Healthcare interactions prior to first hospital admission with alcohol-related liver disease

BACKGROUND AND AIMS

To examine the healthcare contacts of patients in the year before an index admission to hospital with alcohol-related liver disease (ArLD) to identify where opportunities for earlier identification of alcohol use disorders (AUD) and ArLD and intervention may occur.

METHODS

A retrospective cohort study using the regional database encompassing NHS organisations across North West London (344 general practitioner [GP] practices, 4 acute hospital trusts and 2 mental health and community health trusts). Patients who had an index admission with ArLD were identified through healthcare coding and compared with a control cohort. Healthcare contacts, blood tests and AUD testing in the year preceding admission were measured.

RESULTS

The ArLD cohort had 1494 participants with an index hospital admission with ArLD. The control cohort included 4462 participants. In the year preceding an index admission with ArLD, 91% of participants had at least one contact with primary care with an average of 2.97 (SD 2.45) contacts; 80% (n = 1199/1494) attended ED, 68% attended an outpatient clinic, and 42% (n = 628/1494) had at least one inpatient admission. Only 9% of the ArLD (137/1494) had formal testing for AUD. Abnormal bilirubin and platelets were more common in the ArLD than the control cohort 25% (138/560) and 28% (231/837), respectively, v 1% (12/1228) and 1% (20/1784).

CONCLUSIONS

Prior to an index admission with ArLD patients have numerous interactions with all healthcare settings, indicating missed opportunities for early identification and treatment.

Rapid antiretroviral therapy in primary HIV-1 infection enhances immune recovery

OBJECTIVE

We present findings from a large cohort of individuals treated during primary HIV infection (PHI) and examine the impact of time from HIV-1 acquisition to antiretroviral therapy (ART) initiation on clinical outcomes. We also examine the temporal changes in the demographics of individuals presenting with PHI to inform HIV-1 prevention strategies.

METHODS

Individuals who fulfilled the criteria of PHI and started ART within 3 months of confirmed HIV-1 diagnosis were enrolled between 2009 and 2020. Baseline demographics of those diagnosed between 2009 and 2015 (before preexposure prophylaxis (PrEP) and universal ART availability) and 2015-2020 (post-PrEP and universal ART availability) were compared. We examined the factors associated with immune recovery and time to viral suppression.

RESULTS

Two hundred four individuals enrolled, 144 from 2009 to 2015 and 90 from 2015 to 2020; median follow-up was 33 months. At PHI, the median age was 33 years; 4% were women, 39% were UK-born, and 84% were MSM. The proportion of UK-born individuals was 47% in 2009-2015, compared with 29% in 2015-2020. There was an association between earlier ART initiation after PHI diagnosis and increased immune recovery; each day that ART was delayed was associated with a lower likelihood of achieving a CD4 + cell count more than 900 cells/μl [hazard ratio 0.99 (95% confidence interval, 95% CI 0.98-0.99), P  = 0.02) and CD4/CD8 more than 1.0 (hazard ratio 0.98 (95% CI 0.97-0.99).

CONCLUSION

Early initiation of ART at PHI diagnosis is associated with enhanced immune recovery, providing further evidence to support immediate ART in the context of PHI. Non-UK-born MSM accounts for an increasing proportion of those with primary infection; UK HIV-1 prevention strategies should better target this group.

Top ten priorities for global saltmarsh restoration, conservation and ecosystem service research

Coastal saltmarshes provide globally important ecosystem services including 'blue carbon' sequestration, flood protection, pollutant remediation, habitat provision and cultural value. Large portions of marshes have been lost or fragmented as a result of land reclamation, embankment construction, and pollution. Sea level rise threatens marsh survival by blocking landward migration where coastlines have been developed. Research-informed saltmarsh conservation and restoration efforts are helping to prevent further loss, yet significant knowledge gaps remain. Using a mixed methods approach, this paper identifies ten research priorities through an online questionnaire and a residential workshop attended by an international, multi-disciplinary network of 35 saltmarsh experts spanning natural, physical and social sciences across research, policy, and practitioner sectors. Priorities have been grouped under four thematic areas of research: Saltmarsh Area Extent, Change and Restoration Potential (including past, present, global variation), Spatio-social contexts of Ecosystem Service delivery (e.g. influences of environmental context, climate change, and stakeholder groups on service provisioning), Patterns and Processes in saltmarsh functioning (global drivers of saltmarsh ecosystem structure/function) and Management and Policy Needs (how management varies contextually; challenges/opportunities for management). Although not intended to be exhaustive, the challenges, opportunities, and strategies for addressing each research priority examined here, providing a blueprint of the work that needs to be done to protect saltmarshes for future generations.

Noninvasive drug adherence monitoring of antipsychotic patients via finger sweat testing

Collection of finger sweat is explored here as a rapid and convenient way of monitoring patient adherence to antipsychotic drugs. Finger sweat samples (n = 426) collected from patients receiving treatment with clozapine, quetiapine and olanzapine were analysed by liquid chromatography mass spectrometry, including a subgroup of patients with paired plasma samples. Finger sweat samples were also analysed from a negative control group and patients who had handled antipsychotic medication only. The finger sweat test (based on the detection of parent drug in one donated sample) was 100% effective in monitoring adherence within commonly prescribed dosing ranges. In comparison to participants who handled the medication only, the test could distinguish between contact and administration through monitoring of the drug metabolite, or the level of parent drug. Additionally, in a subgroup of patients prescribed clozapine, a statistically significant correlation was observed between the mass of parent drug in finger sweat and plasma concentration. The finger sweat technology shows promise as a dignified, noninvasive method to monitor treatment adherence in patients taking antipsychotics.

The Liverpool alcohol-related liver disease algorithm identifies twice as many emergency admissions compared to standard methods when applied to Hospital Episode Statistics for England

BACKGROUND

Emergency admissions in England for alcohol-related liver disease (ArLD) have increased steadily for decades. Statistics based on administrative data typically focus on the ArLD-specific code as the primary diagnosis and are therefore at risk of excluding ArLD admissions defined by other coding combinations.

AIM

To deploy the Liverpool ArLD Algorithm (LAA), which accounts for alternative coding patterns (e.g., ArLD secondary diagnosis with alcohol/liver-related primary diagnosis), to national and local datasets in the context of studying trends in ArLD admissions before and during the COVID-19 pandemic.

METHODS

We applied the standard approach and LAA to Hospital Episode Statistics for England (2013-21). The algorithm was also deployed at 28 hospitals to discharge coding for emergency admissions during a common 7-day period in 2019 and 2020, in which eligible patient records were reviewed manually to verify the diagnosis and extract data.

RESULTS

Nationally, LAA identified approximately 100% more monthly emergency admissions from 2013 to 2021 than the standard method. The annual number of ArLD-specific admissions increased by 30.4%. Of 39,667 admissions in 2020/21, only 19,949 were identified with standard approach, an estimated admission cost of £70 million in under-recorded cases. Within 28 local hospital datasets, 233 admissions were identified using the standard approach and a further 250 locally verified cases using the LAA (107% uplift). There was an 18% absolute increase in ArLD admissions in the seven-day evaluation period in 2020 versus 2019. There were no differences in disease severity or mortality, or in the proportion of admissions with decompensation of cirrhosis or alcoholic hepatitis.

CONCLUSIONS

The LAA can be applied successfully to local and national datasets. It consistently identifies approximately 100% more cases than the standard coding approach. The algorithm has revealed the true extent of ArLD admissions. The pandemic has compounded a long-term rise in ArLD admissions and mortality.

SARS-CoV-2 sero-prevalence in the workforces of three large workplaces in South Wales: a sero-epidemiological study

BACKGROUND

Sero-prevalence studies quantify the proportion of a population that has antibodies against SARS-CoV-2, and can be used to identify the extent of the COVID-19 pandemic at a population level. The aim of the study was to assess the sero-prevalence of SARS-CoV-2 antibodies in the workforce at three workplaces: a food factory, non-food factory and call-centre.

METHODS

Nine hundred ninety-three participants were recruited from three workplaces in South Wales. Participants completed a questionnaire and had a lateral flow point-of-care SARS-CoV-2 antibody test administered by a healthcare professional. The data were analysed using multivariable logistic regression, both using complete records only and following multiple imputation.

RESULTS

The sero-prevalence of SARS-CoV-2 antibodies ranged from 4% (n = 17/402) in the non-food factory to 10% (n = 28/281) in the food factory (OR 2.93; 95% CI 1.26 to 6.81). After taking account of confounding factors evidence of a difference remained (cOR comparing food factory to call centre (2.93; 95% CI 1.26 to 6.81) and non-food factory (3.99; 95% CI 1.97 to 8.08) respectively). The SARS-CoV-2 antibody prevalence also varied between roles within workplaces. People working in office based roles had a 2.23 times greater conditional odds (95% CI 1.02 to 4.87) of being positive for SARS-CoV-2 antibodies than those working on the factory floor.

CONCLUSION

The sero-prevalence of SARS-CoV-2 antibodies varied by workplace and work role. Whilst it is not possible to state whether these differences are due to COVID-19 transmission within the workplaces, it highlights the importance of considering COVID-19 transmission in a range of workplaces and work roles.

779 An Unusual Manifestation of Tophaceous Gout in The Flexor Digitorum Superficialis Tendon of An Immunocompromised Patient: A Case Report and Literature Review

Aim

This case report showcases an unusual presentation of tophaceous gout, in an immunocompromised patient. Furthermore, through a literature review, we highlight challenges posed by immunocompromised patients, the clinical manifestations of gout in the hand and principles of management.

Method

We report the case of a 62-year-old lady with previous liver transplant on immunosuppressants. She was admitted with a left palmar abscess, pyogenic tenosynovitis of the index finger and was taken to theatre for debridement and washout. Superimposed infection was apparent. This originated from an exophytic mass extending from the palm to FDS tendon insertion. This was debulked and histologically confirmed as gout. A review of the literature was performed using key search terms on PubMed relating to manifestations of gout in the tendons of the hand, and in patients on immunosuppression.

Results

Reports in the literature describe cases of gouty tendinopathy in both flexor and extensor tendons. Reported symptoms include triggering, tendon rupture and tenosynovitis. Gout occurs in a higher frequency in transplant patients. This can be attributed to medications such as cyclosporine which predispose to hyperuricaemia. Management of this condition involves medical optimisation. Despite concurrent problems with wound healing in the immunocompromised with gout, surgical intervention may be required. Indications include superimposed infection, attenuated tendon glide, joint movement, and neuropathy. Perioperative antibiotics are recommended in all immunocompromised patients.

Conclusions

This case highlights an unusual presentation of gout and the challenges of managing patients on immunosuppressant therapy. A greater awareness of this condition will allow for appropriate management in this high-risk patient cohort.

483 Complete Sciatic Nerve Transection from A Closed Femoral Fracture: A Case Report

Introduction

Complete transection of the sciatic nerve following a closed femoral fracture is exceedingly uncommon. Delayed diagnosis may result due to this unrecognised injury pattern.

Case Description:

An 18-year-old male motorcyclist was referred following a significantly displaced closed, femoral fracture. The patient was sedated at the scene and transferred to theatre for definitive fixation, where an open reduction was performed via an anterior approach. Symptoms of paresthesia and weakness were reported immediately postoperatively, and formal neurological examination prompted an emergency MRI. On this basis, the patient was transferred to plastics and underwent surgical exploration, where complete transection of the sciatic nerve was identified just proximal to the bifurcation into the common peroneal and tibial nerve. A nerve gap of five centimetres was identified requiring reconstruction with grouped fascicular sural nerve grafts.

Discussion:

Complete transection of the sciatic nerve is a devastating injury that compromises the function of the posterior compartment of the thigh and all motor function below the knee. To our knowledge, reports of complete sciatic nerve transection secondary to a closed fracture of the femoral shaft are extremely rare in the pertinent literature, with only two other cases reported to date.

613 Microsurgical Salvage of Neonatal Upper Limb Ischaemia Subsequent to Intrauterine Brachial Vessel Constriction

Introduction

We report a case of limb salvage due to intra uterine brachial artery thrombosis. Treatment modalities include medical, endovascular, and surgical. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity.

Description

A male baby at (36 + 6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. The child was noted to have a ‘flail’ ischeamic limb post-delivery. There were no palpable pulses in the limb and ultrasonography confirmed thrombosis of the proximal brachial artery. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularisation was achieved with a contralateral interposition reversed great saphenous vein graft.

Discussion

Neonatal limb ischaemia is a rare disease entity with devastating morbidity- including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The initial diagnosis is based on the characteristic sequelae of ischaemia. Therapy should be individualised based on the clinical presentation. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity.

The Operative Incidence of Syndactyly in Northern Ireland. A 10-Year Review

BACKGROUND

Syndactyly is a common congenital condition that can present sporadically or in relation to an underlying genetic condition. Little contemporary published data exists detailing specific rates of presentation and surgical intervention, especially in Western European population. This is the first published review of operative intervention rates for the condition over time in Northern Ireland.

METHODS

A ten-year retrospective review of electronic operative records from January 2007 - October 2017 was carried out within Northern Ireland's regional tertiary centre Royal Belfast Hospital for Sick Children (RBHSC). All congenital hand surgery in the country was performed here during the period reviewed, by a single surgeon. Patient age at surgical intervention, their sex, digits involved and clinical grade of syndactyly was recorded.

RESULTS

One hundred and twenty four cases were returned following the review. On individual analysis 22 cases were excluded as they were not primary congenital syndactyly. The remaining 102 cases were all Caucasian. Six cases were toe syndactyly while 96 cases involved the upper limb digits. The group consisted of 70 males and 32 female infants. Age range at time of surgical intervention was 8 months to 14 years with a median age of 26 months. For clinical grade of upper limb syndactyly; 35 cases in the data set were classed as simple incomplete, 34 cases as simple complete, 17 as complex and 5 cases as complicated syndactyly. The remaining 5 cases lacked clear documentation. The most common site of syndactyly was between the ring and middle finger (40/102). Annual frequency of operative intervention has trended upwards in the period studied.

CONCLUSION

This case review adds epidemiological data on the operative incidence of syndactyly cases in Northern Ireland - a relatively isolated genetic population. Overall rates of incidence have increased over the past 10 years. It remains unclear if this is due to new environmental influences on the developing population or increased referral for surgical intervention over time.Levels of evidence - IV (Case Series).

An unusual incident: carbon monoxide poisoning risk in 540 homes due to faulty wood burner installations

BACKGROUND

This report describes the public health management of an unusual incident involving an increased risk of carbon monoxide (CO) exposure due to the installation of at least 541 wood burners in a local authority area in Wales.

PUBLIC HEALTH ACTIONS

An incident management team (IMT) was convened. The IMT assessed and managed the public health risk associated with the wood burners and promoted CO awareness in the local population.

OUTCOMES

At least 541 homes were found to have had a wood burner potentially incorrectly installed by a Heating Equipment Testing and Approval Scheme-registered engineer. Local residents were made aware of the dangers and provided with free CO alarms.

CONCLUSIONS

This incident highlights that even registered engineers may fail to follow guidelines. It is important to inform the public of the need to have a working CO alarm at home, as well as educating the public and professionals about the symptoms and signs of CO poisoning.

How I treat… alcohol-related liver disease

Age-standardised mortality from liver disease in the United Kingdom has risen by 400% since 1970, with three-quarters of deaths from alcohol-related liver disease (ARLD). The 2013 National Confidential Enquiry into Patient Outcome and Death report found that only 47% of the patients dying in hospital from liver disease experienced 'good' care. We discuss common complications in the care of patients with ARLD and the evidence-based best practice that can improve patient outcomes, with a focus on the initial management of patients presenting acutely to the medical take.

Control of a community outbreak of hepatitis A in an area of low endemicity, Wales, 2016

Incidence of hepatitis A in Wales is low (average of 0.48/100,000 inhabitants from 2004-2015). We describe a community outbreak of hepatitis A involving 3 schools (primary and secondary) in South Wales between March and June 2016 and reflect on the adequacy of the control measures used. Anyone in South Wales epidemiologically linked to a serological and/or RNA positive confirmed case of hepatitis A during the 15-50 d before onset of symptoms (diarrhea, vomiting, fever, nausea, AND jaundice, or jaundice-associated symptom) was defined as a case. Case identification was based on laboratory or GP suspicion notification, changing to active surveillance toward the end. As per national guidance, household contacts were identified and offered immunisation while in schools vaccination followed evidence of transmission. We went beyond guidance by vaccinating street play mates and in secondary schools. Mass vaccination uptake was calculated. There were 17 cases, mostly in children under 16 y of age. All cases had an epidemiological link to either a school or a household case (except primary) and no travel history. Street playing was the only epidemiological link between 2 cases in different schools. A total of 139 household contacts were identified. All schools, including secondary one, had a transmission event preceding mass vaccination (overall uptake 85%, reaching 1,574 individuals) and no tertiary cases emerged after the campaigns. We recommend extending guidance to include actions taken that helped curb this outbreak: 1) vaccinating in secondary school and 2) broadening the household contact definition. Based on our learning we further suggest 3) vaccinating upon identification of a single case who attended school while infectious regardless of source and 4) active case finding by serologically testing contacts.

Estimated reduction in expenditure on hospital-acquired pressure injuries after an intervention for early identification and treatment

AIM

An intervention designed to reduce numbers of hospital-acquired pressure injuries was delivered in Counties Manukau Health hospitals. An audit of a sample of patients was carried out to estimate the cost savings that would have been acquired across the district health board (DHB) due to a reduction in pressure injuries.

METHOD

The pressure injury intervention was delivered from 2011 to 2015. A monthly prospective audit of patients with stages 1, 2, 3 and 4 pressure injuries was carried out. This involved a random sample of five patients per ward in all hospitals in Counties Manukau DHB.

RESULTS

It was found that the annual estimated cost of treating pressure injuries in hospital patients was NZ$12,290,484 less in 2015 than in 2011.

CONCLUSION

Implementation of strategies for managing hospital-acquired pressure injuries can lead to potentially large financial savings for hospitals, as well as reducing the burden of managing this difficult condition for patients and staff.

Community nurse-led initiation of antiviral therapy for chronic hepatitis C in people who inject drugs does not increase uptake of or adherence to treatment

BACKGROUND

Chronic hepatitis C is common in people who inject drugs (PWID) and this population serves as a reservoir for infection. Treatment levels are low among this group, ranging from 1 to 19%. We explored whether a nurse-initiated community treatment model increased uptake of and adherence to interferon-based therapies.

METHODS

This was a cluster randomized trial of nurse-initiated versus physician-initiated antiviral therapy with pegylated interferon and ribavirin for hepatitis C virus in community clinics (trial registration: ISRCTN07774040).

RESULTS

The proportion of participants initiating treatment during follow-up was 10% with nurse-initiated (6/62) and 9% with physician-initiated (6/76) therapy. Adherence was similar in both groups, with only one patient in each arm not adhering to therapy. There were no serious adverse events, but interferon-related side effects were common. Drug and alcohol use did not change during therapy.

CONCLUSION

Despite easy access to antiviral therapy, uptake of treatment was poor, with no significant difference between the groups. Nurse-led initiation of interferon-based antiviral therapy in PWID did not lead to increased uptake of, response to or adherence with treatment. Further service improvement is unlikely to increase the proportion of PWID undergoing antiviral therapy for hepatitis C virus and early adoption of interferon-free regimens may increase the proportion initiating and completing treatment.

London Trauma Conference 2015

I1: Trauma, Pre-hospital and Cardiac Arrest Care 2015

Pascale Avery, Leopold Salm, Flora Bird

A1: Retrospective evaluation of HEMS ‘Direct to CT’ protocol

Anja Hutchinson, Ashley Matthies, Anthony Hudson, Heather Jarman

A2 Rush hour – Crush hour: temporal relationship of cyclist vs. HGV trauma admissions. A single site observational study

Maria Bergman Nilsson, Tom Konig, Nigel Tai

A3 Semiprone position endotracheal intubation during continuous cardiopulmonary resuscitation in drowned children with regurgitation: a case report and experimental manikin study

Espen Fevang, Børge Hognestad, Håkon B. Abrahamsen

A4 An audit of CO2 A-a gradient in non-trauma patients receiving pre-hospital anaesthesia

Olivia V Cheetham, Matthew JC Thomas, Kieron D Rooney

A5 Can the use of c-spine immobilisation collars be avoided in non-trauma patients presenting to the Emergency Department?

Josephine Murray, Malcolm Tunnicliff

A6 Curriculum mapping in ED point of care simulation

Joseph W Collinson, Thomas Brown, Christopher Pritchett

A7 Point of care multidisciplinary trauma team simulation & participant satisfaction in a geographically remote trauma unit in Cornwall

Christopher SA Pritchett, Mark Jadav, Gareth Meredith, Jamie Plumb, Steve Harris, Roger Langford

A8 Conservative management of head injury inpatients - the challenge of simplifying injury management in a non-neurosurgical hospital

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Roberts

A9 Improving the care of traumatic brain injury at non-neurosurgical hospitals: Introducing a head injury pathway and single place of care is associated with significant improvements in neurological observation

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Lin, N Roberts

A10 The experience of inter-disciplinary students undertaking cardiac arrest moulage training

Samuel Bulford, Silas Houghton-Budd, Sam Pearson, Megan Clear-Hill

A11 Impact brain apnoea – nine cases

David J Menzies, James P Leonard, Conor Keogh, Ray Quinn, John D Hinds

A12 Time well spent? Improving the performance improvement programme in a busy Trauma Unit

N Roberts, D Ashton-Cleary, M Jadav

A14 Clinical significant and outcome of pulmonary contusions in patients with blunt chest trauma

Ismail Mahmood, Ayman El-Menyar, Basil Younis, Ahmed Khalid, Syed Nabir, Mohamed Nadeem Ahmed, Omer Al-Yahri, Hassan Al-Thani

A15 Plastics operative workload in major trauma centres: a national prospective survey

Katie Young, Susan A. Hendrickson, Georgina Phillips, Matthew D. Gardiner, Shehan Hettiaratchy

A16 A survey to assess the accuracy of estimating height by pre-hospital clinicians: can we reliably predict those most at risk of serious injury?

Alexandra Alice Crossland, Anthony Hudson

A17 An audit of the cause, outcome and adherence to treatment Standard Operating Procedure (SOP) for all traumatic cardiac arrests at a Helicopter Emergency Medical Service over a 12-month period

Nicholas C Brassington, Anthony Hudson, Emily McWhirter

A18 Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services

Bjørn O Reid, Marius Rehn, Oddvar Uleberg, Andreas J Krüger

A19 Training in resuscitative thoracotomy: have we cracked it? A survey of higher Emergency Medicine trainees in London

Cara Jennings, Yasmin Kapadia, Duncan Bew

A20 London’s Air Ambulance (LAA): 25-years of drownings in an urban environment

Jenny Townsend, Tom P Hurst, Elizabeth A Foster

A21 Live patients in trauma simulation – more than just simulation on a shoestring?

Thomas B Brown, Joseph Collinson, Christopher Pritchett, Toby Slade

A22 Collecting core data in pre-hospital critical care using a consensus based template

Kristin Tønsager, Marius Rehn, Kjetil G.Ringdal, Andreas J.Krüger

A23 Prehospital interventions before and after implementation of a physician staffed helicopter

Rasmus Hesselfeldt, Sandra Wulffeld, Asger Sonne, Lars S. Rasmussen, Jacob Steinmetz

A24 Duration of ventilation following prehospital drug assisted intubation; a retrospective review

Thomas J Renninson, Nadine Thomson, Harvey Pynn, Timothy J Hooper

A25 Non-haemorrhagic shock in trauma: a novel guideline for management in ED

Anthony Hudson, Jacinta Dawson, Ashley Matthies

A26 Patient-tailored triage decisions by anaesthetist-staffed pre-hospital critical care teams

Morten Langfeldt Friberg, Leif Rognås

A27 Anatomical accuracy and appropriate sizing of pre-hospital thoracostomies

Jessica FG Wills, Anthony Hudson

A28 Pre-hospital management of mass casualty civilian shootings

Conor DA Turner, Marius Rehn

A30 The prevalence of alcohol-related trauma recidivism: a systematic review

James Nunn, Mete Erdogan, Robert S. Green

A31 Development of a hospital-wide program for simulation-based training in trauma care and management

Samuel Minor, Mete Erdogan, Kathy Hartlen, Robert S. Green

A32 Out of Hospital Cardiac Arrests (OOHCA); lessons from Hollywood

Ruth Bird, Rachael L. Grupping

A33 Mechanism of injury as a predictor of severity of injury in road traffic collisions: a literature review

Amelia M. Stacey, Marius Rehn, David J. Lockey

A34 Lessons to be learned from prehospital airway intervention documentation? Are airway intervention documentation templates as successful in-hospital as prehospitally?

S. Abiks, L. Cutler, K. Monaghan, A. Al-Rais, C. Hymers, R. Bloomer, Y. Kapadia

A35 Novel biomarkers in prehospital management of traumatic brain injury (the PreTBI study protocol)

Sophie-Charlott Seidenfaden, Ingunn S. Riddervold, Hans Kirkegaard, Niels Juul, Morten T. Bøtker

A36 Hospital outcomes of traumatic railway incidents: a seven-year observational retrospective study of a major trauma centre

Alice Gao, Zane Perkins; Gareth Grier, Alex Tzannes

A37 Does taking a third crew member affect the on-scene time of HEMS jobs?

Nathan Hudson-Peacock, Quentin Otto, Laurie Phillipson, Rik Thomas, Ainsley Heyworth

A38 Does pre-hospital rapid sequence induction affect on-scene time of HEMS jobs?

Quentin Otto, Nathan Hudson-Peacock, Laurie Phillipson, Ainsley Heyworth, Erica Ley

A39 Code red: shock index as a prehospital indicator of massive haemorrhage

Daniel Banner, Ainsley Heyworth, Erica Ley

A40 Air ambulance tasking: how accurate are our current methods?

Madeleine Benson, Nathan Hudson-Peacock, Tony Stone, Erica Ley, Louise Rousson, Ainsley Heyworth

A41 Modern trauma burden in a district general hospital

Beth A Lineham, Matthew J Lee, Martin Gough

A42 Establishing a legal service for major trauma patients in two UK major trauma centres

William H Seligman, Hannah E Thould, Andrew Dinsmore, Charlotte Tan, Julian Thompson, C Andy Eynon, David J Lockey

A43 Prehospital assessment and care of patients – a study of the use of guidelines when assessing head trauma

Rebecka M Rubenson Wahlin, Veronica Lindström, Sari Ponzer, Veronica Vicente

A44 An audit of pre-hospital blood pressure management resulting from head injury

Pamela Eligio, Anthony Hudson

A45 The surgical contribution of surface shading volumetric rendering techniques in rib fracture management

Robert Young, Dimitri Amiras, Ian Sinha

Acute viral bronchiolitis in South Africa: Strategies for management and prevention

Management of acute viral bronchiolitis is largely supportive. There is currently no proven effective therapy other than oxygen for hypoxic children. The evidence indicates that there is no routine benefit from inhaled, rapid short-acting bronchodilators, adrenaline or ipratropium bromide for children with acute viral bronchiolitis. Likewise, there is no demonstrated benefit from routine use of inhaled or oral corticosteroids, inhaled hypertonic saline nebulisation, montelukast or antibiotics. The last should be reserved for children with severe disease, when bacterial co-infection is suspected. Prevention of respiratory syncytial virus (RSV) disease remains a challenge. A specific RSV monoclonal antibody, palivizumab, administered as an intramuscular injection, is available for children at risk of severe bronchiolitis, including premature infants, young children with chronic lung disease, immunodeficiency, or haemodynamically significant congenital heart disease. Prophylaxis should be commenced at the start of the RSV season and given monthly during the season. The development of an RSV vaccine may offer a more effective alternative to prevent disease, for which the results of clinical trials are awaited. Education of parents or caregivers and healthcare workers about diagnostic and management strategies should include the following: bronchiolitis is caused by a virus; it is seasonal; it may start as an upper respiratory tract infection with low-grade fever; symptoms are cough and wheeze, often with fast breathing; antibiotics are generally not needed; and the condition is usually self limiting, although symptoms may occur for up to four weeks in some children.

Colonic motor abnormalities in slow transit constipation defined by high resolution, fibre-optic manometry

BACKGROUND

Slow transit constipation (STC) is associated with colonic motor abnormalities. The underlying cause(s) of the abnormalities remain poorly defined. In health, utilizing high resolution fiber-optic manometry, we have described a distal colonic propagating motor pattern with a slow wave frequency of 2-6 cycles per minute (cpm). A high calorie meal caused a rapid and significant increase in this activity, suggesting the intrinsic slow wave activity could be mediated by extrinsic neural input. Utilizing the same protocol our aim was to characterize colonic meal response STC patients.

METHODS

A fiber-optic manometry catheter (72 sensors at 1 cm intervals) was colonoscopically placed with the tip clipped at the ascending or transverse colon, in 14 patients with scintigraphically confirmed STC. Manometric recordings were taken, for 2 h pre and post a 700 kCal meal. Data were compared to 12 healthy adults.

KEY RESULTS

Prior to and/or after the meal the cyclic propagating motor pattern was identified in 13 of 14 patients. However, the meal, did not increase the cyclic motor pattern (preprandial 7.4 ± 7.6 vs postprandial 8.3 ± 4.5 per/2 h), this is in contrast to the dramatic increase observed in health (8.3 ± 13.3 vs 59.1 ± 89.0 per/2 h; p < 0.001).

CONCLUSIONS & INFERENCES

In patients with STC a meal fails to induce the normal increase in the distal colonic cyclic propagating motor patterns. We propose that these data may indicate that the normal extrinsic parasympathetic inputs to the colon are attenuated in these patients.

The psychological impact of participating in colorectal cancer screening by faecal immuno-chemical testing--the Australian experience

BACKGROUND

Occult blood-based colorectal cancer (CRC) screening may result in adverse psychological outcomes for participants. The aims of this study were to measure the psychological consequences of participating in screening at key points along the screening and diagnostic pathway, and examine variation over time within or between test outcome groups.

METHODS

A total of 301 people (positives=165, negatives=136) aged 50-76 years were surveyed via validated psychological questionnaires after result notification, post colonoscopy (positives only) and 1 year following result notification.

RESULTS

Negatives scored significantly higher in quality of life domains and lower state anxiety, anger and depression in comparison to positives both after result notification and at 1 year follow-up. Positives had significantly decreased state anxiety and depression at 1 year and improvement in HLoC power and reduced screening decision doubtfulness post colonoscopy. Positives experienced heightened CRC risk perception both after result notification and at 1 year follow-up in comparison to negatives, but reported less difficulty participating in ongoing screening.

CONCLUSIONS

In positives, increased anxiety and doubtfulness about the decision to screen declined over time. Lower CRC risk perception in negatives indicates the need for education to promote CRC screening participation.

Curated microRNAs in urine and blood fail to validate as predictive biomarkers for high-risk prostate cancer

Purpose

The purpose of this study was to determine if microRNA profiling of urine and plasma at radical prostatectomy can distinguish potentially lethal from indolent prostate cancer.

Materials and Methods

A panel of microRNAs was profiled in the plasma of 70 patients and the urine of 33 patients collected prior to radical prostatectomy. Expression of microRNAs was correlated to the clinical endpoints at a follow-up time of 3.9 years to identify microRNAs that may predict clinical response after radical prostatectomy. A machine learning approach was applied to test the predictive ability of all microRNAs profiled in urine, plasma, and a combination of both, and global performance assessed using the area under the receiver operator characteristic curve (AUC). Validation of urinary expression of miRNAs was performed on a further independent cohort of 36 patients.

Results

The best predictor in plasma using eight miRs yielded only moderate predictive performance (AUC = 0.62). The best predictor of high-risk disease was achieved using miR-16, miR-21 and miR-222 measured in urine (AUC = 0.75). This combination of three microRNAs in urine was a better predictor of high-risk disease than any individual microRNA. Using a different methodology we found that this set of miRNAs was unable to predict high-volume, high-grade disease.

Conclusions

Our initial findings suggested that plasma and urinary profiling of microRNAs at radical prostatectomy may allow prognostication of prostate cancer behaviour. However we found that the microRNA expression signature failed to validate in an independent cohort of patients using a different platform for PCR. This highlights the need for independent validation patient cohorts and suggests that urinary microRNA signatures at radical prostatectomy may not be a robust way to predict the course of clinical disease after definitive treatment for prostate cancer.

Second generation direct antivirals and the way to interferon-free regimens in chronic HCV

Treatment for those infected with chronic hepatitis C virus [HCV] has until recently been hampered by the lack of therapies other than pegylated interferon and ribavirin, which have limited efficacy and a difficult side effect profile. To address this, multiple new direct acting antiviral drugs which specifically target the non-structural proteins involved in HCV replication are in phase II/III development. This review will discuss the HCV replication cycle, mechanisms of action of the new direct acting antiviral drugs, results from published trials into their efficacy and the potential for interferon free treatment regimens in the future.

Frontier battery development for hybrid vehicles

Background

Interest in hybrid-electric vehicles (HEVs) has recently spiked, partly due to an increasingly negative view toward the U.S. foreign oil dependency and environmental concerns. Though HEVs are becoming more common, they have a significant price premium over gasoline-powered vehicles. One of the primary drivers of this “hybrid premium” is the cost of the vehicles’ batteries. This paper focuses on these batteries used in hybrid vehicles, examines the types of batteries used for transportation applications and addresses some of the technological, environmental and political drivers in battery development and the deployment of HEVs.

Methods

This paper examines the claim, often voiced by HEV proponents, that by taking into account savings on gasoline and vehicle maintenance, hybrid cars are cheaper than traditional gasoline cars. This is done by a quantitative benefit-cost analysis, in addition to qualitative benefit-cost analysis from political, technological and environmental perspectives.

Results

The quantitative benefit-cost analysis shows that, taking account of all costs for the life of the vehicle, hybrid cars are in fact more expensive than gasoline-powered vehicles; however, after five years, HEVs will break even with gasoline cars.

Conclusions

Our results show that it is likely that after 5 years, using hybrid vehicles should be cheaper in effect and yield a positive net benefit to society. There are a number of externalities that could significantly impact the total social cost of the car. These externalities can be divided into four categories: environmental, industrial, R&D and political. Despite short-term implications and hurdles, increased HEV usage forecasts a generally favorable long-term net benefit to society. Most notably, increasing HEV usage could decrease greenhouse gas emissions, while also decreasing U.S. dependence on foreign oil.