95% CI 1.01–1.09) across the whole population, by 13% (OR 1.13, 95% CI 1.03–1.24) for children 15 years and under, and by 19% (OR 1.19, 95% CI 1.04–1.36) for children 5 years and under. A less precise association in the same direction was found for those over 65 years. For diagnostic subgroups, non-significant increases in ED presentations were observed for asthma, diabetes, hypertension, and atrial fibrillation. These findings may assist ED surge capacity planning and public health preparedness and response activities for heatwave events in Tasmania, highlighting the importance of using local research to inform local practice.

Use of health services in the last year of life and cause of death in people with intellectual disability: a retrospective matched cohort study

OBJECTIVE

To describe the cause of death together with emergency department presentations and hospital admissions in the last year of life of people with intellectual disability.

METHOD

A retrospective matched cohort study using de-identified linked data of people aged 20 years or over, with and without intellectual disability who died during 2009 to 2013 in Western Australia. Emergency department presentations and hospital admissions in the last year of life of people with intellectual disability are described along with cause of death.

RESULTS

Of the 63 508 deaths in Western Australia from 2009 to 2013, there were 591 (0.93%) decedents with a history of intellectual disability. Decedents with intellectual disability tended to be younger, lived in areas of more social disadvantage, did not have a partner and were Australian born compared with all other decedents. A matched comparison cohort of decedents without intellectual disability (n=29 713) was identified from the general population to improve covariate balance.Decedents with intellectual disability attended emergency departments more frequently than the matched cohort (mean visits 3.2 vs 2.5) and on average were admitted to hospital less frequently (mean admissions 4.1 vs 6.1), but once admitted stayed longer (average length of stay 5.2 days vs 4.3 days). People with intellectual disability had increased odds of presentation, admission or death from conditions that have been defined as ambulatory care sensitive and are potentially preventable. These included vaccine-preventable respiratory disease, asthma, cellulitis and convulsions and epilepsy.

CONCLUSION

People with intellectual disability were more likely to experience potentially preventable conditions at the end of their lives. This indicates a need for further improvements in access, quality and coordination of healthcare to provide optimal health for this group.

Clinics in diagnostic imaging (182). Acute descending aortic dissection with aortic root retrograde extension

A 77-year-old man presented with acute-onset severe chest pain radiating to the back and elevated blood pressure. Multiphasic computed tomography of the aorta revealed an intimal tear in the descending thoracic aorta which extended both retrograde to the aortic root and antegrade to the infra-renal abdominal aorta. The initial impression, that the images showed a Stanford type B aortic dissection, was because the portion of the false lumen that extended beyond the aortic arch remained unopacified even on delayed phases, making it challenging to assess the extent of the dissection flap. Bedside transthoracic echocardiography revealed a pericardial effusion. Cardiac tamponade ensued and the patient passed away shortly after presentation. This case highlights the need for early and accurate imaging assessment of acute aortic dissection, including accurate identification of the site of intimal tear and the extent of the dissection flap.

The route to diagnosis: emergency presentation of lung cancer

A significant proportion of lung cancer patients are first diagnosed as part of an emergency presentation (EP) to acute medical services. This route to diagnosis is a strong negative predictor of survival, and is associated with age, deprivation and medical co-morbidities. Patients are less likely to receive anticancer treatment than those diagnosed through elective routes. The causes of EP of cancer are complex. When it is unavoidable, prompt input from specialist lung cancer services is needed. Preventing EP of lung cancer involves streamlined diagnostic pathways, public health campaigns about symptoms, decision-support tools for general practitioners, improved communication and access for primary and secondary care, and focus on vague symptoms. Reducing EP of lung cancer is important when improving outcomes and patient experience.

Multiple myeloma: routes to diagnosis, clinical characteristics and survival - findings from a UK population-based study

Prompt cancer diagnosis may align UK survival with European averages. We examined the impact of route to diagnosis on survival for multiple myeloma patients diagnosed 2012–2013 using data from our population‐based patient cohort that links to national death notifications and collects details on treatment and response (n = 441). Emergency presentation was associated with advanced disease and poorer outcomes, and was the commonest route to diagnosis (28·1%) followed by General Practitioner urgent (19·0%) and two‐week wait (17·2%) referrals. CRAB (elevated Calcium, Renal failure, Anaemia, Bone lesions) distribution varied by route (P < 0·001), with patients with emergency presentations most likely to have ≥2 features and significantly worse survival (log‐rank test χ² = 13·8, P = 0·0002).

Cervical cancer still presents symptomatically 20 years after the introduction of a structured national screening programme

OBJECTIVE

To investigate the pattern of presentation of cervical cancer and to identify the characteristics of women who present symptomatically with cervical cancer.

METHODS

A retrospective study of all cervical cancer cases diagnosed over a 4-year period. Details of mode of presentation, stage at diagnosis and cytological/gynaecological history were collated.

RESULTS

In total, 148 cases were identified with a median age of 46 years (range, 20-91 years). In this population, 112 (75.7%) women were within the screening age range. Forty-eight (33.6%) were asymptomatic at diagnosis and presented through the colposcopy clinic. All asymptomatic women (100%) had stage I disease at diagnosis, compared with 37.2% of the symptomatic group (P < 0.001). Postmenopausal bleeding was the most common presenting symptom (33%), followed by postcoital bleeding (14.2%), intermenstrual bleeding (12.2%) and increased vaginal discharge (3.4%). The majority of symptomatic women presented through colposcopy, gynaecological oncology or gynaecology clinics (87.6%); however, 6.5% presented through the emergency department. Women who presented symptomatically were significantly older than asymptomatic women (54.9 versus 38.1 years, P < 0.001). Women at risk of social isolation (non-English speakers, alcohol abusers, heavy smokers, receiving treatment for psychiatric disease) were more likely to present with symptoms, through the emergency department and with advanced disease at diagnosis (stage II+) (P < 0.001).

CONCLUSIONS

A review of local cervical cancer cases can highlight areas of weakness in a screening programme and can identify populations who are at risk in presenting symptomatically with advanced disease.

The role of primary care in cancer diagnosis via emergency presentation: qualitative synthesis of significant event reports

BACKGROUND

Patients diagnosed with cancer in the context of an emergency presentation (EP) have poorer outcomes. It is often assumed that such patients present to the emergency department without consulting their general practitioner (GP). Little work has been done to identify primary care involvement before hospital attendance.

METHODS

Participating primary care practices completed a significant event audit (SEA) report for the last patient diagnosed with cancer as a result of an EP. Accounts were synthesised and a qualitative approach to analysis undertaken.

RESULTS

SEAs for 222 patients were analysed. A range of cancers were included, the most common being lung (32.4%) and upper gastrointestinal (19.8%). In most cases, patients had contact with their practice before diagnosis, primarily in the period immediately before admission. In only eight cases had there been no input from primary care. Accounts of protracted primary care contact generally demonstrated complexity, often related to comorbidity, patient-mediated factors or reassurance provided by negative investigations. Learning points identified by practices centred on the themes of presentation and diagnosis, consultation and safety-netting, communication and system issues, patient factors and referral guidelines.

CONCLUSIONS

There is extensive primary care input into patients whose diagnosis results from EP, and for the most part potential 'delay' in referral can be reasonably explained by the complexity of the presentation or by coexisting patient factors.

Status epilepticus: Our experience in a tertiary care centre in Northwestern India

INTRODUCTION

Status epilepticus (SE) is a medical emergency. Aim of this study was to examine the etiology and outcome of adult patients in status epilepticus presenting to our center.

PATIENTS AND METHODS

A prospective study was conducted from January 2009 to December 2010. Newly diagnosed patients as well as known case of seizure disorder presenting with status epilepticus were included. Detailed history, clinical examination, baseline investigation, neuroimaging electroencephalogram findings were recorded. Patients were treated using a standard protocol and were followed-up for 2 weeks after discharge. Quantification of precipitating factors was done using proportion, mean and standard deviation.

RESULTS

80 consecutive patients were studied. Mean age was 38.43 ± 16.56 years (range 13 to 78 years). Male to female ratio was 4:1. 57.5% were known cases of seizure disorders. Generalized tonic-clonic seizure was commonest presentation in 91.30%. Majority (97.5%) had convulsive SE. Poor drug compliance was found to be the commonest precipitant (50% patients), followed by central nervous system infection (20% patients. Alcohol intake contributed in 12.5% cases, whereas, precipitating factor couldn't be traced in 7.5% patients'. In 55% patients, SE was controlled with no recurrence or complication and in 25% there was recurrence after control of SE. 15% patients ended up with persistent sequel (cognitive and psychosomatic dysfunction, neurological deficit etc.) lasting for 2 weeks or more. The mortality was 5%.

CONCLUSION

Poor compliance with drugs (in established cases of seizure disorders) and central nervous systems infections/structural lesions (in new onset cases) were commonest causes of SE in our study group. Conventional first line antiepileptics were able to control seizures in only 55% patients.