Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 1: What is the significance of a 'boggy' (soft) scalp haematoma in head-injured children?

A short-cut review was carried out to establish whether the presence of a soft (boggy) scalp haematoma predicts the presence of intracranial injury in head-injured children. Three studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are shown in table 1. The clinical bottom line is that the presence of a soft (boggy) scalp haematoma appears to predict positive findings on CT imaging. In the one study that directly addressed the three-part question, it was concluded to warrant CT imaging. Since that time, however, concern regarding the risks associated with irradiation of children may challenge a strategy of imaging otherwise asymptomatic children with no other indication for CT imaging.

A Pliocene Precipitation Isotope Proxy-Model Comparison Assessing the Hydrological Fingerprints of Sea Surface Temperature Gradients.

The Pliocene offers insights into future climate, with near-modern atmospheric pCO2 and global mean surface temperature estimated to be 3-4°C above pre-industrial. However, the hydrological response differs between future global warming and early Pliocene climate model simulations. This discrepancy results from the use of reduced meridional and zonal sea surface temperature (SST) gradients, based on foraminiferal Mg/Ca and Alkenone proxy evidence, to force the early Pliocene simulation. Subsequent, SST reconstructions based on the organic proxy TEX86, have found warmer temperatures in the warm pool, bringing the magnitude of the gradient reductions into dispute. We design an independent test of Pliocene SST scenarios and their hydrological cycle "fingerprints." We use an isotope-enabled General Circulation Model, iCAM5, to model the distribution of water isotopes in precipitation in response to four climatological SST and sea-ice fields representing modern, abrupt 4 × CO2, late Pliocene and early Pliocene climates. We conduct a proxy-model comparison with all the available precipitation isotope proxy data, and we identify target regions that carry precipitation isotopic fingerprints of SST gradients as priorities for additional proxy reconstructions. We identify two regions with distinct precipitation isotope (D/H) fingerprints resulting from reduced SST gradients: the Maritime Continent (D-enriched due to reduced convective rainfall) and the Sahel (wetter, more deep convection, D-depleted). The proxy-model comparison using available plant wax reconstructions, mostly from Africa, is promising but inconclusive. Additional proxy reconstructions are needed in both target regions and in much of the world for significant tests of SST scenarios and dynamical linkages to the hydrological cycle.

Socio-demographic heterogeneity in the prevalence of COVID-19 during lockdown is associated with ethnicity and household size: Results from an observational cohort study.

BACKGROUND: Accumulating evidence indicates that COVID-19 causes adverse outcomes in ethnic minority groups. However, little is known about the impact of ethnicity and household size on acquiring infection with SARS-CoV-2. METHODS: We undertook a retrospective cohort study, in Leicester (UK), of all individuals assessed for COVID-19 with polymerase chain reaction (PCR) testing at University Hospitals of Leicester NHS Trust between 1st March and 28th April 2020. We used logistic regression to identify sociodemographic, clinical and temporal factors associated with SARS-CoV-2 PCR positivity before/after lockdown. FINDINGS: 971/4051 (24.0%) patients with suspected COVID-19 were found to be PCR positive for SARS-CoV-2. PCR positivity was more common amongst individuals from ethnic minortiy backgrounds than their White counterparts (White 20.0%, South Asian 37.5%, Black 36.1%, Other 32.2%; p<0.001 for all ethnic minority groups vs White). After adjustment, compared to White ethnicity, South Asian (aOR 2.44 95%CI 2.01, 2.97), Black (aOR 2.56 95%CI 1.71, 3.84) and Other (aOR 2.53 95%CI 1.74, 3.70) ethnicities were more likely to test positive, as were those with a larger estimated household size (aOR 1.06 95%CI 1.02, 1.11). We saw increasing proportions of positive tests in the three weeks post-lockdown amongst the ethnic minority , but not the White, cohort. Estimated household size was associated with PCR positivity after, but not before, lockdown (aOR 1.10 95%CI 1.03, 1.16). INTERPRETATION: In individuals presenting with suspected COVID-19, those from ethnic minority communities and larger households had an increased likelihood of SARS-CoV-2 PCR positivity. Pandemic control measures may have more rapid impact on slowing viral transmission amongst those of White ethnicity compared to ethnic minority groups, Research is urgently required to understand the mechanisms underlying these disparities and whether public health interventions have differential effects on individuals from ethnic minority groups. FUNDING: 10.13039/100006662 NIHR.

Representation to the accident and emergency department within 1-year of a fractured neck of femur.

BACKGROUND: The fractured neck of femur (NOF) is a leading cause of morbidity and mortality. The mortality attendant upon such fractures is 10% at 1 month and 30% at one year with a cost to the NHS of £1.4 billion annually. This retrospective study sought to examine rates and prevailing trends in representation to A&E in the year following a NOF fracture in an attempt to identify the leading causes behind the morbidity and mortality associated with this fracture. METHODS: 1108 patients who suffered a fractured NOF between 1 January 2002 and 31 December 2007 were identified from a University Hospital A&E database. This database was then used to identify those patients who represented within 1-year following the initial fracture. The presenting complaint, provisional diagnosis and the outcome of this presentation were identified at this time. RESULTS: 234 patients (21%) returned to A&E on 368 occasions in the year following a hip fracture. 77% (284/368) of these presentations necessitated admission. Falls, infection and fracture were the leading causes of representation. Falls accounted for 20% (57/284) of admissions; 20.7% of patients were admitted because of a fracture, while 56.6% of admissions were for medical ailments of which infection was the chief precipitant (28% (45/161)). DISCUSSION: The causes for representation are varied and multifactorial. The results of this study suggest that some of those events or ailments necessitating readmission may be obviated and potentially reduced by interventions that can be instituted during the primary admission and continued following discharge.