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Introduction: This study aims to evaluate the accuracy of the Échelle québécoise de triage préhospitalier en traumatologie (EQTPT) to identify patients who will need urgent and specialized trauma care in the La Capitale-Nationale region, province of Quebec. Methods: A detailed review of prehospital and in-hospital medical charts was conducted for a sample of patients transported following a trauma by ambulance to one of the five CHU de Quebec's emergency departments (ED) between November 2016 and March 2017. Data related to the trauma mechanism, population, injuries sustained, diagnosis, intervention and patient outcomes were extracted. The study primary outcome was the use of at least one urgent and specialized trauma care defined as: admission to the intensive care unit (ICU), urgent surgery within less than 24 hours after arrival (excluding orthopedic surgery for one limb only), intubation in ED, angioembolization within 24 hours after ED arrival, activation of a massive transfusion protocol in the ED. Also, patients who died secondary to their trauma were also considered as requiring urgent care. Results: 902 patients were included. The mean age (SD) was 59 (28.5) years old, 494 (54.8%) were female. The main trauma mechanisms were falls (592 (65.6%)) followed by motor vehicle accident (201 (22%)). 367 (40.7%) patients were transported directly to the tertiary trauma centre from the field. 231 (25.6%) patients had at least one criteria included in the steps 1, 2 or 3 of the EQTPT. Subsequently, most patients (649 (71.9%) were discharged home from the ED while 177 (19.6%) patients were admitted to the hospital. 82 (9.1%) patients required urgent and specialized trauma care. Of these 82 patients, 27 patients (32%) were identified in step 1 of the protocol, 12 patients (14.6%) in step 2, 5 patients (6.1%) in step 3, 13 patients (15.9%) in step 4 and 2 patients (2.4%) in step 5 while 23 (28.0%) patients were not identified by any steps of the EQTPT protocol. Therefore, 44 (53.6%) of the patients requiring urgent and specialized trauma care were identified by the criteria proposed in the steps 1, 2 or 3. Conclusion: In this retrospective cohort study, the EQTPT was insensitive to identify trauma patients who will need prompt and complex trauma management. Studies are required to determine the factors that could help improve its accuracy.
In the NHS Forth Valley (Central Scotland) substance misuse service (SMS), there is an arrangement whereby the details of individuals administered naloxone for overdose via the ambulance service are passed to the SMS. Each patient has an allocated keyworker (nurse). It is accepted that near fatal overdoses (NFOs) are possible precursors to fatal overdose and drug-related deaths.
– if the information is being disseminated appropriately;
– service response and follow-up for individuals;
– patterns which might influence prescribing practice.
A list of NFOs of known patients for the previous two years was acquired from the ambulance service. There was a retrospective review of the SMS prescribing database and clinical casenotes.
– 81% male;
– 53% aged < 40;
– 14% of NFO's involved those in titration phase;
– 86% were prescribed methadone. Methadone average dose 57 mg (20–80 mg) and 54% were prescribed > 60 mg/day.
Receipts of information:
– sixty-one percent of keyworkers were notified.
– in most cases when the keyworkers was informed, there was prompt action to contact and review patients (0–21 days). However, only 21% had a timely review (within 1 month) by a doctor following NFO.
There needs to be an improvement in the dissemination of information between the ambulance service, administrative staff and keyworkers. Most NFO patients were prescribed > 60 mg of methadone. There needs to better identification of “harm-reduction” prescribing whereby methadone doses should be reduced at times of ongoing drug use. Fourteen percent of NFO's involved those in titration phase (twice weekly reviews) which provides an opportunity to screen and intervene for potential NFOs.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Evidence suggests that dietary intake of UK children is currently suboptimal. It is therefore imperative to identify effective and sustainable methods of improving dietary habits and knowledge in this population, whilst also promoting the value of healthiness of food products beyond price. Schools are ideally placed to influence children's knowledge and health, and Project Daire, in partnership with schools, food industry partners and stakeholders, aims to improve children's knowledge of, and interest in, food to improve health, wellbeing and educational attainment.
Daire is a randomised-controlled, factorial design trial evaluating two interventions. In total, n = 880 Key Stage (KS) 1 and 2 pupils have been recruited from 18 primary schools in the North West of Northern Ireland and will be randomised to one of four 6-month intervention arms: i) ‘Engage’, ii) ‘Nourish’, iii) ‘Engage’ and ‘Nourish’ and iv) Delayed. ‘Engage’ is an age-appropriate, cross-curricular educational intervention on food, agriculture, science and careers linked to the current curriculum. ‘Nourish’ is an intervention aiming to alter schools’ food environments and increase exposure to local foods. Study outcomes include food knowledge, attitudes, trust, diet, behaviour, health and wellbeing and will be collected at baseline and six months. Qualitative data on teacher/pupil opinions will also be collected. The intervention phase is currently ongoing. We present baseline results from our involvement and food attitudes measure from all participating schools. Results were compared by Key Stage and sex using Pearson Chi-Squared test.
Baseline results from our food involvement and attitudes measure are presented for n = 880 KS1 (n = 454) and KS2 (n = 426) pupils. KS1 pupils were more likely to always or sometimes help with food shopping (89.0%) whilst KS2 pupils were more likely to always or sometimes help with food preparation (69.0%). A higher proportion of KS1 pupils reported liking to try new foods (66.1%) and that it was important that food looked (64.5%), tasted (71.1%) and smelled good (60.6%) compared with KS2 children (P < 0.01). Girls were more likely to always or sometimes help with food shopping (96.2%) and preparation (73%) when compared with boys; whilst a higher proportion of girls reported they liked to try new foods (48.2%) and that it was important that food looked (68%) smelled (50.5%) and tasted (71.8%) good compared with boys (P < 0.01).
Results suggest that involvement in food preparation and shopping, willingness to try new foods and attitudes towards food presentation varied by KS and sex in this cohort.
The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
The Wisconsin Twin Project comprises multiple longitudinal studies that span infancy to early adulthood. We summarize recent papers that show how twin designs with deep phenotyping, including biological measures, can inform questions about phenotypic structure, etiology, comorbidity, heterogeneity, and gene–environment interplay of temperamental constructs and mental and physical health conditions of children and adolescents. The general framework for investigations begins with rich characterization of early temperament and follows with study of experiences and exposures across childhood and adolescence. Many studies incorporate neuroimaging and hormone assays.
We read with interest the recent editorial, “The Hennepin Ketamine Study,” by Dr. Samuel Stratton commenting on the research ethics, methodology, and the current public controversy surrounding this study.1 As researchers and investigators of this study, we strongly agree that prospective clinical research in the prehospital environment is necessary to advance the science of Emergency Medical Services (EMS) and emergency medicine. We also agree that accomplishing this is challenging as the prehospital environment often encounters patient populations who cannot provide meaningful informed consent due to their emergent conditions. To ensure that fellow emergency medicine researchers understand the facts of our work so they may plan future studies, and to address some of the questions and concerns in Dr. Stratton’s editorial, the lay press, and in social media,2 we would like to call attention to some inaccuracies in Dr. Stratton’s editorial, and to the lay media stories on which it appears to be based.
Ho JD, Cole JB, Klein LR, Olives TD, Driver BE, Moore JC, Nystrom PC, Arens AM, Simpson NS, Hick JL, Chavez RA, Lynch WL, Miner JR. The Hennepin Ketamine Study investigators’ reply. Prehosp Disaster Med. 2019;34(2):111–113
Identifying genetic relationships between complex traits in emerging adulthood can provide useful etiological insights into risk for psychopathology. College-age individuals are under-represented in genomic analyses thus far, and the majority of work has focused on the clinical disorder or cognitive abilities rather than normal-range behavioral outcomes.
This study examined a sample of emerging adults 18–22 years of age (N = 5947) to construct an atlas of polygenic risk for 33 traits predicting relevant phenotypic outcomes. Twenty-eight hypotheses were tested based on the previous literature on samples of European ancestry, and the availability of rich assessment data allowed for polygenic predictions across 55 psychological and medical phenotypes.
Polygenic risk for schizophrenia (SZ) in emerging adults predicted anxiety, depression, nicotine use, trauma, and family history of psychological disorders. Polygenic risk for neuroticism predicted anxiety, depression, phobia, panic, neuroticism, and was correlated with polygenic risk for cardiovascular disease.
These results demonstrate the extensive impact of genetic risk for SZ, neuroticism, and major depression on a range of health outcomes in early adulthood. Minimal cross-ancestry replication of these phenomic patterns of polygenic influence underscores the need for more genome-wide association studies of non-European populations.
Introduction: Medical transport services are essential in the regionalization of trauma care. Given the limited number of designated trauma centers, transport times can be prolonged, with patient care managed by paramedics for the duration of their transfer. Pain management is a paramount component, but oligoanalgesia can occur. The primary objective of this study was to evaluate pain management practices during transport of trauma patients by air. Methods: We conducted a 12-month review of ORNGE electronic paramedic records. ORNGE is the exclusive provider of air and land transport in Ontario, Canada. Cases from 1 January 2015 to 31 December 2015 were screened. Patients were identified according to inclusion (≥18 years old requiring transportation to designated trauma center) and exclusion criteria (GCS<14; intubation; accompanied by a nurse or physician). Information was collected in a standardized, piloted data form used by a single trained data extractor. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment according to changes on a 10-point numeric rating scale (NRS), patterns of analgesia administration, and analgesia-related adverse events (AEs). Results were reported as mean, (standard deviation), [range], or percentage. Results: Of 600 potential records, 372 patients met our inclusion criteria with the following characteristics: age 47.0 [19-92] years; 70.4% male; 97.0% blunt injury. Duration of transport was 82.4 (46.3) minutes. Pain was initially assessed in 90.0% of patients. Overall, NRS at baseline was 4.9 (2.8). Of the 62.4% who received analgesia, NRS at baseline was 5.9 (2.5). Fentanyl was most commonly administered (78.5%) at 44.3 [25-60] mcg. NRS after the first dose of analgesia decreased by 1.1 (1.6) points. A total of 73.7% of patients received further analgesia, equal to 2.4 [1-19] additional doses. While 23.4% of patients had no change in NRS after the first dose of analgesia, subsequent doses resulted in no change in NRS in over 65% [65.4-71.3] of patients. A total of 43 AEs (6.7%) were recorded after 638 doses of analgesia, and the most common AE was nausea (39.5%). Conclusion: The majority of patients were assessed for pain. Although the first analgesia administration had minimal effect on NRS, subsequent doses appeared to have even less of an impact. AEs were infrequent.
Introduction: While methods have been developed to assess pain and provide analgesia to hospitalized intubated patients, little is known about current EMS practices in providing similar care during air and land medical transports. Therefore, we sought to determine if opioid analgesia is provided to intubated patients during transportation in out-of-hospital setting. Methods: We conducted a health record review examining electronic records of intubated patients transported by Ornge in 2015. Ornge is the exclusive provider of air and land transport of critically ill patients in Ontario, Canada with over 18,000 transports per year. We identified cases using Ornge’s database and selected intubated patients meeting inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was frequency of administration and dose adequacy of an opioid analgesic. Secondary outcomes included: choice of analgesics used (fentanyl, hydromorphone or morphine), adverse events, and impact of age, sex, or reason for transfer on pain management. We present descriptive statistics. Results: Our strategy identified 500 potential cases, of which 448 met our inclusion criteria. Among those 448 patients, 154 (34.4%) were females, 328 (73.4%) received analgesia and 211 (64.3%) received more than one dose during transport (median frequency of 2 doses, IQR=1 to 3). The average transport time was 148 minutes and repeated dosing (>1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.6%) and most commonly used dose was 50 micrograms (51.8%). Adverse events occurred in 8 (2.5%) patients with 5 patients having new hypotension (MAP <65 mm Hg). There was no significant difference in administration of analgesia based on patient’s age or sex (68.8% of females and 75.3% of male patients received analgesia). Interestingly, 30.8% of patients repatriated to originating-hospital received analgesia compared to 72.3% of patients receiving analgesia for all other reasons for transfers. Conclusion: More than 73% of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex or reason for transfer other than home repatriation.
Introduction: Redirecting low acuity patients from emergency departments to primary care walk-in clinics has been identified as a priority by many health authorities. Promoting family physicians for the management of ambulatory patients with urgent health concerns reflects the assumption that primary care facilities can offer high-quality and more affordable ambulatory emergency care. However, no performance assessment framework has been developed for ambulatory emergency care and consequently, quality of care provided in these alternate settings has never been formally compared. Primary objective: To identify structure, process and outcome indicators for ambulatory emergency care. Methods: We will identify and develop quality indicators (QIs) for ambulatory emergency care using a RAND/UCLA Appropriateness Method (RAM) composed of three different steps. First, we will perform a scoping literature review to inventory 1) all previously recommended QIs assessing care provided to ambulatory emergency patients in the ED or the primary care settings; 2) all conditions evaluated with the retrieved QIs; and 3) all outcomes measured by the same QIs. Second, a steering committee composed of the research team and of international experts in performance assessment in emergency and primary care will be presented with the lists of QI-related conditions and outcomes. They will be asked to identify potential outcome indicators for ambulatory emergency care by generating any relevant combinations of one condition and one outcome (e.g. acute asthma exacerbation/re-consultation). Committee members will be given the latitude to use and pair any conditions or outcomes not included in the lists as long as they think the resulting indicators are compatible with the study objectives. Using a structured nominal group approach, they will combine their suggestions and refine the list of potential QIs. This list of potential outcome indicators composed of pairs “condition/outcome” will be merged with the list of already published QIs identified during the literature review. Third, as per the RAM standards, we will assemble an international multidisciplinary panel (n=20) of patients, emergency and primary care providers, researchers and decision makers, after recommendations from international emergency and primary care associations, and from the Canadian Strategy for Patient-Oriented Research (SPOR) Support Units. Through iterative rounds of ratings using both web-based survey tools and videoconferencing, panelists will independently assess all candidate QIs. They will be asked to rate on a nine-level scale to what extent each QI is a relevant and useful measure of ambulatory emergency care quality. From one round to the next, QIs with a median panelist rating score of one to three will be excluded. Those with a median score of seven or more will be automatically included in the final list. QIs with median score of four to six will be retained for future deliberations among the panelists. Rounds of ratings will be conducted until all QIs are classified. Impact: The QIs identified will be used to develop a performance assessment framework for ambulatory emergency care. This will represent an essential step toward testing the assumption that EDs and primary care walk-in clinics provide equivalent care quality to low acuity patients.
In the article above there is a spelling mistake in the Figure 3 legend. Largge should be Large. The correct Figure 3 legend is shown below:-
Figure 3 Biomass values of herbivorous fish functional groups – browsers, grazers and detritivores, and scrapers and small excavators – for each island. Large excavators and bioeroders were not observed, and thus are not included in the graph.
Page 5, right column in the ‘Ecological perspective and management implications section’, in the second paragraph the third sentence should read . . .One potential management tool that considers these needs and limitations is the installation of composting toilets, after due consideration of local cultural sensitivities. . .
Small-island coral reef ecosystems are usually closely coupled to the activities of human inhabitants. Ahus Island (Papua New Guinea) is an isolated Pacific island with a rapidly growing population, heavy reliance on marine resources and limited infrastructure. We hypothesized that untreated sewage was driving distinct benthic assemblages around Ahus and neighbouring uninhabited Onetah. At sites with varying proximities to beach toilets, fore-reef herbivorous fish biomass and benthic composition were measured alongside reef-flat sedimentary oxygen consumption (SOC); a high SOC rate reflects high organic input into coastal waters, thus serving as a potential indicator of sewage input. Fish biomass was low (17.1–20.1 g m–2), but consistent between sites. However, cyanobacteria dominated the fore-reef closest to toilets (62 ± 3%) with highest reef-flat SOC, whereas hard corals dominated furthest away (63 ± 1%), where SOC was lowest. To our knowledge, this is the first study that used SOC to detect local differences in sewage pollution. The results indicate that whilst corals can maintain their dominance on overfished reefs, additional sewage stress may drive pronounced benthic shifts, highlighting the urgency to improve small-island waste management.