Can patients apply the Ottawa ankle rules to themselves?

ABSTRACT Objective: To determine whether patients with an ankle injury obtained the same results as clinicians when applying the Ottawa ankle rules (a validated clinical decision rule) to themselves. Methods: Patients aged .15 years presenting to an inner city emergency department within 48 h of an ankle injury were asked to assess their own injury using the Ottawa ankle rules. The results of their self-assessment were compared with those of a treating clinician. Results: Poor interobserver agreement was found between patients and clinicians. Conclusions: Making the Ottawa ankle rule more widely available to the general public is unlikely to reduce healthcare demand. Indeed, given the apparently low specificity of the rule, demand could actually increase as a result. The Ottawa ankle rules have been extensively validated as a clinical decision rule for use by healthcare professionals in detecting possible bony injury-and therefore the need for radiography-in patients with a recent ankle injury. 2 The Ottawa ankle rules can be reliably applied by a range of healthcare professionals, including emergency nurse practitioners. 3 If they could also be reliably applied by patients to their own ankle injuries, there is the potential to reduce healthcare consultations following ankle sprain with consequent resource savings, particularly if the rules were widely publicised. The aim of this pilot study was to determine the agreement between patients and clinicians when applying the Ottawa ankle rules, and therefore whether adult patients with a recent ankle injury are potentially able to accurately apply the Ottawa ankle rules to themselves. METHODS A convenience sample of 50 patients attending a single inner city emergency department with a recent (within 48 h) ankle injury were asked if they wished to participate in the study by a researcher triaging the patient. All patients were offered analgesia. Patients who elected not to enter the study were examined by a researcher and treated according to usual practice. If the patient entered the study, informed written consent was obtained and they were then given an information sheet and pictorial questionnaire describing the Ottawa ankle rules (see online Appendix 1). Participants were asked to examine their own ankle and to enter the results on the questionnaire before formal clinical assessment. The patient was then seen by an emergency department clinician (doctor, emergency nurse practitioner or extended scope physiotherapist) who was blind to the patient's assessment of his or her own injury. The clinician made an independent assessment of the injury and arranged radiographs as appropriate. The clinician then completed a study questionnaire giving details of his/her assessment and an interpretation of any radiographs. The formal radiology report was also reviewed and, where any disagreement occurred, the radiology report was taken as the reference standard. If radiography was not performed, the emergency and radiology department records were checked to see if the patient presented in the following month with a lower limb injury. The kappa statistic was used to determine the level of agreement between the patient and clinician, with x 2 testing to compare their overall opinion. RESULTS Fifty patients (25 men, 25 women) of mean age 32 years (range 16-63) were recruited to the study. The mean duration from injury to presentation was 17 h. All 50 patients rated themselves as positive on at least one of the five Ottawa criteria, and therefore all patients concluded that they required a radiograph. On examination by the clinician, 45 of the 50 patients were positive on at least one of the Ottawa criteria and therefore required a radiograph. Of the remaining five patients, one had a ruptured Achilles tendon and one underwent radiography for other reasons. None of the other three patients who did not undergo radiography returned to the emergency department or had lower limb radiographs at the same hospital during the following month. Of the patients who underwent radiography, seven (14%) had fractures identified by both the clinician and the reporting radiologist. Three (6%) had fractures suspected by the clinician but not confirmed by the radiologist. The remaining 36 patients (72%) who had radiographs did not have a fracture. No fractures were missed by an ED clinician. Agreement between the patient and clinician in relation to each of the five Ottawa criteria is shown in tables 1 and 2. There was very little agreement between patients and clinicians on whether they could walk initially or in the emergency department, but greater agreement regarding local tenderness. Overall, 90% of clinicians and 100% of patients rated the rule as positive, demonstrating a statistically significant difference between the final opinions of the two groups (p = 0.02, x 2 test). The kappa values show

Paediatric distal radial fracture manipulation: Multicentre analysis of process times

Background: Children with simple radial fractures requiring manipulation are conventionally admitted for manipulation under general anaesthesia. On the assumption that children (and their parents) wish to spend as little time in hospital as possible, a study was undertaken to explore the experience of children with distal radial fractures admitted for general anaesthesia. Methods: A retrospective analysis was performed of the time taken from arrival at the emergency department (ED) to general anaesthesia and the time taken from arrival at the ED to hospital discharge in three centres in south-west England: the Bristol Children's Hospital, Derriford (Plymouth) Hospital and the Royal Devon & Exeter Hospital. Results: The median wait for general anaesthesia was >8 h and the median wait from ED admission to discharge was >21 h. This compares with a typical arrival to discharge time for paediatric procedural sedation of 4-5 h in the ED of the Royal Devon & Exeter Hospital. Conclusions: Given the assumption that children (and their parents) wish to spend as little time in hospital as possible, there appears to be a role for procedural sedation in the ED for this group of children, with a significantly reduced turnaround time anticipated

Psychological wellbeing in survivors of cardiac arrest, and its relationship to neurocognitive function

© 2016 Objective To characterise psychological wellbeing in survivors of out-of-hospital cardiac arrest (OHCA), and examine its relationship to cognitive function. Patients Forty-one highly functioning cardiac arrest survivors were drawn from the follow-up cohort of a randomised controlled trial of initial airway management in OHCA (ISRCTN:18528625). Design Psychological wellbeing was assessed with a self-report questionnaire (the Depression Anxiety and Stress Scale; DASS) and cognitive function was examined using the Delayed Matching to Samples (DMS) test from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Results Mean anxiety levels were significantly higher in this patient group than normative data drawn from the general population (p=0.046). Multiple regression analyses showed that cognitive function, measured by the DMS, did not predict any of the DASS scales. Conclusions Anxiety plays an important role in determining perceived QoL in high functioning survivors, but psychological wellbeing is unrelated to cognitive function in this group. To achieve a comprehensive assessment of wellbeing, resuscitation research should consider outcomes beyond neurological function alone

PAin SoluTions In the Emergency Setting (PASTIES)—patientcontrolled analgesia versus routine care in emergency department patients with pain from traumatic injuries: Randomised trial

Objective To determine whether patient controlled analgesia (PCA) is better than routine care in patients presenting to emergency departments with moderate to severe pain from traumatic injuries.Design Pragmatic, multicentre, parallel group, randomised controlled trial.Setting Five English hospitals.Participants 200 adults (71% (n=142) male), aged 18 to 75 years, who presented to the emergency department requiring intravenous opioid analgesia for the treatment of moderate to severe pain from traumatic injuries and were expected to be admitted to hospital for at least 12 hours.Interventions PCA (n=99) or nurse titrated analgesia (treatment as usual; n=101).Main outcome measures The primary outcome was total pain experienced over the 12 hour study period, derived by standardised area under the curve (scaled from 0 to 100) of each participant’s hourly pain scores, captured using a visual analogue scale. Pre-specified secondary outcomes included total morphine use, percentage of study period in moderate/severe pain, percentage of study period asleep, length of hospital stay, and satisfaction with pain management.Results 200 participants were included in the primary analyses. Mean total pain experienced was 47.2 (SD 21.9) for the treatment as usual group and 44.0 (24.0) for the PCA group. Adjusted analyses indicated slightly (but not statistically significantly) lower total pain experienced in the PCA group than in the routine care group (mean difference 2.7, 95% confidence interval −2.4 to 7.8). Participants allocated to PCA used more morphine in total than did participants in the treatment as usual group (mean 44.3 (23.2) v 27.2 (18.2) mg; mean difference 17.0, 11.3 to 22.7). PCA participants spent, on average, less time in moderate/severe pain (36.2% (31.0) v 44.1% (31.6)), but the difference was not statistically significant. A higher proportion of PCA participants reported being perfectly or very satisfied compared with the treatment as usual group (86% (78/91) v 76% (74/98)), but this was also not statistically significant.Conclusions PCA provided no statistically significant reduction in pain compared with routine care for emergency department patients with traumatic injuries.Trial registration European Clinical Trials Database EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients’ safety : assessor-blind pilot comparison

Background: There are currently no field data about the effect of implementing European Working Time Directive (EWTD)-compliant rotas in a medical setting. Surveys of doctors’ subjective opinions on shift work have not provided reliable objective data with which to evaluate its efficacy. Aim: We therefore studied the effects on patient's safety and doctors’ work-sleep patterns of implementing an EWTD-compliant 48 h work week in a single-blind intervention study carried out over a 12-week period at the University Hospitals Coventry & Warwickshire NHS Trust. We hypothesized that medical error rates would be reduced following the new rota. Methods: Nineteen junior doctors, nine studied while working an intervention schedule of <48 h per week and 10 studied while working traditional weeks of <56 h scheduled hours in medical wards. Work hours and sleep duration were recorded daily. Rate of medical errors (per 1000 patient-days), identified using an established active surveillance methodology, were compared for the Intervention and Traditional wards. Two senior physicians blinded to rota independently rated all suspected errors. Results: Average scheduled work hours were significantly lower on the intervention schedule [43.2 (SD 7.7) (range 26.0–60.0) vs. 52.4 (11.2) (30.0–77.0) h/week; P < 0.001], and there was a non-significant trend for increased total sleep time per day [7.26 (0.36) vs. 6.75 (0.40) h; P = 0.095]. During a total of 4782 patient-days involving 481 admissions, 32.7% fewer total medical errors occurred during the intervention than during the traditional rota (27.6 vs. 41.0 per 1000 patient-days, P = 0.006), including 82.6% fewer intercepted potential adverse events (1.2 vs. 6.9 per 1000 patient-days, P = 0.002) and 31.4% fewer non-intercepted potential adverse events (16.6 vs. 24.2 per 1000 patient-days, P = 0.067). Doctors reported worse educational opportunities on the intervention rota. Conclusions: Whilst concerns remain regarding reduced educational opportunities, our study supports the hypothesis that a 48 h work week coupled with targeted efforts to improve sleep hygiene improves patient safety

The 3D Grazing Collision of Two Black Holes

We present results for two colliding black holes (BHs), with angular momentum, spin, and unequal mass. For the first time gravitational waveforms are computed for a grazing collision from a full 3D numerical evolution. The collision can be followed through the merger to form a single BH, and through part of the ringdown period of the final BH. The apparent horizon is tracked and studied, and physical parameters, such as the mass of the final BH, are computed. The total energy radiated in gravitational waves is shown to be consistent with the total mass of the spacetime and the final BH mass. The implication of these simulations for gravitational wave astronomy is discussed.Comment: 4 pages, 7 figures, revte

The Positive Relationship between Moderate-to-Vigorous Physical Activity and Bone Mineral Content Is Not Mediated by Free Leptin Index in Prepubertal Children: The PANIC Study.

PurposeModerate-to-vigorous physical activity (MVPA) positively influences bone mineral content (BMC) in prepubertal children, but it is unknown whether this relationship is partially mediated by free leptin index. The aim of this study was to examine whether the relationship between MVPA and total body less head (TBLH) BMC is mediated or moderated by free leptin index in prepubertal children.MethodsWe performed a cross-sectional analysis on 401 children (194 girls) from baseline examinations of the Physical Activity and Nutrition in Childhood Study. We applied the four-way decomposition mediation analysis method to assess whether free leptin index, measured from fasted blood samples, mediated the relationship between accelerometer-measured MVPA and TBLH BMC measured by dual-energy X-ray absorptiometry.ResultsMVPA had a positive controlled direct effect on TBLH BMC in girls and boys (β = 0.010 to 0.011, p p > 0.05).ConclusionOur study indicates that MVPA positively influences TBLH BMC through pathways not related to free leptin index in predominantly normal-weight prepubertal children, likely primarily through mechanical loading. The relationships between MVPA, free leptin index and TBLH BMC may be influenced by other factors such as pubertal status and adiposity, so it is unknown whether these observations extend to overweight and obese children at different stages of puberty

The Positive Relationship between Moderate-to-Vigorous Physical Activity and Bone Mineral Content Is Not Mediated by Free Leptin Index in Prepubertal Children: The PANIC Study.

PURPOSE: Moderate-to-vigorous physical activity (MVPA) positively influences bone mineral content (BMC) in prepubertal children, but it is unknown whether this relationship is partially mediated by free leptin index. The aim of this study was to examine whether the relationship between MVPA and total body less head (TBLH) BMC is mediated or moderated by free leptin index in prepubertal children. METHODS: We performed a cross-sectional analysis on 401 children (194 girls) from baseline examinations of the Physical Activity and Nutrition in Childhood Study. We applied the four-way decomposition mediation analysis method to assess whether free leptin index, measured from fasted blood samples, mediated the relationship between accelerometer-measured MVPA and TBLH BMC measured by dual-energy X-ray absorptiometry. RESULTS: MVPA had a positive controlled direct effect on TBLH BMC in girls and boys (β = 0.010 to 0.011, p 0.05). CONCLUSION: Our study indicates that MVPA positively influences TBLH BMC through pathways not related to free leptin index in predominantly normal-weight prepubertal children, likely primarily through mechanical loading. The relationships between MVPA, free leptin index and TBLH BMC may be influenced by other factors such as pubertal status and adiposity, so it is unknown whether these observations extend to overweight and obese children at different stages of puberty

Randomised trial of the fascia iliaca block versus the ‘3-in-1’ block for femoral neck fractures in the emergency department

Introduction: Femoral neck fractures are a common and painful injury. Femoral nerve blocks, and a variant of this technique termed the ‘3-in-1’ block, are often used in this patient group, but their effect is variable. The fascia iliaca compartment block (FIB) has been proposed as an alternative, but the relative effectiveness of the two techniques in the early stages of care is unknown. We therefore compared the FIB versus the 3-in-1 block in a randomised trial conducted in two UK emergency departments. Methods: Parallel, two-group randomised equivalence trial. Consenting patients >18 years with a femoral neck fracture were randomly allocated to receive either a FIB or a 3-in-1 block. The primary outcome was pain measured on a 100 mm visual analogue scale at 60 min. The between-group difference was adjusted for centre, age, sex, fracture type, pre-block analgesia and pre-block pain score. Results: 178 patients were randomised and 162 included in the primary analysis. The mean 100 mm visual analogue pain scale score at 60 min was 38 mm in the FIB arm and 35 mm in the 3-in-1 arm. The adjusted difference between the arms was 3 mm, with a 95% CI (−4.7 to 10.8) that excluded a clinically important difference between the two interventions. Conclusions: FIB is equivalent to the 3-in-1 block for immediate pain relief in adult neck of femur fractures