The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT): a randomised crossover feasibility study

Background : The appropriate management of patients with ST-segment elevation myocardial infarction (STEMI) depends on accurate interpretation of the 12-lead ECG by paramedics. Computer interpretation messages on ECGs are often provided, but the effect they exert on paramedics’ decision-making is not known. The objective of this study was to assess the feasibility of using an online assessment tool, and collect pilot data, for a definitive trial to determine the effect of computer interpretation messages on paramedics’ diagnosis of STEMI. Methods : The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT) feasibility study was a randomised crossover trial using a bespoke, web-based assessment tool. Participants were randomly allocated 12 of 48 ECGs, with an equal mix of correct and incorrect computer interpretation messages, and STEMI and STEMI-mimics. The nature of the responses required a cross-classified multi-level model. Results : 254 paramedics consented into the study, 205 completing the first phase and 150 completing phase two. The adjusted OR for a correct paramedic interpretation, when the computer interpretation was correct (true positive for STEMI or true negative for STEMI-mimic), was 1.80 (95% CI 0.84 to 4.91) and 0.58 (95% CI 0.41 to 0.81) when the computer interpretation was incorrect (false positive for STEMI or false negative for STEMI-mimic). The intraclass correlation coefficient for correct computer interpretations was 0.33 for participants and 0.17 for ECGs, and for incorrect computer interpretations, 0.06 for participants and 0.01 for ECGs. Conclusions : Determining the effect of computer interpretation messages using a web-based assessment tool is feasible, but the design needs to take clustered data into account. Pilot data suggest that computer messages influence paramedic interpretation, improving accuracy when correct and worsening accuracy when incorrect

Do RATs save lives? A retrospective analysis of out-of-hospital cardiac arrest in an English Ambulance Service

Study aimThis study aims to determine the impact of the red arrest teams (RATs) on survival to 30 days and return of spontaneous circulation (ROSC) at hospital.MethodsA retrospective cohort study analysing routinely collected data was undertaken. All adult (≥18 years) OHCAs entered onto the YAS computer aided dispatch (CAD) system between the 1st October, 2015 and 30th September, 2017 were included if the patient was resuscitated, and the cause of the arrest was considered to be medical in origin. Multivariable logistic regression models were created to enable adjustment for common predictors of survival and ROSC.ResultsDuring the 2-year data collection period, 15,151 cardiac arrests that were attended by Yorkshire Ambulance Service. After removing ineligible cases, 5,868 cardiac arrests remained. RATs attended 2,000/5,868 (34.1%) incidents, with each RAT attending a median of 13 cardiac arrests (IQR 7–23, minimum 1, maximum 78).The adjusted odds ratios suggest that a RAT on scene is associated with a slight increase in the odds of survival to 30 days (OR 1.01, 95%CI 0.74–1.38) and odds of ROSC on arrival at hospital (OR 1.13, 95%CI 0.99–1.29), compared to the odds of not having a RAT present, although neither results are statistically significant.ConclusionThe presence of a RAT paramedic was associated with a small increase in survival to 30 days and ROSC on arrival at hospital, although neither were statistically significant. Larger prospective studies are required to determine the effect of roles such as RAT on outcomes from OHC

Soiled airway tracheal intubation and the effectiveness of decontamination by paramedics (SATIATED): a randomised controlled manikin study.

Introduction: Vomiting and regurgitation are commonly encountered in out-of-hospital cardiac arrest (OHCA), with a reported incidence of 20-30%. This is of concern since patients who have suffered an OHCA are already in extremis. If standard suctioning techniques are not sufficient to maintain a clear airway and provide ventilation, then these patients will die, irrespective of the quality of chest compressions and the timeliness of defibrillation. This study aimed to determine whether a short teaching session of the suction assisted laryngoscopy and airway decontamination (SALAD) technique improved paramedics' ability to successfully intubate a contaminated airway. Methods: A modified airway manikin with the oesophagus connected to a reservoir of 'vomit', and a bilge pump capable of propelling the vomit up into the oropharynx, was used to simulate a soiled airway. The intervention consisted of a brief SALAD training session with a demonstration and opportunity to practice. Participants were randomly allocated into two groups: AAB, who made two pre-training intubation attempts and one post-training attempt, and ABB, who made one pre-training and two post-training attempts, to adjust for improvement in performance due to repetition. Results: In this manikin study, following a brief SALAD training session, more paramedics were able to intubate a soiled airway on their first attempt, compared to those without training (90.2% vs. 53.7%, difference of 36.6%, 95% CI 24-49.1%, p < 0.001). In addition, the mean difference in time taken to perform a successful intubation between groups was statistically significant for attempts 1 and 2 (mean difference 11.71 seconds, 95% CI 1.95-21.47 seconds, p = 0.02), but not attempts 1 and 3 (mean difference -2.52 seconds, 95% CI -11.64-6.61 seconds, p = 0.58). This result is likely to be confounded by the use of tracheal suction, which only occurred in the post-training attempts and added additional time to the intubation attempts. There was no statistically significant difference in success rates on the third attempt between AAB and ABB (89.0% vs. 86.6%, difference 2.4%, 95% CI 7.6-12.4%, p = 0.63). Conclusion: In this study, the use of the SALAD technique significantly improved first attempt success rates when paramedics were intubating a simulated soiled airway

Do RATs save lives? A service evaluation of an out-of-hospital cardiac arrest team in an English ambulance service.

Introduction: Out-of-hospital cardiac arrest (OHCA) is a major public health problem, leading to a substantial number of deaths in the UK. In response to this, the Yorkshire Ambulance Service NHS Trust (YAS) has introduced red arrest teams (RATs). RAT members attend a three-day training course, focusing on the technical and non-technical skills that are required to effectively team lead an OHCA and provide high quality post-resuscitation care. This evaluation aims to determine the impact of the RATs on survival to 30 days and return of spontaneous circulation (ROSC) at hospital. Methods: All adult (≥ 18 years) OHCAs entered onto the YAS computer aided dispatch (CAD) system between 1 October 2015 and 30 September 2017 were included if the patient was resuscitated and the cause of the arrest was considered to be medical in origin. Multi-variable logistic regression models were created to enable adjustment for common predictors of survival and ROSC. Results: During the 2-year data collection period, YAS attended 15,151 cardiac arrests. After removing ineligible cases, 5868 cardiac arrests remained. RATs attended 2000/5868 (34.1%) incidents, with each RAT attending a median of 13 cardiac arrests (IQR 7-23, min. 1, max. 78).The adjusted odds ratios suggest that a RAT on scene is associated with a slight increase in the odds of survival to 30 days (OR 1.01, 95% CI 0.74-1.38) and odds of ROSC on arrival at hospital (OR 1.13, 95% CI 0.99-1.29), compared to the odds of not having a RAT present, although neither result is statistically significant. Conclusion: The presence of a RAT paramedic was associated with a small increase in survival to 30 days and ROSC on arrival at hospital, although neither were statistically significant. Larger prospective studies are required to determine the effect of roles such as RAT on outcomes from OHCA

Seven steps for improving influenza vaccination rates in risk-groups: findings from a national cross sectional survey in UK general practice

The problem: Seasonal influenza vaccination rates in at-risk population in the UK are below the national and international target of 75%. Of people aged over 65 years in England 72.8% received influenza (flu) vaccine in 2010/11, just below the target of 75%. However, flu vaccination rates during 2010/11 in the under 65 year old at-risk groups was just 50.4%, which fell far short of 75%; in pregnant women who were not otherwise at risk the vaccination rate was only 36.6%, despite increasing evidence showing the beneficial effects of protection against flu for both mothers and babies. Evidence-based guidance, to advise practices how to optimise all aspects of their flu vaccination campaigns and maximise their likelihood of protecting at-risk patients against flu and its serious sequelae is greatly needed. This study sought to identify which strategies and procedures were associated with higher rates of flu vaccine uptake. The approach: An online questionnaire survey was administered to general practitioners (GPs), nursing staff and practice managers in 795 practices across England. We used logistic regression to analyse data for factors independently associated with higher practice flu vaccination rates in at-risk groups. Findings: The survey was completed by 569 practice managers, 335 nursing staff and 107 GPs. We identified seven independent factors associated with higher flu vaccination rates. Having a lead staff member for planning the flu campaign and producing a written report of practice performance predicted an 8% higher vaccination rate for at-risk patients aged <65 years (OR 1.37; 95% CI 1.10 to 1.71). These strategies, plus sending a personal invitation to all eligible patients and only stopping vaccination when Quality and Outcomes framework (QOF) targets were reached, predicted a 7% higher vaccination rate (OR 1.45; 95% CI 1.10 to 1.92) in patients aged 65 years and over. Using a lead member of staff for identifying eligible patients, with either a modified manufacturer’s or in-house search program for interrogating the practice computer system, independently predicted a 4% higher vaccination rate in patients aged 65 years and over (OR 1.22; 95% CI 1.06 to 1.41 / OR 1.20; 95% CI 1.03 to 1.40). The provision of flu vaccine by midwives was associated with a 4% higher vaccination rate in pregnant women (OR 1.19; 1.02 to 1.40). Consequences: Clear leadership, effective communication with patients, and methods used to identify and contact eligible patients were independently associated with significantly higher rates of flu vaccination. Financial targets appear to incentivise practices to work harder to maximise seasonal influenza vaccine uptake. The strategies identified here could help primary care providers to substantially increase their seasonal flu vaccination rates to meet or even exceed national targets

Study of How Adiposity in Pregnancy has an Effect on outcomeS (SHAPES):protocol for a prospective cohort study

Introduction Maternal obesity increases the risk of multiple maternal and infant pregnancy complications, such as gestational diabetes and pre-eclampsia. Current UK guidelines use body mass index (BMI) to identify which women require additional care due to increased risk of complications. However, BMI may not accurately predict which women will develop complications during pregnancy as it does not determine amount and distribution of adipose tissue. Some adiposity measures (eg, waist circumference, ultrasound measures of abdominal visceral fat) can better identify where body fat is stored, which may be useful in predicting those women who need additional care.Methods and analysis This prospective cohort study (SHAPES, Study of How Adiposity in Pregnancy has an Effect on outcomeS) aims to evaluate the prognostic performance of adiposity measures (either alone or in combination with other adiposity, sociodemographic or clinical measures) to estimate risk of adverse pregnancy outcomes. Pregnant women (n=1400) will be recruited at their first trimester ultrasound scan (11+2–14+1 weeks’) at Newcastle upon Tyne National Health Service Foundation Trust, UK. Early pregnancy adiposity measures and clinical and sociodemographic data will be collected. Routine data on maternal and infant pregnancy outcomes will be collected from routine hospital records. Regression methods will be used to compare the different adiposity measures with BMI in terms of their ability to predict pregnancy complications. If no individual measure performs better than BMI, multivariable models will be developed and evaluated to identify the most parsimonious model. The apparent performance of the developed model will be summarised using calibration, discrimination and internal validation analyses.Ethics and dissemination Ethical favourable opinion has been obtained from the North East: Newcastle &amp; North Tyneside 1 Research Ethics Committee (REC reference: 22/NE/0035). All participants provide informed consent to take part in SHAPES. Planned dissemination includes peer-reviewed publications and additional dissemination appropriate to target audiences, including policy briefs for policymakers, media/social-media coverage for public and conferences for researchTrial registration number ISRCTN82185177

Precision medicine in laryngeal cancer: protocol of the laryngeal cancer cohort (LARCH).

IntroductionLaryngeal cancer disproportionately affects socioeconomically disadvantaged patients. Treatment can render a patient nil by mouth or in need of a permanent tracheostomy. In the past 30 years, survival has remained at best static and at worst it has declined. Currently, there is no method of prognosticating how a patient will respond to treatment.The LARyngeal Cancer coHort (LARCH) aims to establish how survival and quality-of-life outcomes compare between surgery and (chemo)radiotherapy in early and advanced laryngeal cancer and how the presenting features of laryngeal cancer influence oncological, functional and quality-of-life outcome.Methods and analysisThis study is the first enhanced laryngeal cancer disease cohort. In the initial phase, we aim to deliver a prospective cohort study of 150 patients in 8 centres over a 3-year period.Patient, tumour, quality-of-life and laryngeal functional data will be collected from patients with squamous cell carcinoma of the larynx at baseline, 6, 12 and 24 months. Multiple logistic regression analyses will be used to quantify locoregional control and identify factors associated with control overall and by treatment modality and identify factors associated with quality of life overall and by treatment modality.Ethics and disseminationMost interventions take place as part of routine care, with LARCH providing a mechanism for recording this data centrally. When successfully recruiting in the North of England, we plan to roll out LARCH nationwide; in the future, LARCH can be used as a trial platform in the disease. The results will be submitted for publication in high-impact international peer-reviewed journals and presented to scientific meetings. Access to the anonymised LARCH dataset by other researchers will be publicised and promoted.Trial registration numberISRCTN27819867

Detection of early sub-clinical lung disease in children with cystic fibrosis by lung ventilation imaging with hyperpolarized gas MRI

Hyperpolarised 3He ventilation-MRI, anatomical lung MRI, lung clearance index (LCI), low-dose CT and spirometry were performed on 19 children (6–16 years) with clinically stable mild cystic fibrosis (CF) (FEV1>−1.96), and 10 controls. All controls had normal spirometry, MRI and LCI. Ventilation-MRI was the most sensitive method of detecting abnormalities, present in 89% of patients with CF, compared with CT abnormalities in 68%, LCI 47% and conventional MRI 22%. Ventilation defects were present in the absence of CT abnormalities and in patients with normal physiology, including LCI. Ventilation-MRI is thus feasible in young children, highly sensitive and provides additional information about lung structure–function relationships

Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA) : a multicentre, open-label, randomised controlled trial

This study was funded by the NIHR Health Technology Assessment programme (12/146/06).Background Tonsillectomy is regularly performed in adults with acute tonsillitis, but with scarce evidence. A reduction in tonsillectomies has coincided with an increase in acute adult hospitalisation for tonsillitis complications. We aimed to assess the clinical effectiveness and cost-effectiveness of conservative management versus tonsillectomy in patients with recurrent acute tonsillitis. Methods This pragmatic multicentre, open-label, randomised controlled trial was conducted in 27 hospitals in the UK. Participants were adults aged 16 years or older who were newly referred to secondary care otolaryngology clinics with recurrent acute tonsillitis. Patients were randomly assigned (1:1) to receive tonsillectomy or conservative management using random permuted blocks of variable length. Stratification by recruiting centre and baseline symptom severity was assessed using the Tonsil Outcome Inventory-14 score (categories defined as mild 0–35, moderate 36–48, or severe 49–70). Participants in the tonsillectomy group received elective surgery to dissect the palatine tonsils within 8 weeks after random assignment and those in the conservative management group received standard non-surgical care during 24 months. The primary outcome was the number of sore throat days collected during 24 months after random assignment, reported once per week with a text message. The primary analysis was done in the intention-to-treat (ITT) population. This study is registered with the ISRCTN registry, 55284102. Findings Between May 11, 2015, and April 30, 2018, 4165 participants with recurrent acute tonsillitis were assessed for eligibility and 3712 were excluded. 453 eligible participants were randomly assigned (233 in the immediate tonsillectomy group vs 220 in the conservative management group). 429 (95%) patients were included in the primary ITT analysis (224 vs 205). The median age of participants was 23 years (IQR 19–30), with 355 (78%) females and 97 (21%) males. Most participants were White (407 [90%]). Participants in the immediate tonsillectomy group had fewer days of sore throat during 24 months than those in the conservative management group (median 23 days [IQR 11–46] vs 30 days [14–65]). After adjustment for site and baseline severity, the incident rate ratio of total sore throat days in the immediate tonsillectomy group (n=224) compared with the conservative management group (n=205) was 0·53 (95% CI 0·43 to 0·65;Publisher PDFPeer reviewe

A proportionate, universal parenting programme to enhance social-emotional well-being in infants and toddlers in England : the E-SEE Steps RCT

Background Mental disorders have become a public health crisis. Early prevention is key. Parenting programmes are effective for children aged ≥ 3 years; however, there is a lack of evidence of their effectiveness for children aged ≤ 2 years. Objectives To establish if the model named Enhancing Social–Emotional Health and Well-being in the Early Years (E-SEE) Steps can (1) enhance child social emotional well-being and establish whether or not it is cost-effective at 20 months of age when compared with services as usual; and (2) be delivered as a proportionate universal model with fidelity. Design A pragmatic two-arm randomised controlled trial and economic appraisal, with an embedded process evaluation to examine the outcomes, implementation and cost-effectiveness of the intervention, and intervention uptake, compared with services as usual. The study had an external pilot phase (which was originally planned as an internal pilot). Setting The intervention was delivered in community settings by early years children’s services and/or public health staff in four sites. Participants A total of 341 parents of infants aged ≤ 8 weeks were randomised in a ratio of 5 : 1 (intervention, n = 285; control, n = 56). The target sample was 606 parents. Intervention Two Incredible Years® parenting programmes (i.e. infant and toddler) delivered in a proportionate universal model with three levels [one universal (book) and two targeted group-based parenting programmes]. Main outcome measures Child social and emotional well-being (primary outcome) was assessed using the Ages and Stages Questionnaire: Social and Emotional, 2nd edition, at 2, 9 and 18 months after randomisation. Parent depression (secondary key outcome) was assessed using the Patient Health Questionnaire-9 items. Both questionnaires were eligibility screeners for targeted groups. Results The primary outcome analysis provided no evidence that the E-SEE Steps model was effective in enhancing child social and emotional well-being. The adjusted mean difference was 3.02 on the original Ages and Stages Questionnaire: Social and Emotional, 2nd edition, in favour of the control [95% confidence interval –0.03 to 6.08; p = 0.052; N = 321 (intervention, n = 268; control, n = 53)]. Analysis of the key secondary outcome (i.e. parent depression levels as assessed by the Patient Health Questionnaire-9 items) provided weak evidence on the Patient Health Questionnaire-9 items in favour of the intervention (adjusted mean difference –0.61, 95% confidence interval –1.34 to 0.12; p = 0.1). Other secondary outcomes did not differ between arms. The economic analysis showed that the E-SEE Steps model was associated with higher costs and was marginally more effective (0.031 quality-adjusted life-years gained from E-SEE Steps compared with SAU, 95% confidence interval –0.008 to 0.071) than services as usual, resulting in an incremental cost-effectiveness ratio of approximately £20,062 per quality-adjusted life-year compared with services as usual. Overall take-up of the targeted parenting programmes was low. Sites, although enthusiastic, identified barriers to delivering the intervention. Limitations The target sample size was not met and the study was not powered to explore the effectiveness of each level of intervention. Most parents in the sample were well educated and, therefore, the results are unlikely to be generalisable, particularly to those at greatest risk of poor social and emotional well-being. Conclusions The E-SEE Steps proportionate universal model did not enhance child social and emotional well-being, but generated non-significant improvements in parent health outcomes, resulting in considerable uncertainty around the cost-effectiveness of the intervention. The primary and key secondary outcome gave inconsistent signals. Although, with system changes, increased resources and adaptations to the intervention, the model could be implemented, evidence for positive outcomes from the E-SEE Steps model is poor. Future work The universal-level E-SEE Step data (i.e. the Incredible Years book) from the external pilot will be pooled with the main trial data for further exploration up to follow-up 1, which is the time point at which most change was seen. Trial registration This trial is registered as ISRCTN11079129. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 8. See the NIHR Journals Library website for further project information