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Acute hyperammonaemia is a medical emergency as it can progress to cerebral oedema, seizures, coma and death. Hepatic encephalopathy secondary to cirrhotic disease or portosystemic shunting are relatively well-known causes, but non-cirrhotic aetiologies of acute hyperammonaemia are less well-known, especially in the emergency department. However, an elevated ammonia is not required to make the diagnosis of hepatic encephalopathy. Although measurement of plasma ammonia is recommended for patients with acute, unexplained, altered mental status, as early identification allows early effective management which may prevent irreversible brain damage, there is currently reduced awareness among physicians of the non-cirrhotic aetiologies of acute hyperammonaemia. Furthermore, measurement of ammonia in patients with cirrhosis has been shown to have low sensitivity and specificity, and not to have altered management in the majority of cases; thus, measurement of ammonia is currently not recommended in guidelines for management of hepatic encephalopathy. We sought to describe the pathophysiology of hyperammonaemia and review the non-cirrhotic causes. This was achieved by review of MEDLINE, PubMed and Web of Science databases to include published English literature within the last 20 years. We also present a framework for investigating the acute non-cirrhotic causes of hyperammonaemia to assist both chemical pathologists and clinicians managing these often challenging cases.
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Patients presenting to the ED after using illicit drugs, including novel psychoactive substances, are a unique source of information on substances that are directly causing acute harm in the community. Conventionally, illicit drug intoxications are assessed and managed in EDs based on self-report and presenting symptoms, with no objective data on the causative agent. The Emerging Drugs Network of Australia (EDNA) is a national toxico-surveillance system that provides analytic data on these drugs, from sentinel Emergency Departments. It is a collaborative national network of emergency physicians, toxicologists, forensic laboratories and public health authorities. The key benefit of EDNA is the capacity to provide timely laboratory-confirmed toxicology data on emerging drug-related threats in the community. This leads to improvements in clinical, forensic laboratory and public health harm reduction responses, reflecting rapid translation of the research.
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The aim of the Australian Traumatic Brain Injury Initiative (AUS-TBI) is to design a data dictionary to inform data collection and facilitate prediction of outcomes for moderate-severe traumatic brain injury (TBI) across Australia. The process has engaged diverse stakeholders across six areas: social, health, clinical, biological, acute interventions, and long-term outcomes. Here, we report the results of the clinical review. Standardized searches were implemented across databases to April 2022. English-language reports of studies evaluating an association between a clinical factor and any clinical outcome in at least 100 patients with moderate-severe TBI were included. Abstracts, and full-text records, were independently screened by at least two reviewers in Covidence. The findings were assessed through a consensus process to determine inclusion in the AUS-TBI data resource. The searches retrieved 22,441 records, of which 1137 were screened at full text and 313 papers were included. The clinical outcomes identified were predominantly measures of survival and disability. The clinical predictors most frequently associated with these outcomes were the Glasgow Coma Scale, pupil reactivity, and blood pressure measures. Following discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous studies evaluating associations between clinical factors and outcomes in patients with moderate-severe TBI. A small number of factors were reported consistently, however, how and when these factors were assessed varied. The findings of this review and the subsequent consensus process have informed the development of an evidence-informed data dictionary for moderate-severe TBI in Australia.
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Patients with acute critical illness require prompt interventions, yet high-quality evidence supporting many investigations and treatments is lacking. Clinical research in this setting is challenging due to the need for immediate treatment and the inability of patients to provide informed consent. Attempts to obtain consent from surrogate decision-makers can be intrusive and lead to unacceptable delays to treatment. These problems may be overcome by pragmatic approaches to study design and the use of supervised waivers of consent, which is ethical and appropriate in situations where there is high risk of poor outcome and a paucity of proven effective treatment.
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Estado Terminal , Serviços Médicos de Emergência , Humanos , Estado Terminal/terapia , Serviços Médicos de Emergência/normas , Serviços Médicos de Emergência/métodos , Consentimento Livre e Esclarecido , Pesquisa Biomédica , Cuidados Críticos/normas , Cuidados Críticos/métodos , Unidades de Terapia Intensiva/organização & administraçãoRESUMO
BACKGROUND: Chronic nitrous oxide (N2O) use causes inactivation of vitamin B12, resulting in neurological and psychiatric symptoms. This case series presents all N2O-related presentations to the emergency department at Royal Perth Hospital between June 2019 and June 2021, alongside the costs of these admissions. CASE PRESENTATION: Twenty-two patients were identified; 68% (n = 15) were male. The median age was 22.4 years (interquartile range [IQR], 20-30). Median daily number of N2O bulbs inhaled was 150 (IQR, 64-300) with a median duration of use of 9 months (IQR, 3-12). Presentations included ataxia, paraesthesia and falls (n = 18), urinary retention (n = 3) and psychotic symptoms (n = 2). Fourteen patients had severe symptoms prompting a magnetic resonance imaging of brain and spine, confirming 12 cases of subacute combined degeneration of the spinal cord. All patients had IMI vitamin B12 therapy, while 14 had oral methionine therapy. The median length of admission was 4 days (IQR 1-23 days). The median cost of admission per day for patients where costs were accessible (n = 7) was $2061 (IQR, $1903-$2860). DISCUSSION AND CONCLUSIONS: A case series of symptomatic chronic N2O use with severe neurological sequelae and significant costs associated per admission. Triangulation of emergency department and Ecstasy and Related Drugs Reporting System data helped prompt a swift public health response, including mandatory warning labels, limits to transaction amounts and legislative changes to the Medicines and Poisons Act to make it illegal for sale if there is a suspicion that it will be abused.
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OBJECTIVE: Alcohol is a major public health issue and the ACEM funds regular 'snapshot' surveys of the prevalence of alcohol-related presentations in EDs. The present study uses these data to investigate ED occupancy and alcohol- and methamphetamine-related presentations at the time of the COVID-19 pandemic. METHODS: Survey-based point prevalence study of EDs in Australia and New Zealand conducted at 02:00 hours local time on the Saturday of the weekend before Christmas in 2019-2022. Primary outcomes were ED occupancy, the number of alcohol-related presentations and methamphetamine-related presentations in each ED at the time of survey. RESULTS: Seventy eight of a possible 152 hospitals answered all four surveys (51%, 95% confidence interval 43-59, individual yearly response rates ranged from 70.5% to 83.3%). The mean number of alcohol-related presentations in EDs at the snapshot time was 4.2 (95% confidence interval 3.2-5.2) in the 2019 survey and 3.8 (3.1-4.6) in 2022 with no significant variation over time. There was also no change in methamphetamine-related presentations which occurred at a lower level. There was a major increase in reported total ED occupancy - from 31.4 to 43.5 in Australia (P < 0.0001, paired t test) and from 22.8 to 38.7 in New Zealand (P = 0.0001). Subgroup analysis showed that both the number being treated and the number waiting to be seen increased, with little change in the number in observation units. CONCLUSIONS: The present study demonstrates that the COVID-19 pandemic did not affect summer alcohol-related ED presentations in Australasia but was associated with an unsustainable increase in ED crowding.
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OBJECTIVES: People may experience a myriad of symptoms after mild traumatic brain injury (mTBI), but the relationship between symptoms and objective assessments is poorly characterized. This study sought to investigate the association between symptoms, resting heart rate (HR), and exercise tolerance in individuals following mTBI, with a secondary aim to examine the relationship between symptom-based clinical profiles and recovery. METHODS: Prospective observational study of adults aged 18 to 65 years who had sustained mTBI within the previous 7 days. Symptoms were assessed using the Post-Concussion Symptom Scale, HR was measured at rest, and exercise tolerance was assessed using the Buffalo Concussion Bike Test. Symptom burden and symptom-based clinical profiles were examined with respect to exercise tolerance and resting HR. RESULTS: Data from 32 participants were assessed (mean age 36.5 ± 12.6 years, 41% female, 5.7 ± 1.1 days since injury). Symptom burden (number of symptoms and symptom severity) was significantly associated with exercise intolerance (P = .002 and P = .025, respectively). Physiological and vestibular-ocular clinical profile composite groups were associated with exercise tolerance (P = .001 and P = .014, respectively), with individuals who were exercise intolerant having a higher mean number of symptoms in each profile than those who were exercise tolerant. Mood-related and autonomic clinical profiles were associated with a higher resting HR (>80 bpm) (P = .048 and P = .028, respectively), suggesting altered autonomic response for participants with symptoms relating to this profile. After adjusting for age and mechanism of injury (sports- or non-sports-related), having a higher mood-related clinical profile was associated with persisting symptoms at 3 months postinjury (adjusted odds ratio = 2.08; 95% CI, 1.11-3.90; P = .013). CONCLUSION: Symptom-based clinical profiles, in conjunction with objective measures such as resting HR and exercise tolerance, are important components of clinical care for those having sustained mTBI. These results provide preliminary support for the concept that specific symptoms are indicative of autonomic dysfunction following mTBI.
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INTRODUCTION: Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA). METHODS: This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases. RESULTS: GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases. DISCUSSION AND CONCLUSIONS: Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.
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Overdose de Drogas , Serviço Hospitalar de Emergência , Oxibato de Sódio , Humanos , Feminino , Adulto , Oxibato de Sódio/intoxicação , Masculino , Austrália Ocidental/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Overdose de Drogas/epidemiologia , Pessoa de Meia-Idade , Adulto Jovem , AdolescenteRESUMO
BACKGROUND: Alcohol-related harm (ARH) is a significant public health concern affecting young individuals, particularly those involved in alcohol-related police incidents resulting in hospitalisation. However, the impact of alcohol on young victims remains under researched. This study aimed to identify the characteristics of offenders and victims involved in these incidents, analyse the types of offences, and understand the under-ascertainment of ARH in hospital records. METHODS: A retrospective longitudinal study of 12-24-year-olds born between 1980 and 2005 was conducted using linked data from hospital admissions, emergency department presentations, and police incident records. Alcohol-related incidents were identified based on the attending officers' opinions in the Western Australia Police's Incident Management System (IMS). Logistic and log-binomial regression were utilised to analyse the factors associated with victimisation and under-ascertainment of ARH. RESULTS: Our study included 22,747 individuals (11,433 victims and 11,314 offenders) involved in alcohol-related police incidents, with a small majority of victims being female (53%, n = 6,074) and a large majority of offenders being male (84.3%, n = 9,532). Most victims did not receive a diagnosis of ARH (71%, n = 760). Women were 10 times more likely to have been a victim in ARH police incidents and 2 times more likely to have an undiagnosed alcohol-related hospital admission than men. Victims and offenders predominantly came from disadvantaged areas and major cities. Aboriginal individuals were overrepresented as both offenders and victims. A significant proportion of individuals experienced emergency department presentations or hospital admissions, with head injuries being the most common. Assault causing bodily harm was the most prevalent offence resulting in hospitalisation (66%, n = 2,018). CONCLUSIONS: There is a noteworthy disparity between the quantity of hospital admissions attributed to alcohol-related incidents and the number of cases that are formally classified as ARH in the hospital system. This disparity highlights a more profound issue of substantial under-ascertainment or inadequate identification of ARH than previously acknowledged. Our findings justify the prioritisation of prevention strategies, beyond improvement in the documentation of alcohol-related hospitalisation. Considering the scale of the problem, and the underestimation of the burden of alcohol-related hospitalisation, a proportional increase in investment is necessary to achieve population-level reductions in ARH.
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Vítimas de Crime , Polícia , Humanos , Masculino , Feminino , Estudos Longitudinais , Estudos Retrospectivos , HospitalizaçãoRESUMO
OBJECTIVE: To assess Australian and New Zealand emergency clinicians' attitudes towards the use of artificial intelligence (AI) in emergency medicine. METHODS: We undertook a qualitative interview-based study based on grounded theory. Participants were recruited through ED internal mailing lists, the Australasian College for Emergency Medicine Bulletin, and the research teams' personal networks. Interviews were transcribed, coded and themes presented. RESULTS: Twenty-five interviews were conducted between July 2021 and May 2022. Thematic saturation was achieved after 22 interviews. Most participants were from either Western Australia (52%) or Victoria (16%) and were consultants (96%). More participants reported feeling optimistic (10/25) than neutral (6/25), pessimistic (2/25) or mixed (7/25) towards the use of AI in the ED. A minority expressed scepticism regarding the feasibility or value of implementing AI into the ED. Multiple potential risks and ethical issues were discussed by participants including skill loss from overreliance on AI, algorithmic bias, patient privacy and concerns over liability. Participants also discussed perceived inadequacies in existing information technology systems. Participants felt that AI technologies would be used as decision support tools and not replace the roles of emergency clinicians. Participants were not concerned about the impact of AI on their job security. Most (17/25) participants thought that AI would impact emergency medicine within the next 10 years. CONCLUSIONS: Emergency clinicians interviewed were generally optimistic about the use of AI in emergency medicine, so long as it is used as a decision support tool and they maintain the ability to override its recommendations.
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Inteligência Artificial , Medicina de Emergência , Humanos , Consultores , Teoria Fundamentada , VitóriaRESUMO
OBJECTIVE: To assess the usefulness of night-time presentations to measure alcohol-related harm (ARH) in young trauma patients, aged 12-24 years, attending Western Australian EDs. METHODS: A retrospective longitudinal study examined alcohol-related ED presentations in Western Australia (WA; 2002-2016) among 12- to 24-year-olds. Data from the Emergency Department Data Collection, WA State Trauma Registry Database and Hospital Morbidity Data Collection were used to identify ARH through specific codes and text searches. These were compared to ARH estimates based on presentation time. Statistical analysis involved sensitivity and specificity calculations and Cox proportional hazards modelling. RESULTS: We identified 2644 (17.8%) night-time presentations as a proxy measure of ARH among the 14 887 presentations of patients aged 12-24 years. This closely matched the 3064 (20.6%) identified as ARH through coding methods. The highest risk for an ARH presentation occurred during the night hours between 00.00 and 04.59 hours. During these hours, the risk was 4.4-5.1 times higher compared to presentations at midday (between 12.00 and 12.59 hours). However, when looking at individual patients, we observed that night-time presentations were not a strong predictor of ARH (sensitivity: 0.39; positive predictive value: 0.46). CONCLUSIONS: Implementing targeted interventions during night hours could be beneficial in addressing ARH presentations. However, relying solely on the time of presentation as a proxy for ARH is unlikely to effectively identify ARH in young individuals. Instead, the present study emphasises the importance of implementing mandatory data collection strategies in EDs to ensure accurate measurement of ARH cases.
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Serviço Hospitalar de Emergência , Etanol , Humanos , Estudos Retrospectivos , Estudos Longitudinais , AustráliaRESUMO
The use of electric scooters (e-scooters) is increasing in Australia and internationally. The increasing availability of e-scooters has led to a rise in the number of injuries, with most patients sustaining orthopaedic injuries. This retrospective case series describes the incidence, management, and hospital costs of the orthopaedic injuries, which presented to the emergency department (ED) of the major trauma center in Western Australia. Data on demographics, ED dispatch destination, management, follow-up clinics, and hospital costs were collected between 2017 and 2022. Since June 2020, there have been 61 e-scooter crashes, which resulted in orthopaedic injuries, with more than half of the crashes occurring after the introduction of regional e-scooter sharing schemes. Thirty-two patients (52%) were admitted to the hospital. The most common orthopaedic fracture was to the upper limb (44%), followed by the lower limb (41%) and the axial skeleton (15%). Fourteen (23%) patients sustained more than one fracture. Twenty-two patients (36%) required operative management. The median number of outpatient clinic attendances per patient was 3 (interquartile range (IQR): 1-5), with inpatients requiring twice the number of clinics as compared to those discharged from the ED. The median cost per presentation was AU$5880.60 (IQR: AU$1283.10-AU$21,150.90) with inpatient costs exceeding those discharged from the ED. The range of the total costs was AU$413.80 to AU$100,239.80. The rise in the accessibility of e-scooters in Western Australia has led to a rise in ED presentations with orthopaedic injuries. Considering the recent implementation of e-scooter sharing schemes in metropolitan areas, ongoing surveillance of e-scooter injuries by clinicians and policy makers is warranted to inform harm minimization strategies.
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INTRODUCTION: Presentations related to illicit drugs are a feature of emergency department practice. Clinicians may form a belief that a patient is intoxicated with illicit drugs based on patient self-report, clinical features on presentation and the local prevalence of illicit drug use. But evidence of the accuracy of this assessment is lacking. The Western Australian Illicit Substance Evaluation (WISE) study enrolled patients believed by their treating clinician to be intoxicated with illicit drugs, and this analysis aims to evaluate the validity of this belief. METHODS: A blood sample was taken on patient arrival and details of patient history, examination and interventions were collected by clinical and research staff. Toxicological examination of biological samples used liquid chromatography-mass spectrometry techniques including Quadrupole Time of Flight screening and Triple Quadrupole targeted analyses. RESULTS: Of 632 study presentations, 518 had illicit drugs detected representing a positive predictive value of 0.82 (95% confidence interval 78.7, 84.9). Those with illicit drugs detected were significantly less likely to arrive by police transport (p = 0.010) or to have used alcohol (p < 0.001). They were significantly more likely to report illicit drug use (p < 0.001) and a much smaller proportion were admitted to a psychiatric ward (3.5% vs. 19.3%, p < 0.0001). Heart rate and systolic blood pressure were significantly higher in the illicit drug group (p = 0.004 and p = 0.003). DISCUSSION AND CONCLUSIONS: In this study, the positive predictive value of clinicians determining if their patient had taken illicit drugs was 0.82. Contemporaneous biochemical analysis in the clinical setting would increase this accuracy and inform patient care.
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Drogas Ilícitas , Transtornos Relacionados ao Uso de Substâncias , Humanos , Drogas Ilícitas/análise , Austrália , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/psicologia , Serviço Hospitalar de Emergência , EtanolRESUMO
INTRODUCTION: The burden of acute illicit drug use in Australia is largely unknown. Establishing a prospective drug surveillance system in emergency departments using analytical confirmation may facilitate the early identification of emerging drugs. We describe demographic data and acute toxicity patterns, stratified by analytical confirmation of illicit drugs and novel psychoactive substances, to emergency departments in Western Australia. METHODS: Patients presenting with severe and/or unusual clinical features consistent with recreational drug toxicity were identified across five Western Australian emergency departments participating in the Emerging Drugs Network of Australia between April 2020 and December 2021. Demographic and toxicology patterns in patients with and without analytically confirmed illicit drugs/novel psychoactive substances from blood samples were collected during the emergency department presentation. RESULTS: The cohort included 434 severe and/or unusual toxicology presentations; median age 33 years (first and third quartiles 25-40 years), 268 (61.8%) males. Any substance (illicit, novel psychoactive substance, pharmaceutical) was detected in 405 (93.3%) presentations. Illicit drugs/novel psychoactive substances were detected in 257 (59.2%) presentations, including 73 (28.3%) with more than one confirmed illicit drug/novel psychoactive substance. Frequent illicit drugs identified were metamfetamine (n = 201, 77.9%) and gamma-hydroxybutyrate (n = 30, 11.6%). Forty-eight novel psychoactive substances were detected within 43 (16.7%) presentations. Novel benzodiazepines were most frequently detected (n = 29, 60.4%). Frequent pharmaceuticals detected included diazepam (n = 100, 26.1%) and clonazepam (n = 40, 10.4%). One hundred and fifty-five (35.7%) presentations were discharged home and 56 (12.9%) were admitted to intensive care. Presentations with detected illicit drugs/novel psychoactive substances had a lower median intensive care length of stay compared to presentations without detected illicit drugs/novel psychoactive substances (32.6 h versus 50.8 h respectively, P < 0.001). CONCLUSIONS: Integration of clinical and analytic data in patients with severe and/or unusual toxicology presentations via the Emerging Drugs Network of Australia provides insight into illicit drug/novel psychoactive substance use responsible for acute harm across Western Australian emergency departments.
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Drogas Ilícitas , Transtornos Relacionados ao Uso de Substâncias , Masculino , Humanos , Adulto , Feminino , Austrália , Psicotrópicos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Serviço Hospitalar de EmergênciaRESUMO
BACKGROUND: Electric scooters (e-Scooters) are a form of motorized vehicle that offers cheap, efficient and environmentally friendly transportation. Increased e-Scooter utilization has been accompanied by increases in e-Scooter related injuries in multiple countries. This project describes the incidence, injury pattern, injury severity and patient factors associated with e-Scooter use from the Western Australian State Trauma Registry. METHODS: Retrospective cohort of all trauma patients captured by the Western Australian State Trauma Registry between 01 July 2017 and 30 June 2022 were analysed. Patient demographics, helmet use, reported drug use, and injury details (including principal and additional diagnoses, ISS) were collected. RESULTS: Eighty-one patients sustained e-Scooter related injuries between 2017 and 2022. Fifty-four (66%) of hospital admissions were recorded in 2021-2022, an annual percent change of 385.7% from the previous year. Most patients were male (80%). Median age was 40 years (IQR: 32-50). Helmet use was reported in 43% of patients. Helmet use was associated with a significantly lower odds of head injury (OR = 4.42, CI: 1.38-14.21; P = 0.01). Thirty-five percent of patients were intoxicated with either alcohol or drugs. Forty-four (54%) patients required surgery. CONCLUSION: E-Scooter crashes are a new mechanism of injury affecting patients captured by the Western Australian State Trauma Registry. Helmet use correlated with a reduced risk of head injury.
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Traumatismos Craniocerebrais , Humanos , Masculino , Adulto , Feminino , Estudos Retrospectivos , Incidência , Austrália/epidemiologia , Traumatismos Craniocerebrais/epidemiologia , Sistema de Registros , Dispositivos de Proteção da Cabeça , Acidentes de TrânsitoRESUMO
PURPOSE: To investigate the effect of IV fluid resuscitation on endothelial glycocalyx (EG) shedding and activation of the vascular endothelium and inflammation. MATERIALS AND METHODS: A planned biomarker sub-study of the REFRESH trial in which emergency department (ED) patients) with suspected sepsis and hypotension were randomised to a restricted fluid/early vasopressor regimen or IV fluid resuscitation with later vasopressors if required (usual care). Blood samples were collected at randomisation (T0) and at 3 h (T3), 6 h (T6)- and 24 h (T24) for measurement of a range of biomarkers if EG shedding, endothelial cell activation and inflammation. RESULTS: Blood samples were obtained in 95 of 99 enrolled patients (46 usual care, 49 restricted fluid). Differences in the change in biomarker over time between the groups were observed for Hyaluronan (2.2-fold from T3 to T24, p = 0.03), SYN-4 (1.5-fold from T3 to T24, P = 0.01) and IL-6 (2.5-fold from T0 to T3, p = 0.03). No difference over time was observed between groups for the other biomarkers. CONCLUSIONS: A consistent signal across a range of biomarkers of EG shedding or of endothelial activation or inflammation was not demonstrated. This could be explained by pre-existing EG shedding or overlap between the fluid volumes administered in the two groups in this clinical trial. Trial registration Australia New Zealand Clinical Trials Registry ACTRN126160000006448 Registered 12 January 2016.
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OBJECTIVES: There is heightened intrigue surrounding the application of arts-based pedagogy in medical education. Art encompasses multiple forms of expression and is used to convey specific meaning and emotion, whereas provoking critical reflection. Our aim was to explore the effectiveness of art and reflective practice in medical education, in the context of the ED. METHODS: Longitudinal methodological study design. Prior to the first, and after the final clinical practicum, medical students watched a 3-min film: 'The Art of the ED'. Written reflections focused on changing perceptions towards the film during their medical education programme. Data were thematically analysed. RESULTS: Three themes were collected from 25 written reflections and included: 'professional growth' exploring personal and professional development across the medical programme; seeing 'patients are people'; and the purpose, structure and function of an ED exposed in 'the reality of ED'. Results highlight that arts-based pedagogy can facilitate meaningful and critical reflection in medical students, whereas also fostering professionalism. Reflecting on the film broadened their perspective into a realm of new possibilities, challenging them to identify implicit bias around ED, and promote professional identity formation. CONCLUSIONS: The combination of art and reflection in medical education enhances reflective learning and can lead to transformative change, including the development of core doctoring values of service, empathy and respect for patient. There are clear benefits to medical education incorporating more arts-based pedagogy that promotes reflective exploration and interpretation of the psychosocial context of health and illness, delivery of more holistic models of care and their role as doctors.
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Educação Médica , Estudantes de Medicina , Humanos , Aprendizagem , Profissionalismo , Meios de Comunicação de Massa , Serviço Hospitalar de Emergência , Estudantes de Medicina/psicologia , CurrículoRESUMO
Traumatic intracranial hypertension (tIH) is a common and potentially lethal complication of moderate to severe traumatic brain injury (m-sTBI). It often develops with little warning and is managed reactively with the tiered application of intracranial pressure (ICP)-lowering interventions administered in response to an ICP rising above a set threshold. For over 45 years, a variety of research groups have worked toward the development of technology to allow for the preemptive management of tIH in the hope of improving patient outcomes. In 2022, the first operationalizable tIH prediction system became a reality. With such a system, ICP lowering interventions could be administered prior to the rise in ICP, thus protecting the patient from potentially damaging tIH episodes and limiting the overall ICP burden experienced. In this review, we discuss related approaches to ICP forecasting and IH prediction algorithms, which collectively provide the foundation for the successful development of an operational tIH prediction system. We also discuss operationalization and the statistical assessment of tIH algorithms. This review will be of relevance to clinicians and researchers interested in development of this technology as well as those with a general interest in the bedside application of machine learning (ML) technology.
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Lesões Encefálicas Traumáticas , Lesões Encefálicas , Hipertensão Intracraniana , Humanos , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico , Hipertensão Intracraniana/etiologia , Hipertensão Intracraniana/complicações , Algoritmos , Pressão Intracraniana/fisiologia , Monitorização FisiológicaRESUMO
Objective: Mechanisms underlying the anaphylactic reaction in humans are not fully understood. Here, we aimed at improving our understanding of anaphylaxis by investigating gene expression changes. Methods: Microarray data set GSE69063 was analysed, describing emergency department (ED) patients with severe anaphylaxis (n = 12), moderate anaphylaxis (n = 6), sepsis (n = 20) and trauma (n = 11). Samples were taken at ED presentation (T0) and 1 h later (T1). Healthy controls were age and sex matched to ED patient groups. Gene expression changes were determined using limma, and pathway analysis applied. Differentially expressed genes were validated in an independent cohort of anaphylaxis patients (n = 31) and matched healthy controls (n = 10), using quantitative reverse transcription-polymerase chain reaction. Results: Platelet aggregation was dysregulated in severe anaphylaxis at T0, but not in moderate anaphylaxis, sepsis or trauma. Dysregulation was not observed in patients who received adrenaline before T0. Seven genes (GATA1 (adjusted P-value = 5.57 × 10-4), TLN1 (adjusted P-value = 9.40 × 10-4), GP1BA (adjusted P-value = 2.15 × 10-2), SELP (adjusted P-value = 2.29 × 10-2), MPL (adjusted P-value = 1.20 × 10-2), F13A1 (adjusted P-value = 1.39 × 10-2) and SPARC (adjusted P-value = 4.06 × 10-2)) were significantly downregulated in severe anaphylaxis patients who did not receive adrenaline before ED arrival, compared with healthy controls. One gene (TLN1 (adjusted P-value = 1.29 × 10-2)) was significantly downregulated in moderate anaphylaxis patients who did not receive adrenaline before ED arrival, compared with healthy controls. Conclusion: Downregulation of genes involved in platelet aggregation and activation is a unique feature of the early anaphylactic reaction not previously reported and may be associated with reaction severity.
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INTRODUCTION: The often unknown nature of acute drug intoxication, especially with illicit drugs and emerging novel psychoactive substances, can present a significant challenge for emergency clinicians. Less experienced clinicians are particularly vulnerable to the diagnostic dilemmas of complex toxicology emergencies. We sought to better understand the confidence of junior doctors in assessing and managing toxicological emergencies across two emergency departments in Perth, Australia. METHODS: An online survey was conducted between August 2020 and February 2021. Self-rated confidence was measured on a five-point Likert Scale across 10 statements. Two open-ended questions were included to capture perceived barriers and facilitators impacting clinical confidence. Quantitative data were analysed using descriptive methods and Fisher's exact test. Free-text responses were analysed using content analysis. RESULTS: A total of 104 surveys were completed (19.2% interns, 40.4% resident medical officers and 40.4% registrars). Self-rated confidence varied across statements and by staff type. The lowest confidence rating was for managing a patient who had overdosed from an unknown substance (31.7%) and the highest rating for referring a patient to psychiatry following deliberate self-poisoning (86.6%). Confidence increased with greater clinical experience for all statements. Qualitative analysis revealed perceptions of clinical preparedness, complexity of patients and a safe and supportive culture as key factors impacting confidence. DISCUSSION AND CONCLUSIONS: Overcoming perceived deficits in knowledge and clinical experience were key to building confidence. Our findings highlight the need for improved access to toxicology-specific curricula and training, and strategies to ensure adequate supervision from senior clinicians.