Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial.

BACKGROUND: Supporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention if it is sufficiently resourced. The objective of this trial was to determine whether an opportunistic ED-based smoking cessation intervention can help people to quit smoking. METHODS: In this multicentre, parallel-group, randomised controlled superiority trial conducted between January and August 2022, adults who smoked daily and attended one of six UK EDs were randomised to intervention (brief advice, e-cigarette starter kit and referral to stop smoking services) or control (written information on stop smoking services). The primary outcome was biochemically validated abstinence at 6 months. RESULTS: An intention-to-treat analysis included 972 of 1443 people screened for inclusion (484 in the intervention group, 488 in the control group). Of 975 participants randomised, 3 were subsequently excluded, 17 withdrew and 287 were lost to follow-up. The 6-month biochemically-verified abstinence rate was 7.2% in the intervention group and 4.1% in the control group (relative risk 1.76; 95% CI 1.03 to 3.01; p=0.038). Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (relative risk 1.80; 95% CI 1.36 to 2.38; p<0.001). No serious adverse events related to taking part in the trial were reported. CONCLUSIONS: An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events. TRIAL REGISTRATION NUMBER: NCT04854616.

Selecting an e-cigarette for use in smoking cessation interventions and healthcare services: findings from patient and public consultation for the COSTED trial.

OBJECTIVES: The Cessation of Smoking Trial in the Emergency Department (COSTED) trial aims to ascertain whether brief advice, the provision of an e-cigarette starter kit and referral to stop smoking services (SSS), increases smoking cessation in people attending the emergency department. Patient and public involvement (PPI) and scoping work were undertaken to select an appropriate e-cigarette for the trial. DESIGN AND SETTING: PPI consultation and feasibility scoping about potential devices with a professional and lay panel, all based in England. Consultation was via email, telephone or video interview. This work took place between April and July 2021, prior to recruitment commencing for the COSTED trial. PARTICIPANTS: A professional panel (n=7) including representatives from academia, SSS and the independent vaping industry, and a PPI lay panel (n=3) who smoke or vape. RESULTS: The professional panel recommended a shortlist of devices which were tested by the PPI lay panel. Key criteria for selecting an appropriate e-cigarette for smoking cessation intervention include satisfaction, usability, affordability and availability. Simplicity of use was highlighted by the PPI lay panel, who found refillable devices complex, and availability of consumables was highlighted as more important than price by both panels. The pod device selected for inclusion was rated highly for satisfaction and usability and had mid-price range and consumables which were widely available. CONCLUSIONS: To select the most appropriate device for the COSTED trial, each criterion required assessment to ensure the best fit to the intervention context and needs of the target population. There is a need for guidance to help enable decision-making about choice of vape products, tailored to service users' needs. We propose a bespoke checklist template, based on our findings, to assist with this process. This has applicability to the recent government announcement of a 'Swap to Stop' programme, offering a vaping starter kit to smokers across England, allowing services flexibility to shape their own programmes and models of delivery. TRIAL REGISTRATION NUMBER: Clinical trial number NCT04854616; pre-results.

Do standard behavioral assays predict foraging behavior of individual Black-capped chickadees (Poecile atricapillus) in response to a predator model or calls?

Black-capped chickadees (Poecile atricapillus) and other species that feed at bird feeders balance the benefit of easy foraging with the added risk of predation. Individual birds respond differently to risky situations, and these differences have been attributed to the birds' personalities, which researchers commonly assess with an "open-field" behavioral assay. However, these behavioral assays in birds have not been compared to behavior in the wild in the context of foraging in the presence of a predator (i.e., risk-taking behavior). We color-banded chickadees in a wild population and conducted behavioral assays in the field. We later used foraging trials to investigate these color-banded individuals' responses to a predator (Cooper's hawk, Accipiter cooperii) model or a series of Cooper's hawk calls. We found that foraging black-capped chickadees responded more strongly to the presence of a predator model than to predator calls. Individual birds differed in their responses, and the behavioral assays (activity and exploration) predicted individual behavior in the wild during the foraging experiments. Activity and exploration assay scores were only weakly related, suggesting these two assays represent different traits. Both highly active birds and fast explorers exhibited some reluctance to visit the feeder (either reduced number of visits or greater latency to visit) when the predator model was present, a relationship that was somewhat unexpected. Our results suggest that standard behavioral assays predict behavior in the wild, but care should be taken when generalizing among species and studies. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Biochemical Verification of Tobacco-Use as an Inclusion Criterion in Smoking Cessation Trials- Lessons From the Cessation of Smoking Trial in the Emergency Department.

INTRODUCTION: Biochemical verification of smoking status prior to recruitment into smoking cessation trials is widely used to confirm smoking status, most commonly using exhaled carbon monoxide (CO). There is variation in the level of CO used as a biochemical inclusion criterion, and thus the possibility for people reporting to be current smokers to be incorrectly excluded from trials. METHODS: As part of the Cessation of Smoking Trial in the Emergency Department, people attending the Emergency Department (ED) who reported being current daily smokers underwent CO testing to confirm eligibility. Elective semi-structured interviews were undertaken with the researchers who recruited participants. As part of the interviews, researchers were asked their views and experiences with CO testing. RESULTS: Of the 1320 participants who reported being current daily smokers and underwent CO testing, 300 (22.7%) blew a CO reading of 7 ppm or less and were excluded from taking part. Possible explanations offered by researchers for participants blowing low CO readings were (1) long wait times in the ED, therefore a long period having elapsed since people had last smoked and (2) patients having reduced smoking for the period before the ED attendance due to ill health. CONCLUSIONS: Biochemical verification has the potential to improve internal validity of smoking cessation for inclusion in trials, but at the cost of reduced generalisability through exclusion of participants who would receive the intervention if it were implemented in practice. We would recommend researchers carefully consider whether it is appropriate and necessary to include biochemical verification as an inclusion criterion.

Cessation of smoking trial in the emergency department (CoSTED): protocol for a multicentre randomised controlled trial.

INTRODUCTION: Attendees of emergency departments (EDs) have a higher than expected prevalence of smoking. ED attendance may be a good opportunity to prompt positive behaviour change, even for smokers not currently motivated to quit. This study aims to determine whether an opportunist smoking cessation intervention delivered in the ED can help daily smokers attending the ED quit smoking and is cost-effective. METHODS AND ANALYSIS: A two-arm pragmatic, multicentred, parallel-group, individually randomised, controlled superiority trial with an internal pilot, economic evaluation and mixed methods process evaluation. The trial will compare ED-based brief smoking cessation advice, including provision of an e-cigarette and referral to local stop smoking services (intervention) with the provision of contact details for local stop smoking services (control). Target sample size is 972, recruiting across 6 National Health Service EDs in England and Scotland. Outcomes will be collected at 1, 3 and 6 months. The primary outcome at 6 months is carbon monoxide verified continuous smoking abstinence. ETHICS AND DISSEMINATION: The trial was approved by the South Central-Oxford B Research Committee (21/SC/0288). Dissemination will include the publication of outcomes, and the process and economic evaluations in peer-reviewed journals. The findings will also be appropriately disseminated to relevant practice, policy and patient representative groups. TRIAL REGISTRATION NUMBER: NCT04854616; protocol V.4.2.

Feasibility and evaluation of an emergency department-based general practitioner streaming and treatment service.

RATIONALE: Offering a primary care service that can provide good quality primary care at emergency departments may reduce pressure on usual emergency department (ED) services. AIMS AND OBJECTIVES: To evaluate the acceptability, satisfaction, and potential impacts of a co-located primary care service at an emergency department. METHODS: This is a prospective feasibility study and service evaluation comprising a narrative summary of activity, satisfaction, well-being, and safety, and comparisons of wait times for ED services by patient category ('minor', 'majors', 'paediatric' or 'resus') before and during the service operation. Patients and staff were asked using semistructured interview topic guides about service perception, well-being, representation within 48 h, safety concerns, and/or satisfaction. Wait times for patient categories in usual ED care service were in secondary care electronic records. Pathway changes were captured under primary care electronic records. RESULTS: Approximately 96% of general practitioner streaming and treatment (GPST) patients were seen within 1 h. There was a statistically significant reduction in ED patients with minor injuries or illnesses waiting >4 h for admission or discharge 'breaches' during the 3 months that GPST was operating compared with the previous 3 months (p ≤ 0.005). Wait times for other ED services did not significantly improve. A total of 769 walk-in patients received GPST consultation and 661 (86%) needed no further ED intervention. Fast discharge was a major determinant of patient satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in eligibility criteria and built environment design features. CONCLUSION: Provision of GPST correlated with shorter waits for discharge from ED. Patient and staff experiences of GPST were positive.

Microscopic resection margins adversely influence survival rates after surgery for colorectal liver metastases: An open ambidirectional Cohort Study.

BACKGROUND: Liver resection is the most effective treatment for patients with colorectal liver metastases (CRLMs). Patients with tumour at the resection margin (R1) are reported to have worse survival compared to those with an uninvolved resection margin (R0). Recent data has questioned this finding. This study investigates whether R1 resections adversely influence survival when compared to R0 resections. MATERIAL AND METHODS: Patients undergoing surgery for CRLM, identified from a prospectively maintained database, from January 2007 to January 2017, were included. Univariate and multivariate survival analyses were performed. p < 0.05 was significant. RESULTS: 282 patients were included. Median age 72 (32-90) years. 236 patients (83.7%) had chemotherapy and surgery, whilst 46 (16.3%) had surgery alone. 149 patients (52.8%) were alive at the end of the study period. R1 resection on univariate survival analysis was associated with better survival (HR 2.12, 95%CI 1.60-4.61, p = 0.0002). Multivariate analysis controlling for age and gender, identified presence of extrahepatic disease (HR 2.03, 95%CI 1.17-3.52, p < 0.001), R0 resection (HR 0.33, 95%CI 0.19-0.59, p = 0.003), primary tumour stage (HR 1.57, 95%CI 1.04-2.40, p = 0.034) and primary tumour differentiation (HR 2.56, 95%CI 1.01-6.46, p = 0.047), as prognostic factors for poorer survival. Five-year and 10-year survival were 54.3% and 41.7% respectively in patients with an R0 resection and, 25.8% and 17.2% in those with an R1 resection. CONCLUSION: The presence of extrahepatic disease, an R1 resection margin, advanced T-stage and poorer tumour differentiation were associated with worse survival in CRLM surgery and R0 resection is recommended.

Short-stay admissions at an inner city hospital: a cross-sectional analysis.

OBJECTIVE: To investigate factors predictive of short hospital admissions and appropriate placement to inpatient versus clinical decision units (CDUs). METHOD: This is a retrospective analysis of attendance and discharge data from an inner-city ED in England for December 2013. The primary outcome was admission for less than 48 hours either to an inpatient unit or CDU. Variables included: age, gender, ethnicity, deprivation score, arrival date and time, arrival method, admission outcome and discharge diagnosis. Analysis was performed by cross-tabulation followed by binary logistic regression in three models using the outcome measures above and seeking to identify factors associated with short-stay admission. RESULTS: There were 2119 (24%) admissions during the study period and 458 were admitted for less than 24 hours. Those who were admitted in the middle of the week or with ambulatory care sensitive conditions (ACSCs) were significantly more likely to experience short-stays. Older patients and those who arrived by ambulance were significantly more likely to have a longer hospital stay. There was no association of length of inpatient stay with being admitted in the last 10 min of a 4 hours ED stay. CONCLUSION: Only a few factors were independently predictive of short stays. Patients with ACSCs were more likely to have short stays, regardless of whether they were admitted to CDU or an inpatient ward. This may be a group of patients that could be targeted for dedicated outpatient management pathways or CDU if they need admission.

A qualitative study exploring the factors influencing admission to hospital from the emergency department.

OBJECTIVE: The number of emergency admissions to hospital in England and Wales has risen sharply in recent years and is a matter of concern to clinicians, policy makers and patients alike. However, the factors that influence this decision are poorly understood. We aimed to ascertain how non-clinical factors can affect hospital admission rates. METHOD: We conducted semistructured interviews with 21 participants from three acute hospital trusts. Participants included 11 emergency department (ED) doctors, 3 ED nurses, 3 managers and 4 inpatient doctors. A range of seniority was represented among these roles. Interview questions were developed from key themes identified in a theoretical framework developed by the authors to explain admission decision-making. Interviews were recorded, transcribed and analysed by two independent researchers using framework analysis. FINDINGS: Departmental factors such as busyness, time of day and levels of senior support were identified as non-clinical influences on a decision to admit rather than discharge patients. The 4-hour waiting time target, while overall seen as positive, was described as influencing decisions around patient admission, independent of clinical need. Factors external to the hospital such as a patient's social support and community follow-up were universally considered powerful influences on admission. Lastly, the culture within the ED was described as having a strong influence (either negatively or positively) on the decision to admit patients. CONCLUSION: Multiple factors were identified which go some way to explaining marked variation in admission rates observed between different EDs. Many of these factors require further inquiry through quantitative research in order to understand their influence further.

Risk factors for admission at three urban emergency departments in England: a cross-sectional analysis of attendances over 1 month.

OBJECTIVE: To investigate factors associated with unscheduled admission following presentation to emergency departments (EDs) at three hospitals in England. DESIGN AND SETTING: Cross-sectional analysis of attendance data for patients from three urban EDs in England: a large teaching hospital and major trauma centre (site 1) and two district general hospitals (sites 2 and 3). Variables included patient age, gender, ethnicity, deprivation score, arrival date and time, arrival by ambulance or otherwise, a variety of ED workload measures, inpatient bed occupancy rates and admission outcome. Coding inconsistencies in routine ED data used for this study meant that diagnosis could not be included. OUTCOME MEASURE: The primary outcome for the study was unscheduled admission. PARTICIPANTS: All adults aged 16 and older attending the three inner London EDs in December 2013. Data on 19 734 unique patient attendances were gathered. RESULTS: Outcome data were available for 19 721 attendances (>99%), of whom 6263 (32%) were admitted to hospital. Site 1 was set as the baseline site for analysis of admission risk. Risk of admission was significantly greater at sites 2 and 3 (adjusted OR (AOR) relative to site 1 for site 2 was 1.89, 95% CI 1.74 to 2.05, p<0.001) and for patients of black or black British ethnicity (AOR 1.29, 1.16 to 1.44, p<0.001). Deprivation was strongly associated with admission. Analysis of departmental and hospital-wide workload pressures gave conflicting results, but proximity to the "4-hour target" (a rule that limits patient stays in EDs to 4 hours in the National Health Service in England) emerged as a strong driver for admission in this analysis (AOR 3.61, 95% CI 3.30 to 3.95, p<0.001). CONCLUSION: This study found statistically significant variations in odds of admission between hospital sites when adjusting for various patient demographic and presentation factors, suggesting important variations in ED-level and clinician-level behaviour relating to admission decisions. The 4-hour target is a strong driver for emergency admission.

National health policy-makers' views on the clarity and utility of Countdown to 2015 country profiles and reports: findings from two exploratory qualitative studies.

BACKGROUND: The use of sets of indicators to assess progress has become commonplace in the global health arena. Exploratory research has suggested that indicators used for global monitoring purposes can play a role in national policy-making, however, the mechanisms through which this occurs are poorly understood. This article reports findings from two qualitative studies that aimed to explore national policy-makers' interpretation and use of indicators from country profiles and reports developed by Countdown to 2015. METHODS: An initial study aimed at exploring comprehension of Countdown data was conducted at the 2010 joint Women Deliver/Countdown conference. A second study was conducted at the 64th World Health Assembly in 2011, specifically targeting national policy-makers. Semi-structured interviews were carried out with 29 and 22 participants, respectively, at each event. Participants were asked about their understanding of specific graphs and indicators used or proposed for use in Countdown country profiles, and their perception of how such data can inform national policy-making. Responses were categorised using a framework analysis. RESULTS: Respondents in both studies acknowledged the importance of the profiles for tracking progress on key health indicators in and across countries, noting that they could be used to highlight changes in coverage, possible directions for future policy, for lobbying finance ministers to increase resources for health, and to stimulate competition between neighbouring or socioeconomically similar countries. However, some respondents raised questions about discrepancies between global estimates and data produced by national governments, and some struggled to understand the profile graphs shown in the absence of explanatory text. Some respondents reported that use of Countdown data in national policy-making was constrained by limited awareness of the initiative, insufficient detail in the country profiles to inform policy, and the absence of indicators felt to be more appropriate to their own country contexts. CONCLUSIONS: The two studies emphasise the need for country consultations to ensure that national policy-makers understand how to interpret and use tools like the Countdown profile for planning purposes. They make clear the value of qualitative research for refining tools used to promote accountability, and the need for country level Countdown-like processes.

Soil erosion and sediment fluxes analysis: a watershed study of the Ni Reservoir, Spotsylvania County, VA, USA.

Anthropogenic forces that alter the physical landscape are known to cause significant soil erosion, which has negative impact on surface water bodies, such as rivers, lakes/reservoirs, and coastal zones, and thus sediment control has become one of the central aspects of catchment management planning. The revised universal soil loss equation empirical model, erosion pins, and isotopic sediment core analyses were used to evaluate watershed erosion, stream bank erosion, and reservoir sediment accumulation rates for Ni Reservoir, in central Virginia. Land-use and land cover seems to be dominant control in watershed soil erosion, with barren land and human-disturbed areas contributing the most sediment, and forest and herbaceous areas contributing the least. Results show a 7 % increase in human development from 2001 (14 %) to 2009 (21.6 %), corresponding to an increase in soil loss of 0.82 Mg ha(-1) year(-1) in the same time period. (210)Pb-based sediment accumulation rates at three locations in Ni Reservoir were 1.020, 0.364, and 0.543 g cm(-2) year(-1) respectively, indicating that sediment accumulation and distribution in the reservoir is influenced by reservoir configuration and significant contributions from bedload. All three locations indicate an increase in modern sediment accumulation rates. Erosion pin results show variability in stream bank erosion with values ranging from 4.7 to 11.3 cm year(-1). These results indicate that urban growth and the decline in vegetative cover has increased sediment fluxes from the watershed and poses a significant threat to the long-term sustainability of the Ni Reservoir as urbanization continues to increase.

Hydrocele of the canal of Nuck--an old problem revisited.

Herein the authors describe the case of a young woman presenting with a tender lump in her groin. Clinically the differential was of either a reactive lymph node or a femoral hernia. Ultrasound scan was urgently arranged and showed a cystic lesion. Surgical exploration was carried out and revealed this to be a hydrocele of the canal of Nuck. This was excised and the patient's symptoms resolved and she was discharged home the following day. We explore the embryology, pathophysiology and management of this rare entity.

Blunt abdominal trauma - An important cause of portal venous pseuodoaneurysm.

Aneurysms and pseudoaneurysms of the portal venous system are rarely seen following abdominal trauma but clinicians need to be aware of them as possible vascular complications following blunt trauma. This case report of a 10 year old boy following a handlebar injury demonstrates a clear causal relationship between trauma and portal venous pseudoaneurysm. Portal venous aneurysms have a prevalence of less than 0.4% and most are found in patients with underlying hepatocellular disease. Many are asymptomatic in which case surveillance is an accepted management strategy, with Doppler ultrasound proving useful. Complications including thrombosis, distal embolism, compression of the biliary tree and haemorrhage are usually indications for surgical management. Portal venous pseudoaneurysms may be managed conservatively but transcatheter embolisation can be used if there are ongoing complications or haemorrhage.

The clinical impact of magnetic resonance imaging in diagnosing focal hepatic lesions and suspected cancer.

AIMS: To compare the clinical utility of contrast enhanced magnetic resonance imaging (MRI) to ultrasound (USS) and computed tomography (CT) in focal hepatic lesions (FHLs) METHODS: This retrospective study analysed 125 consecutive iron oxide enhanced (SPIO) MRI. RESULTS: MRI made a difference in 74% of patients who had USS and in 42% of patients who had a CT scan. In suspected cancer, MRI changed diagnosis in 58% and 37% (13/35), respectively. CONCLUSIONS: MRI is superior to other noninvasive imaging modalities for lesion identification and characterisation.