Qualitative interview study of patients', ambulance practitioners' and emergency department clinicians' perceptions of prehospital pain management

Introduction Pre-hospital pain management is increasingly important with most patients (80%) presenting to UK ambulance services in pain and 20% of patients reporting inadequate pain relief. Improving prehospital pain management is important for service quality. Our aim was to investigate perceptions of pain management from patients, ambulance and emergency care staff. Methods Qualitative data were gathered through focus group (5) and interviews (28). Participants were purposively sampled from patients recently transported to hospital in pain, ambulance staff and emergency department clinicians. Interviews were audiotaped and transcribed using thematic analysis to iteratively develop themes supported by data analysis software, MAXQDA. Results Themes emerging from the data included: (a) expectations and beliefs (b) assessment methods (c) drug treatment (d) non-drug treatment and (f) improvement strategies for pain. Patients and staff expected pain to be relieved in the ambulance; instances of refusal of or inadequate analgesia were not uncommon because patients were concerned about drug side effects or, did not want to be transported. Pain was commonly assessed using a verbal pain score; clinical observation was often discordant with subjective experience. Communication difficulties, non-cooperation or influence of alcohol or drugs were found as barriers to pain assessment. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Suggestions to improve prehospital pain management included addressing barriers, modifying the available drugs and developing agreed multi-organisational pain management protocols supported by training for staff. Discussion Patients and practitioners expected pain to be relieved in the ambulance. Suggestions to improve prehospital pain management included addressing identified barriers, modifying the available drugs, using non-drug measures and developing agreed multi-organisational pain management protocols supported by appropriate training for staff. Our findings will inform development of protocols and quality improvement programmes along the pathway of prehospital pain management

Reliability and validity of an Ambulance Patient Reported Experience Measure (A-PREM): pilot study

Background There are no prehospital ambulance Patient Reported Experience Measures (A-PREMs) routinely used to support service comparisons and improvement. We developed an A-PREM, generating items through secondary analysis of ambulance patient interview data, and refining the instrument using expert assessment and cognitive interviews of service users. We aimed to pilot the A-PREM (48 experience and 12 attribute items) investigating user acceptability, reliability and construct validity. Methods Ambulance users attended by a UK regional ambulance service within the previous six months, excluding those suffering cardiac arrest, were sent a self-administered A-PREM. Returned questionnaires were entered into Microsoft Excel and imported into SPSS v22 for analysis. Experience items were recoded to range from 0 (don’t know/can’t remember) to 3 (best recorded experience). Descriptive analysis for item frequencies and missing values, reliability analyses for potential scales and tests of correlation and association were conducted. Results In all, 111 A-PREMs (22.2%) were returned. Missing data were highest for call-taking items. There was a significant association with a shorter wait for first response for four items measuring overall experience of call-taking (χ, p=0.05), ambulance staff (p<0.001), ambulance overall (p=0.001) and A&E (p=0.023). Four separate experience scales encompassing call taking (AmbCallScore, α=0.91), care at scene (AmbCareScore, α=0.90), care on leaving the patient (AmbLeaveScore, α=0.69), and care on transport (AmbTranScore α=0.71), showed satisfactory to high internal consistencies and distributions indicating generally positive experiences. AmbCallScore, AmbCareScore and AmbLeaveScore showed significantly higher scores (ANOVA) with shorter wait to first response. There were no significant differences for overall measures or scales by sex or age of participant, whether they were transported to hospital or not and whether it was their first experience of the ambulance service. Conclusion Our findings show that the A-PREM should be tested more widely for evidence of reliability, validity and sensitivity to different care and settings

Efficacy of Intravitreal dexamethasone implant in different patterns of diabetic macular edema

Purpose: Different patterns of diabetic macular edema (DME) suggest different pathogenesis and drug response. We evaluated the outcomes after intravitreal dexamethasone (DEX) implant for DME with or without serous retinal detachment (SRD). Methods: In this retrospective study, 22 naïve patients (23 eyes) with DME who underwent a single DEX implant were evaluated. Based on the optical coherence tomographic pattern of DME, 12 eyes had a cystoid macular edema pattern (Group 1) and 11 eyes had an SRD pattern (Group 2). The best-corrected visual acuity (BCVA), central retinal thickness (R), central retinal volume (CRV), SRD height (SRDh), and intraocular pressure (IOP) were recorded before and at two and four months after the treatment. Results: There were no significant differences between the groups regarding demographic, clinical data and outcomes at baseline. In Group 1, the CRT and CRV significantly decreased at two months (P = 0.002 and P = 0.01, respectively), while the BCVA significantly improved at four months (P = 0.03). In Group 2, the CRT and CRV significantly improved (P &lt; 0.01 and P ≤ 0.01, respectively) during the follow-up period. At four months, both groups showed a recurrence of DME, Group 1 in particular (two-month CRT reduction, -149 ± 127 μm vs four-month CRT reduction, -72 ± 174 μm; P = 0.04). The mean reduction in CRV was significantly different at four months (Group 1, -0.49 ± 1.7 mm3vs Group 2, -1.3 ± 1.3 mm3; P = 0.04). In Group 2, the SRDh significantly decreased at two (P = 0.01) and four months (P = 0.01). Four cases with elevated IOP were managed. Conclusion: DEX implants were found to be effective in different patterns of DME. The SRD pattern may predict a longer-lasting morphologic efficacy

A SURVEY ON THE FRAUDULENT USE OF ANABOLIC SUBSTANCES IN BOVINES SLAUGHTERED IN MOLISE

An investigation has been performed on the fraudulent use of anabolic substances in the Region of Molise. One hundred fourty-four bovines (12-24 months old, 123 males and 21 females) have been included in the survey. Ante-mortem assessment on their behaviour and clinical analysis on some target organs were carried out. After slaughtering, samples of prostate, bulbo-urethral glands, Bartholin's glands, mammary gland, ovaries, thymus and thyroid were collected and processed for an anatomo-histopathological evaluation, as suggested in the guidelines of the Italian National Plan for Residues (PNR) 2009. Overall, the 15% of the subjects analysed have been classified as "suspect", whereas the 44% as "uncertain" and the remaining 59% as "negative". The lesion most frequently found was a serious atrophy of the thymic parenchyma with fat infiltration (15% of males and 14% of females), suggesting a prevalence of an illegal use of cortisonic drugs