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We conducted joint analyses from five randomized clinical trials (RCTs) of online family problem-solving therapy (OFPST) for children with traumatic brain injury (TBI) to identify child and parent outcomes most sensitive to OFPST and trajectories of recovery over time.
We examined data from 359 children with complicated mild to severe TBI, aged 5–18, randomized to OFPST or a control condition. Using profile analyses, we examined group differences on parent-reported child (internalizing and externalizing behavior problems, executive function behaviors, social competence) and family outcomes (parental depression, psychological distress, family functioning, parent–child conflict).
We found a main effect for measure for both child and family outcomes [F(3, 731) = 7.35, p < .001; F(3, 532) = 4.79, p = .003, respectively], reflecting differing degrees of improvement across measures for both groups. Significant group-by-time interactions indicated that children and families in the OFPST group had fewer problems than controls at both 6 and 18 months post baseline [t(731) = −5.15, p < .001, and t(731) = −3.90, p = .002, respectively, for child outcomes; t(532) = −4.81, p < .001, and t(532) = −3.80, p < .001, respectively, for family outcomes].
The results suggest limited differences in the measures’ responsiveness to treatment while highlighting OFPST’s utility in improving both child behavior problems and parent/family functioning. Group differences were greatest at treatment completion and after extended time post treatment.
Whole grain cereal breakfast consumption has been associated with beneficial effects on glucose and insulin metabolism as well as satiety. Pearl millet is a popular ancient grain variety that can be grown in hot, dry regions. However, little is known about its health effects. This study investigated the effect of a pearl millet porridge (PMP) compared with a well-known Scottish oats porridge (SOP) on glycaemic, gastrointestinal, hormonal and appetitive responses. In a randomized, two way crossover trial, 26 healthy participants consumed two iso-energetic/volumetric PMP or SOP breakfast meals, served with a drink of water. Blood samples for glucose, insulin, GLP-1, GIP and PYY, gastric volumes and appetite ratings were collected for two hours postprandially, followed by an ad libitum meal and food intake records for the remainder of the day. The incremental area under the curve (iAUC2h) for blood glucose was not significantly different between the porridges (p ˃ 0.05). The iAUC2h gastric volume was larger for PMP compared with SOP (p = 0.045). The iAUC2h GIP concentration was significantly lower for PMP compared with SOP (p = 0.001). Other hormones and appetite responses were similar between meals. In conclusion, this study reports, for the first time, data on glycaemic and physiological responses to a pearl millet breakfast, showing that this ancient grain could represent a sustainable, alternative, with health-promoting characteristics comparable to oats. GIP is an incretin hormone linked to triacylglycerol absorption in adipose tissue, therefore the lower GIP response for PMP may be an added health benefit.
Little is known about the implications of accessing an outdoor range for broiler chicken welfare, particularly in relation to the distance ranged from the shed. Therefore, we monitored individual ranging behaviour of commercial free-range broiler chickens and identified relationships with welfare indicators. The individual ranging behaviour of 305 mixed-sex Ross 308 broiler chickens was tracked on a commercial farm from the second day of range access to slaughter age (from 16 to 42 days of age) by radio frequency identification (RFID) technology. The radio frequency identification antennas were placed at pop-holes and on the range at 2.7 and 11.2 m from the home shed to determine the total number of range visits and the distance ranged from the shed. Chickens were categorised into close-ranging (CR) or distant-ranging (DR) categories based on the frequency of visits less than or greater than 2.7 m from the home shed, respectively. Half of the tracked chickens (n=153) were weighed at 7 days of age, and from 14 days of age their body weight, foot pad dermatitis (FPD), hock burn (HB) and gait scores were assessed weekly. The remaining tracked chickens (n=152) were assessed for fear and stress responses before (12 days of age) and after range access was provided (45 days of age) by quantifying their plasma corticosterone response to capture and 12 min confinement in a transport crate followed by behavioural fear responses to a tonic immobility (TI) test. Distant-ranging chickens could be predicted based on lighter BW at 7 and 14 days of age (P=0.05), that is before range access was first provided. After range access was provided, DR chickens weighed less every week (P=0.001), had better gait scores (P=0.01) and reduced corticosterone response to handling and confinement (P<0.05) compared to CR chickens. Longer and more frequent range visits were correlated with the number of visits further from the shed (P<0.01); hence distant ranging was correlated with the amount of range access, and consequently the relationships between ranging frequency, duration and distance were strong. These relationships indicate that longer, more frequent and greater ranging from the home shed was associated with improved welfare. Further research is required to identify whether these relationships between ranging behaviour and welfare are causal.
Wave run-up phenomena driven by nonlinear wave interactions with a fixed rectangular box are investigated. Experiments are carried out in different types of uni-directional waves with normal incidence. Significant wave run-ups featuring tertiary interaction effects, similar to those reported by Molin et al. (J. Fluid Mech., vol. 528, 2005, pp. 323–354) for a fixed vertical plate, are observed in regular wave tests. Transient wave group tests are conducted for comparison, to facilitate the analysis of the tertiary interactions in irregular waves. The most striking observation is that the wave surface elevations at the centre of the front face of the fixed box can reach
the incident waves even in irregular waves, much larger than the
predicted from linear theory and observed for the transient groups. The extra amplification builds up slowly and is localized on the weather side of the box. It is believed to result from tertiary interactions between the incident and reflected wave fields upstream, which induce a local lensing effect and thus wave focusing on the weather side. These interactions, though a nonlinear process, occur at the first harmonic quantities rather than high harmonics. Supporting evidence is extracted from random wave runs using NewWave analysis, where surface amplifications and phase lag – both key characteristics of tertiary wave interactions – are identified. The identification of these tertiary interactions in irregular waves is new, and may be of practical importance.
Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
Free surface oscillations in a narrow gap between elongated parallel bodies are studied numerically. As this represents both a highly resonant system and an arrangement of relevance to offshore operations, the nature of the damping is of primary interest, and has a critical role in determining the response. Previous experimental work has suggested that the damping could be attributed to laminar boundary layers; here our numerical wave tank successfully resolves both wave and boundary layer scales to provide strong numerical evidence in support of this conclusion. The simulations follow the experiments in using wave groups so that the computation is tractable, and both linear and second harmonic excitation of the gap are demonstrated.
Freak or rogue waves are so called because of their unexpectedly large size relative to the population of smaller waves in which they occur. The 25.6 m high Draupner wave, observed in a sea state with a significant wave height of 12 m, was one of the first confirmed field measurements of a freak wave. The physical mechanisms that give rise to freak waves such as the Draupner wave are still contentious. Through physical experiments carried out in a circular wave tank, we attempt to recreate the freak wave measured at the Draupner platform and gain an understanding of the directional conditions capable of supporting such a large and steep wave. Herein, we recreate the full scaled crest amplitude and profile of the Draupner wave, including bound set-up. We find that the onset and type of wave breaking play a significant role and differ significantly for crossing and non-crossing waves. Crucially, breaking becomes less crest-amplitude limiting for sufficiently large crossing angles and involves the formation of near-vertical jets. In our experiments, we were only able to reproduce the scaled crest and total wave height of the wave measured at the Draupner platform for conditions where two wave systems cross at a large angle.
Recovery Colleges are opening internationally. The evaluation focus has been on outcomes for Recovery College students who use mental health services. However, benefits may also arise for: staff who attend or co-deliver courses; the mental health and social care service hosting the Recovery College; and wider society. A theory-based change model characterising how Recovery Colleges impact at these higher levels is needed for formal evaluation of their impact, and to inform future Recovery College development. The aim of this study was to develop a stratified theory identifying candidate mechanisms of action and outcomes (impact) for Recovery Colleges at staff, services and societal levels.
Inductive thematic analysis of 44 publications identified in a systematised review was supplemented by collaborative analysis involving a lived experience advisory panel to develop a preliminary theoretical framework. This was refined through semi-structured interviews with 33 Recovery College stakeholders (service user students, peer/non-peer trainers, managers, community partners, clinicians) in three sites in England.
Candidate mechanisms of action and outcomes were identified at staff, services and societal levels. At the staff level, experiencing new relationships may change attitudes and associated professional practice. Identified outcomes for staff included: experiencing and valuing co-production; changed perceptions of service users; and increased passion and job motivation. At the services level, Recovery Colleges often develop somewhat separately from their host system, reducing the reach of the college into the host organisation but allowing development of an alternative culture giving experiential learning opportunities to staff around co-production and the role of a peer workforce. At the societal level, partnering with community-based agencies gave other members of the public opportunities for learning alongside people with mental health problems and enabled community agencies to work with people they might not have otherwise. Recovery Colleges also gave opportunities to beneficially impact on community attitudes.
This study is the first to characterise the mechanisms of action and impact of Recovery Colleges on mental health staff, mental health and social care services, and wider society. The findings suggest that a certain distance is needed in the relationship between the Recovery College and its host organisation if a genuine cultural alternative is to be created. Different strategies are needed depending on what level of impact is intended, and this study can inform decision-making about mechanisms to prioritise. Future research into Recovery Colleges should include contextual evaluation of these higher level impacts, and investigate effectiveness and harms.
Wave loading on marine structures is the major external force to be considered in the design of such structures. The accurate prediction of the nonlinear high-order components of the wave loading has been an unresolved challenging problem. In this paper, the nonlinear harmonic components of hydrodynamic forces on a bottom-mounted vertical cylinder are investigated experimentally. A large number of experiments were conducted in the Danish Hydraulic Institute shallow water wave basin on the cylinder, both on a flat bed and a sloping bed, as part of a European collaborative research project. High-quality data sets for focused wave groups have been collected for a wide range of wave conditions. The high-order harmonic force components are separated by applying the ‘phase-inversion’ method to the measured force time histories for a crest focused wave group and the same wave group inverted. This separation method is found to work well even for locally violent nearly-breaking waves formed from bidirectional wave pairs. It is also found that the
th-harmonic force scales with the
th power of the envelope of both the linear undisturbed free-surface elevation and the linear force component in both time variation and amplitude. This allows estimation of the higher-order harmonic shapes and time histories from knowledge of the linear component alone. The experiments also show that the harmonic structure of the wave loading on the cylinder is virtually unaltered by the introduction of a sloping bed, depending only on the local wave properties at the cylinder. Furthermore, our new experimental results reveal that for certain wave cases the linear loading is actually less than 40 % of the total wave loading and the high-order harmonics contribute more than 60 % of the loading. The significance of this striking new result is that it reveals the importance of high-order nonlinear wave loading on offshore structures and means that such loading should be considered in their design.
Wave-induced roll motions of liquefied natural gas carriers with partially filled spherical tanks are of practical concern. The fluid within the tanks may be excited into resonance and thus strong sloshing motion may occur at certain frequencies. However, the nature of the coupling between internal sloshing and global roll motions, possibly via higher harmonics, is uncertain. A NewWave-type approach, based on the average shape of large waves, is used to examine nonlinearity of the roll response with and without liquid cargo motion. A phase-combination method based on weakly nonlinear theory is adopted to extract the components of the high frequency signals coupled to the low frequency signals. A significant contribution is observed from the higher harmonics of the main roll response, which are coupled to the liquid cargo sloshing motion. This coupling between higher harmonics of the main roll resonance and internal sloshing appears to be linear, despite the internal sloshing being coupled nonlinearly to the low frequency roll.
This paper revisits the problem of forces on obstacle arrays in combined waves, an in-line steady current and structural dynamic motions. The intended application is the design and re-assessment of dynamically responding offshore platforms. Planar grids of perforated plates are moved in forced motion on three scales through otherwise stationary water. A new analytical wave–current–structure blockage model is developed by building on the existing wave–current blockage model presented by Santo et al. (J. Fluid Mech., vol. 739, 2014b, pp. 143–178) using a similar set of experiments but with forced motion on two scales. The new model, which is an improved Morison relative-velocity formulation, is tested against the experimental data for a range of structural to wave oscillation frequency ratios,
, 2.5 and 3. For relatively small current speed (
) and oscillatory structural velocity (
) compared with the oscillatory wave velocity (
), the drag force time history on grids is well approximated by a summation of the wave drag and the current drag components independently, without a
cross-term, consistent with the previous model. The wave drag component contains an additional
contribution, while the current drag component may or may not contain an additional
contribution depending on
. The measured drag force is observed to be asymmetric in time due to biasing from the mean flow. This is supported by numerical simulation using a porous block as a numerical model of the grids, although the simulated force asymmetry is weaker. All these effects can be sufficiently accounted for in the analytical model. The new model is shown to fit the variation of the experimental forces and force harmonics in time well for a wide range of cases, requiring only calibration of the Morison type drag and inertia coefficients. In contrast, the industry-standard version of the Morison relative-velocity formulation cannot reproduce the variation of the measured force in time, so present practice should be regarded as inadequate for combined steady, low frequency and high frequency motion acting on obstacle arrays.
For sufficiently directionally spread surface gravity wave groups, the set-down of the wave-averaged free surface, first described by Longuet-Higgins and Stewart (J. Fluid Mech. vol. 13, 1962, pp. 481–504), can turn into a set-up. Using a multiple-scale expansion for two crossing wave groups, we examine the structure and magnitude of this wave-averaged set-up, which is part of a crossing wave pattern that behaves as a modulated partial standing wave: in space, it consists of a rapidly varying standing-wave pattern slowly modulated by the product of the envelopes of the two groups; in time, it grows and decays on the slow time scale associated with the translation of the groups. Whether this crossing wave pattern actually enhances the surface elevation at the point of focus depends on the phases of the linear wave groups, unlike the set-down, which is always negative and inherits the spatial structure of the underlying envelope(s). We present detailed laboratory measurements of the wave-averaged free surface, examining both single wave groups, varying the degree of spreading from small to very large, and the interaction between two wave groups, varying both the degree of spreading and the crossing angle between the groups. In both cases, we find good agreement between the experiments, our simple expressions for the set-down and set-up, and existing second-order theory based on the component-by-component interaction of individual waves with different frequencies and directions. We predict and observe a set-up for wave groups with a Gaussian angular amplitude distribution with standard deviations of above
for energy spectra), which is relatively large for realistic sea states, and for crossing sea states with angles of separation of
and above, which are known to occur in the ocean.
The Taipan galaxy survey (hereafter simply ‘Taipan’) is a multi-object spectroscopic survey starting in 2017 that will cover 2π steradians over the southern sky (δ ≲ 10°, |b| ≳ 10°), and obtain optical spectra for about two million galaxies out to z < 0.4. Taipan will use the newly refurbished 1.2-m UK Schmidt Telescope at Siding Spring Observatory with the new TAIPAN instrument, which includes an innovative ‘Starbugs’ positioning system capable of rapidly and simultaneously deploying up to 150 spectroscopic fibres (and up to 300 with a proposed upgrade) over the 6° diameter focal plane, and a purpose-built spectrograph operating in the range from 370 to 870 nm with resolving power R ≳ 2000. The main scientific goals of Taipan are (i) to measure the distance scale of the Universe (primarily governed by the local expansion rate, H0) to 1% precision, and the growth rate of structure to 5%; (ii) to make the most extensive map yet constructed of the total mass distribution and motions in the local Universe, using peculiar velocities based on improved Fundamental Plane distances, which will enable sensitive tests of gravitational physics; and (iii) to deliver a legacy sample of low-redshift galaxies as a unique laboratory for studying galaxy evolution as a function of dark matter halo and stellar mass and environment. The final survey, which will be completed within 5 yrs, will consist of a complete magnitude-limited sample (i ⩽ 17) of about 1.2 × 106 galaxies supplemented by an extension to higher redshifts and fainter magnitudes (i ⩽ 18.1) of a luminous red galaxy sample of about 0.8 × 106 galaxies. Observations and data processing will be carried out remotely and in a fully automated way, using a purpose-built automated ‘virtual observer’ software and an automated data reduction pipeline. The Taipan survey is deliberately designed to maximise its legacy value by complementing and enhancing current and planned surveys of the southern sky at wavelengths from the optical to the radio; it will become the primary redshift and optical spectroscopic reference catalogue for the local extragalactic Universe in the southern sky for the coming decade.
The tortuous journey from theoretical suspicions to direct detection of gravitational waves took a hundred years and followed a crooked course. The field equations of general relativity evidently have wave-like solutions, but physical reality of these implied waves was doubted by many — including Einstein himself — for nearly fifty years. The question of physical reality was settled theoretically by the late 1950s, but for several more decades serious questions remained about what types of astrophysical systems might generate gravitational waves, and with what energies. The discovery of binary pulsar PSR B1913+16 led to dedicated development of much more accurate pulsar timing techniques, and results of these experiments motivated further theoretical work to clear up the quantitative questions about energy generation. By the late 1980s the generation of gravitational waves by the Hulse-Taylor binary pulsar was firmly established to be in quantitative agreement with general relativity. This experimental proof was almost surely a prerequisite for the funding of LIGO, the Laser Interferometer Gravitational-Wave Observatory, in 1992, which after nearly another quarter century achieved the first direct detection of gravitational waves.
Precision agriculture (PA) may improve the sustainability of Chinese agriculture. Ten experts were interviewed and 34 farm workers surveyed regarding their understanding, attitudes and perceptions towards PA. PA technologies were considered inaccessible, unsuitable and unnecessary for smaller farms. High cost, lack of perceived benefits, and skills and capability required to adopt PA represented barriers to adoption. Financial incentives/subsidies, the need for tangible benefits and tailored solutions to be demonstrated to farmers, and agronomic and peer support were desired. Future research should further explore PA with Chinese stakeholders and end-users in China, to inform future socio-technological developments.
Introduction: Point of care ultrasonography (PoCUS) is an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown rule out certain shock etiologies, and improve diagnostic certainty, however evidence on benefit in the management of hypotensive patients is limited. We report the findings from our international multicenter RCT assessing the impact of a PoCUS protocol on diagnostic accuracy, as well as other key outcomes including mortality, which are reported elsewhere. Methods: Recruitment occurred at 4 North American and 3 Southern African sites. Screening at triage identified patients (SBP<100 mmHg or shock index >1) who were randomized to either PoCUS or control groups. Scans were performed by PoCUS-trained physicians. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. Final chart review was blinded to initial impressions and PoCUS findings. Categorical data was analyzed using Fishers two-tailed test. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. The perceived shock category changed more frequently in the PoCUS group 20/127 (15.7%) vs. control 7/125 (5.6%); RR 2.81 (95% CI 1.23 to 6.42; p=0.0134). There was no significant difference in change of diagnostic impression between groups PoCUS 39/123 (31.7%) vs control 34/124 (27.4%); RR 1.16 (95% CI 0.786 to 1.70; p=0.4879). There was no significant difference in the rate of correct category of shock between PoCUS (118/127; 93%) and control (113/122; 93%); RR 1.00 (95% CI 0.936 to 1.08; p=1.00), or for correct diagnosis; PoCUS 90/127 (70%) vs control 86/122 (70%); RR 0.987 (95% CI 0.671 to 1.45; p=1.00). Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We found that the use of PoCUS did change physicians’ perceived shock category. PoCUS did not improve diagnostic accuracy for category of shock or diagnosis.
Introduction: Point of care ultrasound (PoCUS) is an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). While PoCUS protocols have been shown to improve early diagnostic accuracy, there is little published evidence for any mortality benefit. We report the findings from our international multicenter randomized controlled trial, assessing the impact of a PoCUS protocol on survival and key clinical outcomes. Methods: Recruitment occurred at 7 centres in North America (4) and South Africa (3). Scans were performed by PoCUS-trained physicians. Screening at triage identified patients (SBP<100 or shock index>1), randomized to PoCUS or control (standard care and no PoCUS) groups. Demographics, clinical details and study findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. The primary outcome measure was 30-day/discharge mortality. Secondary outcome measures included diagnostic accuracy, changes in vital signs, acid-base status, and length of stay. Categorical data was analyzed using Fishers test, and continuous data by Student T test and multi-level log-regression testing. (GraphPad/SPSS) Final chart review was blinded to initial impressions and PoCUS findings. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no difference between groups for the primary outcome of mortality; PoCUS 32/129 (24.8%; 95% CI 14.3-35.3%) vs. Control 32/129 (24.8%; 95% CI 14.3-35.3%); RR 1.00 (95% CI 0.869 to 1.15; p=1.00). There were no differences in the secondary outcomes; ICU and total length of stay. Our sample size has a power of 0.80 (α:0.05) for a moderate effect size. Other secondary outcomes are reported separately. Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We did not find any mortality or length of stay benefits with the use of a PoCUS protocol, though a larger study is required to confirm these findings. While PoCUS may have diagnostic benefits, these may not translate into a survival benefit effect.
Introduction: Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for emergency department (ED) patients with undifferentiated non-traumatic hypotension. While PoCUS has been shown to improve early diagnosis, there is a minimal evidence for any outcome benefit. We completed an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key resuscitation markers in this group. We report diagnostic impact and mortality elsewhere. Methods: The SHoC-ED1 study compared the addition of PoCUS to standard care within the first hour in the treatment of adult patients presenting with undifferentiated hypotension (SBP<100 mmHg or a Shock Index >1.0) with a control group that did not receive PoCUS. Scans were performed by PoCUS-trained physicians. 4 North American, and 3 South African sites participated in the study. Resuscitation outcomes analyzed included volume of fluid administered in the ED, changes in shock index (SI), modified early warning score (MEWS), venous acid-base balance, and lactate, at one and four hours. Comparisons utilized a T-test as well as stratified binomial log-regression to assess for any significant improvement in resuscitation amount the outcomes. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no significant difference in mean total volume of fluid received between the control (1658 ml; 95%CI 1365-1950) and PoCUS groups (1609 ml; 1385-1832; p=0.79). Significant improvements were seen in SI, MEWS, lactate and bicarbonate with resuscitation in both the PoCUS and control groups, however there was no difference between groups. Conclusion: SHOC-ED1 is the first RCT to compare PoCUS to standard of care in hypotensive ED patients. No significant difference in fluid used, or markers of resuscitation was found when comparing the use of a PoCUS protocol to that of standard of care in the resuscitation of patients with undifferentiated hypotension.
Introduction: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). Current established protocols (e.g. RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. Recently the SHoC Protocol was published, recommending 3 core scans; cardiac, lung, and IVC; plus other scans when indicated clinically. We report the abnormal ultrasound findings from our international multicenter randomized controlled trial, to assess if the recommended 3 core SHoC protocol scans were chosen appropriately for this population. Methods: Recruitment occurred at seven centres in North America (4) and South Africa (3). Screening at triage identified patients (SBP<100 or shock index>1) who were randomized to PoCUS or control (standard care with no PoCUS) groups. All scans were performed by PoCUS-trained physicians within one hour of arrival in the ED. Demographics, clinical details and study findings were collected prospectively. A threshold incidence for positive findings of 10% was established as significant for the purposes of assessing the appropriateness of the core recommendations. Results: 138 patients had a PoCUS screen completed. All patients had cardiac, lung, IVC, aorta, abdominal, and pelvic scans. Reported abnormal findings included hyperdynamic LV function (59; 43%); small collapsing IVC (46; 33%); pericardial effusion (24; 17%); pleural fluid (19; 14%); hypodynamic LV function (15; 11%); large poorly collapsing IVC (13; 9%); peritoneal fluid (13; 9%); and aortic aneurysm (5; 4%). Conclusion: The 3 core SHoC Protocol recommendations included appropriate scans to detect all pathologies recorded at a rate of greater than 10 percent. The 3 most frequent findings were cardiac and IVC abnormalities, followed by lung. It is noted that peritoneal fluid was seen at a rate of 9%. Aortic aneurysms were rare. This data from the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients, supports the use of the prioritized SHoC protocol, though a larger study is required to confirm these findings.