Multicentre open label randomised controlled trial of immediate enhanced ambulatory ECG monitoring versus standard monitoring in acute unexplained syncope patients:the ASPIRED study

Introduction Diagnosing underlying arrhythmia in emergency department (ED) syncope patients is difficult. There is a evidence that diagnostic yield for detecting underlying arrhythmia is highest when cardiac monitoring devices are applied early, ideally at the index visit. This strategy has the potential to change current syncope management from low diagnostic yield Holter to higher yield ambulatory monitoring, reduce episodes of syncope, reduce risk of recurrence and its potential serious consequences, reduce hospital admissions, reduce overall health costs and increase quality of life by allowing earlier diagnosis, treatment and exclusion of clinically important arrhythmias. Methods and analyses This is a UK open prospective parallel group multicentre randomised controlled trial of an immediate 14-day ambulatory patch heart monitor vs standard care in 2234 patients presenting acutely with unexplained syncope. Our patient focused primary endpoint will be number of episodes of syncope at 1 year. Health economic evaluation will estimate the incremental cost per syncope episode avoided and quality-adjusted life year gained. Ethics and dissemination Informed consent for participation will be sought. The ASPIRED trial received a favourable ethical opinion from South East Scotland Research Ethics Committee 01 (21/SS/0073). Results will be disseminated via scientific publication, lay summary and visual abstract

Classification of patient-safety incidents in primary care

Primary care lags behind secondary care in the reporting of, and learning from, incidents that put patient safety at risk. In primary care, there is no universally agreed approach to classifying the severity of harm arising from such patient-safety incidents. This lack of an agreed approach limits learning that could lead to the prevention of injury to patients. In a review of research on patient safety in primary care, we identified 21 existing approaches to the classification of harm severity. Using the World Health Organization's (WHO's) International Classification for Patient Safety as a reference, we undertook a framework analysis of these approaches. We then developed a new system for the classification of harm severity. To assess and classify harm, most existing approaches use measures of symptom duration (11/21), symptom severity (11/21) and/or the level of intervention required to manage the harm (14/21). However, few of these approaches account for the deleterious effects of hospitalization or the psychological stress that may be experienced by patients and/or their relatives. The new classification system we developed builds on WHO's International Classification for Patient Safety and takes account not only of hospitalization and psychological stress but also of so-called near misses and uncertain outcomes. The constructs we have outlined have the potential to be applied internationally, across primary-care settings, to improve both the detection and prevention of incidents that cause the most severe harm to patients

One size does not fit all:Toward regional conservation practice guidance to reduce phosphorus loss risk in the Lake Erie watershed

Agricultural phosphorus (P) losses to surface water bodies remain a global eutrophication concern, despite the application of conservation practices on farm fields. Although it is generally agreed upon that the use of multiple conservation practices (“stacking”) will lead to greater improvements to water quality, this may not be cost effective to farmers, reducing the likelihood of adoption. At present, wholesale recommendations of conservation practices are given; however, the application of specific conservation practices in certain environments (e.g., no-till with surface application, cover crops) may not be effective and can even lead to unintended consequences. In this paper, we present the Lake Erie watershed as a case study. The Lake Erie watershed contains regions with unique physical geographies that include differences in climate, soil, topography, and land use, which have implications for both P transport from agricultural fields and the efficacy of conservation practices in mitigating P losses. We define major regions within the Lake Erie watershed where common strategies for conservation practice implementation are appropriate, and we propose a five-step plan for bringing regionally tailored, adaptive, and cost-conscious conservation practice into watershed planning. Although this paper is specific to the Lake Erie watershed, our framework can be transferred across broader geographic regions to provide guidance for watershed planning