Recent Submissions

  • Point-of-care ultrasound is a useful adjunct tool to a clinician's assessment in the evaluation of severe hyponatraemia

    Al Alaisi, Salam; Coats, Timothy; Levy, Miles; Melson, Eka; Rahman, Faizanur; Rahman, Latif; Reddy, Narendra; Sardar, Muhammad; Shafiq, Shahriar (2024-01-16)
    Introduction: Hyponatraemia is the most common electrolyte disorder in inpatients resulting mainly from an imbalance in water homeostasis. Intravascular fluid status assessment is pivotal but is often challenging given multimorbidity, polypharmacy and diuretics use. We evaluated the utility of point-of-care ultrasound (POCUS) as an adjunct tool to standard practice for fluid assessment in severe hyponatraemia patients. Methods: Patients presenting with severe hyponatremia (Serum Sodium [Na] < 120 mmol/L; Normal range: 135-145 mol/L), managed by standard care were included. Hyponatraemia biochemistry work-up and POCUS examination were undertaken. Both clinician and POCUS independently assigned one of the three fluid status groups of hypovolaemia, hypervolaemia or euvolaemia. The final diagnosis of three fluid status groups at admission was made at the time of discharge by retrospective case review. Clinician's (standard of care) and POCUS fluid assessments were compared to that of the final diagnosis at the time of discharge. Results: n = 19 patients were included. Median Na on admission was 113 mmol/L (109-116), improved to 129 ± 3 mmol/L on discharge. POCUS showed the higher degree of agreement with the final diagnosis (84%; n = 16/19), followed by the clinician (63%; n = 12/19). A trend towards higher accuracy of POCUS compared to clinician assessment of fluid status was noted (84% vs. 63%, p = 0.1611). Biochemistry was unreliable in 58% (n = 11/19) likely due to renal failure, polypharmacy or diuretic use. Inappropriate emergency fluid management was undertaken in 37% (n = 7/19) of cases based on initial clinician assessment. Thirst symptom correlated to hypovolaemia in 80% (4/5) cases. Conclusion: As subjective clinical and biochemistry assessments of fluid status are often unreliable due to co-morbidities and concurrent use of medications, POCUS can be a rapid objective diagnostic tool to assess fluid status in patients with severe hyponatraemia, to guide accurate emergency fluid management.
  • Prevalence of invasive bacterial infection in febrile infants ≤90 days with a COVID-19 positive test: a systematic review and meta-analysis

    Roland, Damian (2023-12-06)
    Background: Febrile infants with an infection by influenza or enterovirus are at low risk of invasive bacterial infection (IBI). Objective: To determine the prevalence of IBI among febrile infants ≤90 days old with a positive COVID-19 test. Methods: MEDLINE, Embase, Cochrane Central Register databases, Web of Science, ClinicalTrials.gov and grey literature were searched for articles published from February 2020 to May 2023. Inclusion criteria: researches reporting on infants ≤90 days of age with fever and a positive test for SARS-CoV-2 (antigen test/PCR). Case reports with <3 patients, articles written in a language other than English, French or Spanish, editorials and other narrative studies were excluded. Preferred Reposting Items for Systematic Reviews and Meta-analysis guidelines were followed, and the National Institutes of Health Quality Assessment Tool was used to assess study quality. The main outcome was the prevalence of IBI (a pathogen bacterium identified in blood and/or cerebrospinal fluid (CSF)). Forest plots of prevalence estimates were constructed for each study. Heterogeneity was assessed and data were pooled by meta-analysis using a random effects model. A fixed continuity correction of 0.01 was added when a study had zero events. Results: From the 1023 studies and 3 databases provided by the literature search, 33 were included in the meta-analysis, reporting 3943 febrile infants with a COVID-19 positive test and blood or CSF culture obtained. The pooled prevalence of IBI was 0.14% (95% CI, 0.02% to 0.27%). By age, the prevalence of IBI was 0.56% (95% CI, 0.0% to 1.27%) in those 0-21 days old, 0.53% (95% CI, 0.0% to 1.22%) in those 22-28 days old and 0.11% (95% CI, 0.0% to 0.24%) in those 29-60 days old. Conclusion: COVID-19-positive febrile infants ≤90 days old are at low risk of IBI, especially infants >28 days old, suggesting this subgroup of patients can be managed without blood tests. Prospero registration number: CRD42022356507.
  • The effect of relative hypotension on 30-day mortality in older people receiving emergency care

    Beishon, Lucy; Coats, Timothy; Van Oppen, James (2023-11-08)
    Research has observed increased mortality among older people attending the emergency department (ED) who had systolic pressure > 7 mmHg lower than baseline primary care values. This study aimed to (1) assess feasibility of identifying this 'relative hypotension' using readily available ED data, (2) externally validate the 7 mmHg threshold, and (3) refine a threshold for clinically important relative hypotension. A single-centre retrospective cohort study linked year 2019 data for ED attendances by people aged over 64 to hospital discharge vital signs within the previous 18 months. Frailty and comorbidity scores were calculated. Previous discharge ('baseline') vital signs were subtracted from initial ED values to give individuals' relative change. Cox regression analysis compared relative hypotension > 7 mmHg with mean time to mortality censored at 30 days. The relative hypotension threshold was refined using a fully adjusted risk tool formed of logistic regression models. Receiver operating characteristics were compared to NEWS2 models with and without incorporation of relative systolic. 5136 (16%) of 32,548 ED attendances were linkable with recent discharge vital signs. Relative hypotension > 7 mmHg was associated with increased 30-day mortality (HR 1.98; 95% CI 1.66-2.35). The adjusted risk tool (AUC: 0.69; sensitivity: 0.61; specificity: 0.68) estimated each 1 mmHg relative hypotension to increase 30-day mortality by 2% (OR 1.02; 95% CI 1.02-1.02). 30-day mortality prediction was marginally better with NEWS2 (AUC: 0.73; sensitivity: 0.59; specificity: 0.78) and NEWS2 + relative systolic (AUC: 0.74; sensitivity: 0.63; specificity: 0.75). Comparison of ED vital signs with recent discharge observations was feasible for 16% individuals. The association of relative hypotension > 7 mmHg with 30-day mortality was externally validated. Indeed, any relative hypotension appeared to increase risk, but model characteristics were poor. These findings are limited to the context of older people with recent hospital admissions.
  • Core outcomes and factors influencing the experience of care for children with severe acute exacerbations of asthma: a qualitative study

    Roland, Damian (2023-11)
    Objective: To identify the outcomes considered important, and factors influencing the patient experience, for parents and caregivers of children presenting to hospital with a severe acute exacerbation of asthma. This work contributes to the outcome-identification process in developing a core outcome set (COS) for future clinical trials in children with severe acute asthma. Design: A qualitative study involving semistructured interviews with parents and caregivers of children who presented to hospital with a severe acute exacerbation of asthma. Setting: Hospitals in 12 countries associated with the global Pediatric Emergency Research Networks, including high-income and middle-income countries. Interviews were conducted face-to-face, by teleconference/video-call, or by phone. Findings: Overall, there were 54 interviews with parents and caregivers; 2 interviews also involved the child. Hospital length of stay, intensive care unit or high-dependency unit (HDU) admission, and treatment costs were highlighted as important outcomes influencing the patient and family experience. Other potential clinical trial outcomes included work of breathing, speed of recovery and side effects. In addition, the patient and family experience was impacted by decision-making leading up to seeking hospital care, transit to hospital, waiting times and the use of intravenous treatment. Satisfaction of care was related to communication with clinicians and frequent reassessment. Conclusions: This study provides insight into the outcomes that parents and caregivers believe to be the most important to be considered in the process of developing a COS for the treatment of acute severe exacerbations of asthma.
  • Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment

    Banerjee, Jaydip (2023-11-16)
    Purpose: The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage. Methods: Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707). Results: We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (ϰ = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (ϰ = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (ϰ = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage. Conclusion: We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.
  • Sustaining interventions in care homes initiated by quality improvement projects: a qualitative study

    Banerjee, Jaydip (2023-11)
    Introduction: Inadequate and varied quality of care in care homes has led to a proliferation of quality improvement (QI) projects. This study examined the sustainability of interventions initiated by such projects. Method: This qualitative study explored the sustainability of seven interventions initiated by three QI projects between 2016 and 2018 in UK care homes and explored the perceived influences to the sustainability of interventions. QI projects were followed up in 2019. Staff leading QI projects (n=9) and care home (n=21, from 13 care homes) and healthcare (n=2) staff took part in semi-structured interviews. Interventions were classified as sustained if the intervention was continued at the point of the study. Thematic analysis of interview data was performed, drawing on the Consolidated Framework for Sustainability (CFS), a 40-construct model of sustainability of interventions. Results: Three interventions were sustained and four interventions were not. Seven themes described perceptions around what influenced sustainability: monitoring outcomes and regular check-in; access to replacement intervention materials; staff willingness to dedicate time and effort towards interventions; continuity of staff and thorough handover/inductions in place for new staff; ongoing communication and awareness raising; perceived effectiveness; and addressing care home priorities. All study themes fell within 18 of the 40 CFS constructs. Discussion: Our findings resonate with the CFS and are also consistent with implementation theories, suggesting sustainability is best addressed during implementation rather than treated as a separate process which follows implementation. Commissioning and funding QI projects should address these considerations early on, during implementation.
  • Tailored psychological intervention for anxiety or depression in COPD (TANDEM): a randomised controlled trial

    Barradell, Amy (24/08/2023)
    This multi-centre, pragmatic, randomised controlled trial evaluated whether a tailored psychological intervention based on a cognitive behavioural approach for people with COPD and symptoms of anxiety and/or depression improved anxiety or depression compared to usual care (UC).People with COPD and moderate to very severe airways obstruction and Hospital Anxiety and Depression Scale subscales scores indicating mild to moderate anxiety (HADS-A) and/or depression (HADS-D), were randomised 1.25:1, intervention (242): UC (181). Respiratory health professionals delivered the intervention face-to-face over 6-8 weeks. Co-primary outcomes were HADS-A and HADS-D measured six months post-randomisation. Secondary outcomes at six and 12 months included: HADS-A and HADS-D (12 months), Beck Depression Inventory II, Beck Anxiety Inventory, St George's Respiratory Questionnaire, social engagement, the EUROQOL instrument 5-level version, smoking status, completion of pulmonary rehabilitation (PR) and health and social care resource use.The intervention did not improve anxiety (HADS-A mean difference, 95% CI, -0.60, -1.40 to 0.21) or depression (HADS-D -0.66, -1.39 to 0.07) at six months. The intervention did not improve any secondary outcomes at either timepoint, nor did it influence completion of PR or healthcare resource use. Deaths in the intervention arm 13/242 (5%) exceeded those in the control arm 3/181 (2%), but none were associated with the intervention. Health economic analysis found the intervention highly unlikely to be cost-effective.This trial has shown, beyond reasonable doubt, that this cognitive behavioural intervention delivered by trained and supervised respiratory health professionals does not improve psychological comorbidity in people with advanced COPD and depression or anxiety.
  • Gallstone ileus: Clinical presentation and radiological diagnosis

    Gaikwad, Shruti; Marathe, Mandar (2023-07-18)
    The term "gallstone ileus" refers to intestinal obstruction brought on by a gallstone lodged within its lumen. The gallstone travels through a fistula that develops because of the constant pressure it exerts on the gall bladder. The symptoms are vague and confounding which can commonly lead to delay in diagnosis. The preferred imaging technique is a computed tomography scan. The diagnosis is confirmed by the identification of Rigler's Triad on a CT scan, which includes a small intestinal obstruction, pneumobilia, and an ectopic stone in the intestine. The condition is associated with several complications and needs to be treated with emergency surgery. This case demonstrates how a patient could have non-specific symptoms and how early detection by imaging was crucial to the patient's treatment.
  • Sedation and analgesia for reduction of pediatric ileocolic intussusception

    Roland, Damian (2023-06-07)
    Importance: Ileocolic intussusception is an important cause of intestinal obstruction in children. Reduction of ileocolic intussusception using air or fluid enema is the standard of care. This likely distressing procedure is usually performed without sedation or analgesia, but practice variation exists. Objective: To characterize the prevalence of opioid analgesia and sedation and assess their association with intestinal perforation and failed reduction. Design, setting, and participants: This cross-sectional study reviewed medical records of children aged 4 to 48 months with attempted reduction of ileocolic intussusception at 86 pediatric tertiary care institutions in 14 countries from January 2017 to December 2019. Of 3555 eligible medical records, 352 were excluded, and 3203 medical records were eligible. Data were analyzed in August 2022. Exposures: Reduction of ileocolic intussusception. Main outcomes and measures: The primary outcomes were opioid analgesia within 120 minutes of reduction based on the therapeutic window of IV morphine and sedation immediately before reduction of intussusception. Results: We included 3203 patients (median [IQR] age, 17 [9-27] months; 2054 of 3203 [64.1%] males). Opioid use was documented in 395 of 3134 patients (12.6%), sedation 334 of 3161 patients (10.6%), and opioids plus sedation in 178 of 3134 patients (5.7%). Perforation was uncommon and occurred in 13 of 3203 patients (0.4%). In the unadjusted analysis, opioids plus sedation (odds ratio [OR], 5.92; 95% CI, 1.28-27.42; P = .02) and a greater number of reduction attempts (OR, 1.48; 95% CI, 1.03-2.11; P = .03) were significantly associated with perforation. In the adjusted analysis, neither of these covariates remained significant. Reductions were successful in 2700 of 3184 attempts (84.8%). In the unadjusted analysis, younger age, no pain assessment at triage, opioids, longer duration of symptoms, hydrostatic enema, and gastrointestinal anomaly were significantly associated with failed reduction. In the adjusted analysis, only younger age (OR, 1.05 per month; 95% CI, 1.03-1.06 per month; P < .001), shorter duration of symptoms (OR, 0.96 per hour; 95% CI, 0.94-0.99 per hour; P = .002), and gastrointestinal anomaly (OR, 6.50; 95% CI, 2.04-20.64; P = .002) remained significant. Conclusions and relevance: This cross-sectional study of pediatric ileocolic intussusception found that more than two-thirds of patients received neither analgesia nor sedation. Neither was associated with intestinal perforation or failed reduction, challenging the widespread practice of withholding analgesia and sedation for reduction of ileocolic intussusception in children.
  • Improving communications in PPE: a solution for 'landline' telephone communication

    Pallett, Edward; Mangat, Jasdip; Chung, Emma (2023-05-23)
    Background: Emergency care staff wearing elastomeric respiratory personal protective equipment (PPE) report difficulties in communicating by telephone. We developed and tested an affordable technological solution aimed at improving telephone call intelligibility for staff wearing PPE. Methods: A novel headset was created to enable a throat microphone and bone conduction headset to be used in combination with a standard hospital 'emergency alert' telephone system. Speech intelligibility of an ED staff member wearing PPE was compared between the proposed headset and current practice by simultaneously recording a version of the Modified Rhyme Test and a Key Sentences Test. Recordings were played back to a group of blinded ED staff listening to pairs of recordings under identical conditions. The proportion of correctly identified words was compared using a paired t-test. Results: Fifteen ED staff correctly identified a mean of 73% (SD 9%) words for speech communicated via the throat microphone system, compared with only 43% (SD 11%) of words for standard practice (paired t-test, p<0.001). Conclusions: Introduction of a suitable headset could significantly improve speech intelligibility during 'emergency alert' telephone calls.
  • Complicated appendicitis in an adult patient

    Babington, Emmanuel
    Introduction: Appendicitis is a common cause for emergency operations in the western part of the world, mostly affecting children and young adults. Ultrasound in well-trained hands is an effective imaging tool in making this diagnosis; however, this does not come without its challenges and potential complications. Case report: This is a case of a 19-year-old male with one-day history of severe pain in the right iliac fossa; blood results showed raised inflammatory markers. Ultrasound revealed a large abnormal loop of bowel containing heterogeneously echogenic contents, and two large appendicoliths at the base and fundus, with the presence of free fluid in the right iliac fossa and oedema in the adjacent mesentery. Laparoscopic appendectomy confirmed the presence of severe appendicitis with generalised peritonitis and appendicolith. Histology revealed gangrenous appendicitis with perforation in two places. Discussion: This case demonstrates that making a diagnosis of an inflamed appendix alone on ultrasound is not enough, and conducting a detailed assessment of the inflamed appendix and its surrounding anatomy is essential so that all the associated findings can be reported to aid in the patient management, reduce hospital stay and improve overall diagnosis and prognosis.
  • Different dosing regimens of Tenecteplase in acute ischemic stroke: A network meta-analysis of the clinical evidence

    The, Ei Zune; Matar, Mazen
    Introduction: Acute ischemic stroke remains the major cause of death and disability and conclusive evidence of Tenecteplase in treating stroke is lacking. Objective: To conduct a meta-analysis to determine whether Tenecteplase produces better outcomes than Alteplase and a network meta-analysis comparing the different dosing regimens of Tenecteplase. Methods: Searches were made in MEDLINE, CENTRAL, and ClinicalTrials.gov. The outcome measures are recanalization, early neurological improvement, functional outcomes at 90 days (modified Rankin Scale 0-1 and 0-2), intracranial hemorrhage, symptomatic intracranial hemorrhage, and mortality within 90 days from treatment. Results: Fourteen studies are included in the meta-analyses and 18 studies in the network meta-analyses. In the meta-analysis, Tenecteplase 0.25 mg/kg has significant results in early neurological improvement (OR = 2.35, and 95% CI = 1.16-4.72) and excellent functional outcome (OR = 1.20, and 95% CI = 1.02-1.42). In the network meta-analysis, Tenecteplase 0.25 mg/kg produces significant results in early neurological improvement (OR = 1.52 [95% CI = 1.13-2.05], p-value = 0.01), functional outcomes (mRS 0-1 and 0-2) (OR = 1.19 [95% CI = 1.03-1.37], p-value = 0.02; OR = 1.21 [95% CI = 1.05-1.39], p-value = 0.01; respectively) and mortality (OR = 0.78 [95% CI = 0.64-0.96], p-value = 0.02) whereas Tenecteplase 0.40 mg/kg increases the chances of symptomatic intracranial hemorrhage (OR = 2.35 [95% CI = 1.19-4.64], p-value = 0.01). Conclusion: While not conclusive, our study lends evidence to 0.25 mg/kg Tenecteplase dose for ischemic stroke treatment. Further randomized trials need to be done to validate this finding. Registration: International prospective register of systematic reviews (PROSPERO) - CRD42022339774URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339774.
  • Respective roles of non-pharmaceutical interventions in bronchiolitis outbreaks: an interrupted time-series analysis based on a multinational surveillance system

    Roland, Damian
    Background: Bronchiolitis is a major source of morbimortality among young children worldwide. Non-pharmaceutical interventions (NPIs) implemented to reduce the spread of severe acute respiratory syndrome coronavirus 2 may have had an important impact on bronchiolitis outbreaks, as well as major societal consequences. Discriminating between their respective impacts would help define optimal public health strategies against bronchiolitis. We aimed to assess the respective impact of each NPI on bronchiolitis outbreaks in 14 European countries. Methods: We conducted a quasi-experimental interrupted time-series analysis based on a multicentre international study. All children diagnosed with bronchiolitis presenting to the paediatric emergency department of one of 27 centres from January 2018 to March 2021 were included. We assessed the association between each NPI and change in the bronchiolitis trend over time by seasonally adjusted multivariable quasi-Poisson regression modelling. Results: In total, 42 916 children were included. We observed an overall cumulative 78% (95% CI -100- -54%; p<0.0001) reduction in bronchiolitis cases following NPI implementation. The decrease varied between countries from -97% (95% CI -100- -47%; p=0.0005) to -36% (95% CI -79-7%; p=0.105). Full lockdown (incidence rate ratio (IRR) 0.21 (95% CI 0.14-0.30); p<0.001), secondary school closure (IRR 0.33 (95% CI 0.20-0.52); p<0.0001), wearing a mask indoors (IRR 0.49 (95% CI 0.25-0.94); p=0.034) and teleworking (IRR 0.55 (95% CI 0.31-0.97); p=0.038) were independently associated with reducing bronchiolitis. Conclusions: Several NPIs were associated with a reduction of bronchiolitis outbreaks, including full lockdown, school closure, teleworking and facial masking. Some of these public health interventions may be considered to further reduce the global burden of bronchiolitis.
  • Time to change the reference ranges of children's physiological observations in emergency care? A prospective study

    Roland, Damian (2023-01-16)
    Aim: High heart and respiratory rates are key indicators in many published guidelines to identify and treat serious bacterial infection and sepsis in children, but the credibility of evidence underpinning what is considered abnormal is questionable. This study established the distribution of heart and respiratory rates of children using a large data set to inform debate on what the 'normal' range of these should look like. The primary aim was to compare the distribution of heart and respiratory rates measured in children recruited from non-tertiary emergency care settings with those published by Advanced Paediatric Life Support (APLS). The secondary aim was to compare the distribution of this study's data set to other national guidance on what constitutes a severe (high-risk) measurement and previously published data sets. Method: Prospective study using anonymised patient data, extracted from electronic patient records of children and young people 0-16 years, recruited from three Emergency Departments and one Urgent Care Centre in Northwest England, UK. Results: Heart and respiratory rates, including the reporting of values at certain centiles and comparisons of averages. Distribution of heart and respiratory rate were consistently higher than those used by the APLS guidance, resulting in a large proportion exceeding the 'severe' cut-offs proposed. This varied greatly by age. Conclusions: This study's data set suggests normal heart rate ranges proposed by the APLS and others is too low and therefore 'abnormal' measurements encompass too large a proportion. The respiratory rate of this data set was more consistent with the guidelines and other published data sets.
  • Assessing healthcare professionals' identification of paediatric dermatological conditions in darker skin tones

    Roland, Damian (2022-11-15)
    The impacts of the lack of skin tone diversity in medical education images on healthcare professionals (HCPs) and patients are not well studied. The aim of this study was to assess the diagnostic knowledge of HCPs and correlate this with confidence and training resources used. An online multiple choice quiz was developed. The participants' demographics, training resources and self-confidence in diagnosing skin conditions were collected. The differences in the results between the subgroups and the correlations between the respondents' experience, self-reported confidence and quiz results were assessed. The mean score of 432 international participants was 5.37 (SD 1.75) out of a maximum of 10 (highest score). Eleven percent (n = 47) reached the 80% pass mark. Subanalysis showed no difference by the continent (p = 0.270), ethnicity (p = 0.397), profession (p = 0.599), training resources (p = 0.198) or confidence (p = 0.400). A significance was observed in the specialty (p = 0.01). A weak correlation between experience and confidence (Spearman's ρ = 0.286), but no correlation between scores and confidence or experience (ρ = 0.087 and 0.076), was observed. Of diagnoses, eczema was recognised in 40% and meningococcal rash in 61%. This is the first study assessing the identification of paediatric skin conditions in different skin tones internationally. The correct identification of common/important paediatric conditions was poor, suggesting a possible difference in knowledge across skin tones. There is an urgent need to improve the representation of all skin tones to ensure equity in patient care.
  • Can passive leg raise predict the response to fluid resuscitation in ED?

    Elwan, Mohammed; Coats, Timothy (2022-10-26)
    Objective: Passive leg raise (PLR) can be used as a reversible preload challenge to stratify patients according to preload response. We aim to evaluate the accuracy of PLR, monitored by a non-invasive cardiac output monitor in predicting to response to fluid resuscitation in emergency department (ED). Methods: We recruited adult patients planned to receive a resuscitation fluid bolus. Patients were monitored using a thoracic electrical bioimpedance (TEB) cardiac output monitor (Niccomo, Medis, Germany). A 3-min PLR was carried out before and after fluid infusion. Stroke volume changes (ΔSV) were calculated and a positive response was defined as ≥ 15% increase. Results: We recruited 39 patients, of which 37 were included into the analysis. The median age was 63 (50-77) years and 19 patients were females. 17 patients (46%) were fluid responders compared to 11 (30%) with positive response to PLR1. ΔSV with PLR1 and fluid bolus showed moderate correlation (r = 0.47, 95% confidence interval, CI 0.17-0.69) and 62% concordance rate. For the prediction of the response to a fluid bolus the PLR test had a sensitivity of 41% (95% CI 22-64) and specificity of 80% (95% CI 58-92) with an area under the curve of 0.59 (95% CI 0.41-0.78). None of the standard parameters showed a better predictive ability compared to PLR. Conclusion: Using TEB, ΔSV with PLR showed a moderate correlation with fluid bolus, with a limited accuracy to predict fluid responsiveness. The PLR test was a better predictor of fluid responsiveness than the parameters commonly used in emergency care (such as heart rate and blood pressure). These data suggest the potential for a clinical trial in sepsis comparing TEB monitored, PLR directed fluid management with standard care.
  • The association between temperature, heart rate, and respiratory rate in children aged under 16 years attending urgent and emergency care settings

    Roland, Damian (2022-12-01)
    Background and importance: Body temperature is considered an independent determinant of respiratory rate and heart rate; however, there is limited scientific evidence regarding the association. This study aimed to assess the association between temperature, and heart rate and respiratory rate in children. Objective: The objective of this study was to validate earlier findings that body temperature causes an increase of approximately 10 bpm rise in heart rate per 1 °C rise in temperature, in children aged under 16 years old. Design: A prospective study using anonymised prospectively collected patient data of 188 635 attendances, retrospectively extracted from electronic patient records. Settings and participants: Four Emergency or Urgent Care Departments in the North West of England. Participants were children and young people aged 0-16 years old who attended one of the four sites over a period of 3 years. Outcome measures and analysis: Multiple linear regression models, adjusted for prespecified confounders (including oxygen saturation, heart rate, respiratory rate, site of attendance, age), were used to examine the influence of various variables on heart rate and respiratory rate. Main results: Among the 235 909 patient visits (median age 5) included, the mean temperature was 37.0 (SD, 0.8). Mean heart rate and respiratory rate were 115.6 (SD, 29.0) and 26.9 (SD, 8.3), respectively. For every 1 °C increase in temperature, heart rate will on average be 12.3 bpm higher (95% CI, 12.2-12.4), after accounting for oxygen saturation, location of attendance, and age. For every 1 °C increase in temperature, there is on average a 0.3% decrease (95% CI, 0.2-0.4%) in respiratory rate. Conclusion: In this study on children attending urgent and emergency care settings, there was an independent association between temperature and heart rate but not between temperature and respiratory rate.
  • Impact of COVID-19 on paediatric emergency department attendances at four English hospitals

    Roland, Damian (2022-02-08)
    Paediatric emergency department (PED) attendances reduced worldwide during the COVID-19 pandemic (2020) but anecdotally babies under 30 days (BUD) appeared less affected. We collated monthly PED attendances (16 years and under) across four hospitals (three district general hospitals and a tertiary specialist PED) in England, UK from January 2017 to December 2020. Gross PED attendances dropped by 34% in 2020 (n=98 256) compared to 2019 (n=148 640). However, cumulative BUD attendances dropped by only 6% in 2020 (n=3922) compared to 2019 (n=4162). Monthly site-specific attendances showed marginal variation. PED attendances broadly decreased in 2020 with less of an impact on BUD.

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