RESUMO
OBJECTIVES: Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache. METHODS: Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination. RESULTS: 5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%). CONCLUSION: The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning. TRIAL REGISTRATION NUMBER: ANZCTR376695.
Assuntos
Serviço Hospitalar de Emergência , Cefaleia , Valor Preditivo dos Testes , Humanos , Feminino , Serviço Hospitalar de Emergência/organização & administração , Masculino , Pessoa de Meia-Idade , Adulto , Cefaleia/etiologia , Cefaleia/diagnóstico , Sensibilidade e Especificidade , IdosoRESUMO
In 2021, there was a significant increase in the number of reported drink spiking incidents across the UK. The new phenomenon of spiking via injection also emerged, which gained significant media attention. Campaigns encouraged potential spiking victims to attend an ED for testing. However, there is limited published research on drink spiking and no published studies on injection spiking. One UK guideline for the management of spiking exists, advising testing 'if clinically indicated' and is likely underused. Therefore, patients are often managed without drug testing, psychological support or a clear onward referral pathway. This practice review will explore the background of spiking, discuss drug testing options and highlight the psychological sequelae of spiking. An example guideline for the management of spiking incidents is attached.
RESUMO
The perspective of patients is increasingly recognised as important to care improvement and innovation. Patient questionnaires such as patient-reported outcome measures may often require cross-cultural adaptation (CCA) to gather their intended information most effectively when used in cultures and languages different to those in which they were developed. The use of CCA could be seen as a practical step in addressing the known problems of inclusion, diversity and access in medical research.An example of the recent adaptation of a patient-reported outcome measure for use with ED patients is used to explore some key features of CCA, introduce the importance of CCA to emergency care practitioners and highlight the limitations of CCA.
Assuntos
Pesquisa Biomédica , Serviços Médicos de Emergência , Humanos , Comparação Transcultural , Serviço Hospitalar de Emergência , Inquéritos e QuestionáriosRESUMO
BACKGROUND AND AIM: Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. METHODS: This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. RESULTS: The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. CONCLUSIONS: This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required.
Assuntos
Transtornos de Enxaqueca , Proclorperazina , Adulto , Serviço Hospitalar de Emergência , Feminino , Humanos , Metoclopramida/uso terapêutico , Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/tratamento farmacológico , Transtornos de Enxaqueca/epidemiologia , Proclorperazina/uso terapêutico , Estudos ProspectivosRESUMO
BACKGROUND: Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as 'thunderclap' undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation. METHODS: This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test. RESULTS: 644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases-significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p<0.001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p<0.001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache. CONCLUSIONS: Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.
Assuntos
Transtornos da Cefaleia Primários , Hemorragia Subaracnóidea , Adulto , Humanos , Tomografia Computadorizada por Raios X/efeitos adversos , Transtornos da Cefaleia Primários/diagnóstico , Transtornos da Cefaleia Primários/epidemiologia , Transtornos da Cefaleia Primários/etiologia , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/diagnóstico por imagem , Serviço Hospitalar de Emergência , Cefaleia/diagnóstico , Cefaleia/etiologia , Estudos de CoortesRESUMO
OBJECTIVE: To describe the patterns of opioid use in patients presenting to the emergency department (ED) with nontraumatic headache by severity and geography. BACKGROUND: International guidelines recognize opioids are ineffective in treating primary headache disorders. Globally, many countries are experiencing an opioid crisis. The ED can be a point of initial exposure leading to tolerance for patients. More geographically diverse data are required to inform practice. METHODS: This was a planned, multicenter, cross-sectional, observational substudy of the international Headache in Emergency Departments (HEAD) study. Participants were prospectively identified throughout March 2019 from 67 hospitals in Europe, Asia, Australia, and New Zealand. Adult patients with nontraumatic headache were included as identified by the local site investigator. RESULTS: Overall, 4536 patients were enrolled in the HEAD study. Opioids were administered in 1072/4536 (23.6%) patients in the ED, and 386/3792 (10.2%) of discharged patients. High opioid use occurred prehospital in Australia (190/1777, 10.7%) and New Zealand (55/593, 9.3%). Opioid use in the ED was highest in these countries (Australia: 586/1777, 33.0%; New Zealand: 221/593, 37.3%). Opioid prescription on discharge was highest in Singapore (125/442, 28.3%) and Hong Kong (12/49, 24.5%). Independent predictors of ED opioid administration included the following: severe headache (OR 4.2, 95% CI 3.1-5.5), pre-ED opioid use (OR 1.42, 95% CI 1.11-1.82), and long-term opioid use (OR 1.80, 95% CI 1.26-2.58). ED opioid administration independently predicted opioid prescription at discharge (OR 8.4, 95% CI 6.3-11.0). CONCLUSION: Opioid prescription for nontraumatic headache in the ED and on discharge varies internationally. Severe headache, prehospital opioid use, and long-term opioid use predicted ED opioid administration. ED opioid administration was a strong predictor of opioid prescription at discharge. These findings support education around policy and guidelines to ensure adherence to evidence-based interventions for headache.
Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Transtornos da Cefaleia/tratamento farmacológico , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Ásia , Austrália , Estudos Transversais , Europa (Continente) , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Guias de Prática Clínica como AssuntoRESUMO
OBJECTIVE: To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). BACKGROUND: Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. METHODS: An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. RESULTS: We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526). CONCLUSION: Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Cefaleia/epidemiologia , Adulto , Ásia/epidemiologia , Australásia/epidemiologia , Estudos Transversais , Diagnóstico Diferencial , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/epidemiologia , Neuroimagem , Exame Neurológico , Estudos Retrospectivos , Hemorragia Subaracnóidea/epidemiologia , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: To quantify psychological distress experienced by emergency, anaesthetic and intensive care doctors during the acceleration phase of COVID-19 in the UK and Ireland. METHODS: Initial cross-sectional electronic survey distributed during acceleration phase of the first pandemic wave of COVID-19 in the UK and Ireland (UK: 18 March 2020-26 March 2020 and Ireland: 25 March 2020-2 April 2020). Surveys were distributed via established specialty research networks, within a three-part longitudinal study. Participants were doctors working in emergency, anaesthetic and intensive medicine during the first pandemic wave of COVID-19 in acute hospitals across the UK and Ireland. Primary outcome measures were the General Health Questionnaire-12 (GHQ-12). Additional questions examined personal and professional characteristics, experiences of COVID-19 to date, risk to self and others and self-reported perceptions of health and well-being. RESULTS: 5440 responses were obtained, 54.3% (n=2955) from emergency medicine and 36.9% (n=2005) from anaesthetics. All levels of doctor seniority were represented. For the primary outcome of GHQ-12 score, 44.2% (n=2405) of respondents scored >3, meeting the criteria for psychological distress. 57.3% (n=3045) had never previously provided clinical care during an infectious disease outbreak but over half of respondents felt somewhat prepared (48.6%, n=2653) or very prepared (7.6%, n=416) to provide clinical care to patients with COVID-19. However, 81.1% (n=4414) either agreed (31.1%, n=2709) or strongly agreed (31.1%, n=1705) that their personal health was at risk due to their clinical role. CONCLUSIONS: Findings indicate that during the acceleration phase of the COVID-19 pandemic, almost half of frontline doctors working in acute care reported psychological distress as measured by the GHQ-12. Findings from this study should inform strategies to optimise preparedness and explore modifiable factors associated with increased psychological distress in the short and long term. TRIAL REGISTRATION NUMBER: ISRCTN10666798.
Assuntos
COVID-19/epidemiologia , Medicina de Emergência/estatística & dados numéricos , Estresse Ocupacional/epidemiologia , Médicos/estatística & dados numéricos , Adulto , Idoso , Anestesia/estatística & dados numéricos , COVID-19/psicologia , Cuidados Críticos/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Irlanda/epidemiologia , Masculino , Pessoa de Meia-Idade , Estresse Ocupacional/etiologia , Médicos/psicologia , Angústia Psicológica , Inquéritos e Questionários , Reino Unido/epidemiologia , Adulto JovemRESUMO
Hypoxia can occur following rewetting of floodplains and cause severe impacts on aquatic biota and biogeochemical processes. The likelihood of such events is influenced by a number of factors including temperature, the mass of plant litter on the floodplain (which is influenced by the duration between inundation events), the volume of water available for dilution of oxygen-demanding dissolved organic matter, and the exchange of water to dilute and disperse that material. Using constructed infrastructure to generate managed inundations on floodplains increases the likelihood of hypoxic "blackwater" events relative to unregulated floods, as larger areas of floodplain are inundated at lower flow rates. A model (the "DODOC plugin") was developed for the Source hydrological modelling software to inform risk mitigation strategies for these managed inundation events. This development enables the interaction between complex hydrology and floodplain inundation on the resulting release of dissolved organic carbon (DOC), and subsequent consumption of dissolved oxygen (DO), to be represented. Key functionality of the plugin includes the ability to represent (i) spatial variability in organic litter build up and degradation, (ii) DOC leaching from litter when inundated, (iii) DO consumption arising from microbial decomposition of the DOC, and (iv) reaeration processes from autotrophic productivity and turbulence as water passes over water level regulating structures. The model is configurable on both river channels (links) and floodplains (storages) to represent changes in DO from both natural and managed inundation events at the scale of an individual floodplain up to multiple floodplains and river reaches. The plugin was parameterised to successfully simulate DOC (R2 = 0.84-0.93) and DO (R2 = 0.74-0.92) along an approx. 100 km study reach of the River Murray in South Australia, once the different behaviour of the labile and refractory components of the DOC was represented in the model. A number of hypothetical operational scenarios were tested using the model to demonstrate parameter sensitivity and to inform planning of managed inundations. The development of the DODOC plugin demonstrates that complex water quality processes can be integrated into the Source (or other) hydrological software, to represent cumulative implications of floodplain inundation events and to minimise the risk of hypoxia.
Assuntos
Hidrologia , Rios , Inundações , Humanos , Hipóxia , Austrália do SulRESUMO
BACKGROUND: Adverse effects on reproductive function are a key concern in young women treated with chemotherapy for advanced Hodgkin's lymphoma. We aimed to identify risk factors for the extent of ovarian damage in women with Hodgkin's lymphoma treated with different chemotherapy regimens to inform accurate advice on options for fertility preservation. METHODS: We recruited female participants from the randomised phase 3 RATHL trial, aged 18-45 years, based on availability of participants at recruiting sites in the UK. The RATHL trial key inclusion criteria were histologically confirmed classic Hodgkin's lymphoma, stage IIB-IV or IIA with adverse features (bulky disease or more than two sites of involvement), no previous treatments, and a performance status of 0-3. As part of RATHL, participants were treated with two cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) or AVD followed by an interim PET-CT scan. Participants who had negative interim scans (PET score of 1 to 3 according to the Lugano classification) were randomly assigned (1:1) by use of minimisation, stratified by interim PET score and study centre, to continue ABVD or AVD for four more cycles. Participants with positive scans (PET score of 4 or 5) were escalated to treatment with bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisolone (BEACOPP-14 or escalated BEACOPP) for four cycles. For the protocol-driven prospective cohort substudy, ovarian function was assessed before treatment, during chemotherapy, and then annually for 3 years by use of serum antimüllerian hormone and follicle-stimulating hormone measurements. The RATHL study is registered with ClinicalTrials.gov, number NCT00678327. FINDINGS: Between Dec 13, 2010, and Dec 19, 2012, 67 eligible participants were recruited for this prospective cohort study; 57 had received ABVD or AVD (ABVD-AVD group) and ten BEACOPP-14 or escalated BEACOPP (BEACOPP group). Follow-up was fixed at 3 years. Antimüllerian hormone concentrations decreased during both chemotherapy regimens. At 1 year after chemotherapy, antimüllerian hormone concentrations recovered to a median of 10·5 pmol/L (IQR 4·3-17·3) in the ABVD-AVD group, but little recovery was seen after BEACOPP (median 0·11 pmol/L [0·07-0·20]). Age also affected the extent of ovarian function recovery, with antimüllerian hormone recovery in participants aged 35 years or older in the ABVD-AVD group to 37% (SD 10) of their before treatment concentrations, compared with full recovery to 127% (SD 12) in those younger than 35 years (p<0·0001). Follicle-stimulating hormone recovery to less than 25 IU/L occurred for 95% of women younger than 35 years in the ABVD-AVD group by 2 years and was also dependent on age (hazard ratio 0·49, 95% CI 0·37-0·65; p<0·0001). INTERPRETATION: Reduced recovery of ovarian function observed in women older than 35 years treated with ABVD or AVD compared with younger women indicates that treatment could reduce their reproductive lifespan and supports discussion of fertility preservation before treatment. Women treated with BEACOPP should be informed of its potential high gonadotoxicity. These findings warrant further investigation in large, prospective studies with fertility and reproductive lifespan as outcomes. FUNDING: Medical Research Foundation and Cancer Research UK.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Doença de Hodgkin/tratamento farmacológico , Infertilidade Feminina/induzido quimicamente , Ovário/efeitos dos fármacos , Adolescente , Adulto , Fatores Etários , Hormônio Antimülleriano/sangue , Biomarcadores/sangue , Feminino , Preservação da Fertilidade , Hormônio Foliculoestimulante Humano/sangue , Doença de Hodgkin/diagnóstico por imagem , Doença de Hodgkin/patologia , Humanos , Infertilidade Feminina/sangue , Infertilidade Feminina/fisiopatologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Ovário/metabolismo , Ovário/fisiopatologia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Estudos Prospectivos , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Reino Unido , Adulto JovemRESUMO
Correct regulation of troponin and myosin contractile protein gene isoforms is a critical determinant of cardiac and skeletal striated muscle development and function, with misexpression frequently associated with impaired contractility or disease. Here we reveal a novel requirement for Prospero-related homeobox factor 1 (Prox1) during mouse heart development in the direct transcriptional repression of the fast-twitch skeletal muscle genes troponin T3, troponin I2, and myosin light chain 1. A proportion of cardiac-specific Prox1 knockout mice survive beyond birth with hearts characterized by marked overexpression of fast-twitch genes and postnatal development of a fatal dilated cardiomyopathy. Through conditional knockout of Prox1 from skeletal muscle, we demonstrate a conserved requirement for Prox1 in the repression of troponin T3, troponin I2, and myosin light chain 1 between cardiac and slow-twitch skeletal muscle and establish Prox1 ablation as sufficient to cause a switch from a slow- to fast-twitch muscle phenotype. Our study identifies conserved roles for Prox1 between cardiac and skeletal muscle, specifically implicated in slow-twitch fiber-type specification, function, and cardiomyopathic disease.
Assuntos
Cardiomiopatia Dilatada/metabolismo , Regulação da Expressão Gênica no Desenvolvimento/fisiologia , Músculo Estriado/embriologia , Miocárdio/metabolismo , Proteínas Supressoras de Tumor/deficiência , Animais , Diferenciação Celular/fisiologia , Imunoprecipitação da Cromatina , Primers do DNA/genética , Imunofluorescência , Proteínas de Homeodomínio/genética , Camundongos , Camundongos Knockout , Análise em Microsséries , Músculo Estriado/metabolismo , Cadeias Leves de Miosina/metabolismo , Reação em Cadeia da Polimerase em Tempo Real , Troponina/metabolismo , Troponina I/metabolismo , Proteínas Supressoras de Tumor/genéticaAssuntos
Anestesia/tendências , COVID-19/epidemiologia , Cuidados Críticos/tendências , Medicina de Emergência/tendências , Médicos/tendências , Angústia Psicológica , Adulto , Anestesia/psicologia , COVID-19/psicologia , COVID-19/terapia , Estudos de Coortes , Cuidados Críticos/psicologia , Feminino , Humanos , Irlanda/epidemiologia , Estudos Longitudinais , Masculino , Pandemias , Médicos/psicologia , Estudos Prospectivos , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Inquéritos e Questionários , Reino Unido/epidemiologiaRESUMO
Loneliness is a near-universal experience. It is particularly common for individuals with (so-called) psychopathological conditions or disorders. In this paper, we explore the experiential character of loneliness, with a specific emphasis on how social goods are experienced as absent in ways that involve a diminished sense of agency and recognition. We explore the role and experience of loneliness in three case studies: depression, anorexia nervosa, and autism. We demonstrate that even though experiences of loneliness might be common to many psychopathologies, these experiences nevertheless have distinctive profiles. Specifically, we suggest that: (i) loneliness is often a core characteristic of depressive experience; (ii) loneliness can drive, and even cement, disordered eating practices and anorectic identity in anorexia nervosa; iii) loneliness is neither a core characteristic of autism nor a driver but is rather commonly experienced as stemming from social worlds, environments, and norms that fail to accommodate autistic bodies and their distinctive forms of life. We aim to do justice to the pervasiveness of loneliness in many - if not all - psychopathologies, while also highlighting the need to attend to psychopathology-specific experiences of loneliness, agency, and (non-)recognition.
RESUMO
BACKGROUND AND IMPORTANCE: Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs). OBJECTIVE: To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions. DESIGN: Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019. SETTING AND PARTICIPANTS: Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems. OUTCOME MEASURES AND ANALYSIS: The outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems. MAIN RESULTS: The study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%). Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield ( r â =â -0.248). CONCLUSION: In this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations.
Assuntos
Cefaleia , Tomografia Computadorizada por Raios X , Adulto , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Estudos Transversais , Cefaleia/diagnóstico por imagem , Serviço Hospitalar de Emergência , Neuroimagem , EncéfaloRESUMO
OBJECTIVE: To describe the characteristics, assessment and management of older emergency department (ED) patients with non-traumatic headache. METHODS: Planned sub-study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non-traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. RESULTS: A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). CONCLUSIONS: Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non-traumatic headache.
Assuntos
Cefaleia , Hemorragia Subaracnóidea , Idoso , Estudos de Coortes , Serviço Hospitalar de Emergência , Cefaleia/diagnóstico , Cefaleia/epidemiologia , Cefaleia/etiologia , Humanos , Estudos Prospectivos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/epidemiologiaRESUMO
In addiction, apparently causally significant phenomena occur at a huge number of levels; addiction is affected by biomedical, neurological, pharmacological, clinical, social, and politico-legal factors, among many others. In such a complex, multifaceted field of inquiry, it seems very unlikely that all the many layers of explanation will prove amenable to any simple or straightforward, reductive analysis; if we are to unify the many different sciences of addiction while respecting their causal autonomy, then, what we are likely to need is an integrative framework. In this paper, we propose the theory of "Externalist" or "4E" - for extended, embodied, embedded, and enactive - cognition, which focuses on the empirical and conceptual centrality of the wider extra-neural environment to cognitive and mental processes, as a candidate for such a framework. We begin in Section 2 by outlining how such a perspective might apply to psychiatry more generally, before turning to some of the ways it can illuminate addiction in particular: Section 3 points to a way of dissolving the classic dichotomy between the "choice model" and "disease model" in the addiction literature; Section 4 shows how 4E concepts can clarify the interplay between the addict's brain and her environment; and Section 5 considers how these insights help to explain the success of some recovery strategies, and may help to inform the development of new ones.
Assuntos
Comportamento Aditivo , Transtornos Mentais , Modelos Psicológicos , Teoria Psicológica , HumanosRESUMO
This study aimed to gain an uncensored insight into the most difficult aspects of working as a frontline doctor across successive COVID-19 pandemic waves. Data collected by the parent study (CERA) was analysed using conventional content analysis. Participants comprised frontline doctors who worked in emergency, anaesthetic, and intensive care medicine in the UK and Ireland during the COVID-19 pandemic (n = 1379). All seniority levels were represented, 42.8% of the sample were male, and 69.2% were white. Four themes were identified with nine respective categories (in parentheses): (1) I'm not a COVID hero, I'm COVID cannon fodder (exposed and unprotected, "a kick in the teeth"); (2) the relentlessness and pervasiveness of COVID ("no respite", "shifting sands"); (3) the ugly truths of the frontline ("inhumane" care, complex team dynamics); (4) an overwhelmed system exacerbated by COVID (overstretched and under-resourced, constant changes and uncertainty, the added hinderance of infection control measures). Findings reflect the multifaceted challenges faced after successive pandemic waves; basic wellbeing needs continue to be neglected and the emotional impact is further pronounced. Steps are necessary to mitigate the repeated trauma exposure of frontline doctors as COVID-19 becomes endemic and health services attempt to recover with inevitable long-term sequelae.
Assuntos
COVID-19 , Médicos , Humanos , Masculino , Pandemias , Pesquisa Qualitativa , SARS-CoV-2RESUMO
This study aimed to develop empirically grounded recommendations and a coherent model of psychological care derived from the experiences and psychological care needs of COVID-19 frontline doctors, using semi-structured interviews and thematic analysis. Participants were UK frontline doctors specialising in Emergency Medicine, Anaesthetics, or Intensive Care (n = 31) purposively sampled for maximum variation on gender, specialty, ethnicity, and trauma-related distress; most worked in ICU during the pandemic (71%). Four themes were derived: (1) 'coping strategies', participants used many, including exercise, mindfulness, and "wait until it gets really bad"; (2) 'sources of support', participants valued embedded psychological support, digital services, and informal conversations with colleagues or family, though there was little opportunity; (3) 'organisational influences on wellbeing', participants reported a love-hate relationship for concepts like 'wellbeing', seen as important but insulting when basic workplace needs were unmet; (4) 'improving engagement with support', analysis suggests we must reduce physical and psychological barriers to access and encourage leaders to model psychologically supportive behaviours. Doctors' frontline COVID-19 working experiences shine a 'spotlight' on pre-existing problems such as lack of physical resources and access to psychological care. Empirically grounded recommendations and a model of incremental psychological care are presented for use in clinical services.
Assuntos
COVID-19 , Médicos , Estudos de Coortes , Humanos , Pandemias , SARS-CoV-2RESUMO
BACKGROUND AND IMPORTANCE: Need for recovery (NFR) describes an individual's need to physically and psychologically recuperate following a period of work. Physicians working in emergency departments (EDs) have higher NFR scores than other occupational groups. Increased NFR may precede occupational burnout and identification provides opportunities for early interventions. OBJECTIVE: To identify the incidence of well-being characteristics for ED physicians and to determine if NFR score is associated with these characteristics, whilst adjusting for potential confounders. DESIGN: This is a secondary analysis of a survey study. Responses to 11 items were summated into the NFR score, from 0 (lowest NFR) to 100. Additional items (n = 44) explored well-being, demographic and occupational characteristics. SETTING AND PARTICIPANTS: Physicians working within 112 EDs in the UK and Ireland were surveyed in June-July 2019. OUTCOME MEASURE AND ANALYSIS: The outcome measure was self-perceptions of well-being including; current burnout, risk of future burnout and feeling overwhelmed at work. Descriptive statistics are presented alongside findings of a multiple regression analysis. MAIN RESULTS: In 4365 participants, the self-perceived incidence of current burnout, high risk of future burnout and feeling overwhelmed at work more than once a week was 24.8, 62.7 and 45.1%, respectively. For every unfavourable response of the NFR scale there was an increase in odds of 34.0% (95% CI, 31.0-37.1) for frequency of feeling overwhelmed; 53.8% (95% CI, 47.5-60.4) for current burnout; 56.2% (95% CI, 51.1-61.6) for high risk of future burnout. CONCLUSION: This study confirms an association between increased NFR score and self-perceived well-being characteristics. Factors previously reported to reduce NFR could therefore be important initiatives to improve well-being of the ED workforce.