CATCH IT: The Effect of Bladder Ultrasound in Decreasing the Time to Collect a Clean-Catch Urine Sample in the Nontoilet-Trained Child: A Randomized Control Trial.

OBJECTIVES: Clean-catch urine is essential in the investigation of an unwell child but can unfortunately be difficult to obtain in nontoilet-trained children. To this end, we compared the difference in time taken to collect clean-catch urine in nontoilet-trained children via the use of point-of-care ultrasound and traditional methods. METHODS: A single-center randomized controlled trial was conducted at an urban pediatric emergency department, recruiting 80 patients, of which 73 underwent data analyses. Participants were randomized to either the control arm, which consisted of the traditional "watch and wait" method of collecting a clean-catch sample, or to the intervention arm, which used point-of-care ultrasound to assess bladder volume and to stimulate the micturition reflex. The primary outcome measured was the mean time taken to collect a clean-catch urine sample. RESULTS: Eighty patients (ultrasound, n = 41; standard care, n = 39) underwent randomization using a random number generator. Seven patients were removed from final analysis due to loss to follow-up for various reasons. Seventy-three patients (ultrasound, n = 37; standard care, n = 36) underwent statistical analysis. The ultrasound group had a median time to clean-catch urine of 40 minutes (interquartile range, 52) and mean time of 52 minutes (standard deviation, 42), and the control group had a median time of 55 minutes (interquartile range, 81), and mean time of 82 minutes (standard deviation, 90). This reached statistical significance (1-tail t test, P = 0.033). The baseline characteristics were similar between both groups for sex and age distribution; however, the mean ages were significantly different (2-tail t test, P = 0.049) with 8.4 months in the control group, and 12.3 months in the ultrasound group. CONCLUSIONS: We found that there was a statistically and clinically significant reduction in mean time taken to collect clean-catch urine in nontoilet-trained children using point-of-care ultrasound compared with the traditional watch and wait method.

Implementation of a risk-stratified, guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): a multicentre, randomized, controlled trial.

ABSTRACT: Current pathways of care for whiplash follow a "stepped care model," result in modest treatment outcomes and fail to offer efficient management solutions. This study aimed to evaluate the effectiveness of a risk-stratified clinical pathway of care (CPC) compared with usual care (UC) in people with acute whiplash. We conducted a multicentre, 2-arm, parallel, randomised, controlled trial in primary care in Australia. Participants with acute whiplash (n = 216) were stratified for risk of a poor outcome (low vs medium/high risk) and randomised using concealed allocation to either the CPC or UC. In the CPC group, low-risk participants received guideline-based advice and exercise supported by an online resource, and medium-risk/high-risk participants were referred to a whiplash specialist who assessed modifiable risk factors and then determined further care. The UC group received care from their primary healthcare provider who had no knowledge of risk status. Primary outcomes were neck disability index (NDI) and Global Rating of Change (GRC) at 3 months. Analysis blinded to group used intention-to-treat and linear mixed models. There was no difference between the groups for the NDI (mean difference [MD] [95% confidence interval (CI)] -2.34 [-7.44 to 2.76]) or GRC (MD 95% CI 0.08 [-0.55 to 0.70]) at 3 months. Baseline risk category did not modify the effect of treatment. No adverse events were reported. Risk-stratified care for acute whiplash did not improve patient outcomes, and implementation of this CPC in its current form is not recommended.

Impact of time of intensive care unit transfer and outcomes in patients with septic shock: An observational study.

OBJECTIVE: To evaluate the association between time from ED presentation to intensive care unit (ICU) transfer on mortality in patients presenting with septic shock. METHODS: Adult patients with suspected septic shock enrolled in the Australasian Resuscitation in Sepsis Evaluation trial were included. The primary outcome of this post-hoc analysis was 90-day mortality. ED-to-ICU time was analysed as both a continuous variable and a binary variable (≤ vs >4 h). Analysis incorporated mixed effects regression, with ICU site as a random effect, time-to-event analysis and competing risks regression; all with and without inverse probability of treatment weighting to account for confounding baseline covariates. RESULTS: Data from 1301 patients were included. Median (interquartile range [IQR]) ED-to-ICU time was 4.3 (3.1, 6.3) hours, with 588 patients (45%) transferred within 4 h. The ≤4-h group were younger, 64 (51, 74) versus 67 (52, 76) years (P = 0.04), with higher APACHE III scores, 50 (37, 65) versus 47 (35, 62) (P = 0.002), and higher unadjusted 90-day mortality, odds ratio (OR) 1.53 (95% confidence interval 1.15, 2.03), P = 0.01. After adjustment for pre-specified confounders, the 90-day mortality OR was 1.09 (0.83, 1.44), P = 0.52. Adjusted for death as a competing event and illness severity, hospital length of stay was similar between groups, whereas ICU duration remained longer for the ≤4-h group. CONCLUSION: In patients presenting to the ED with septic shock, ED-to-ICU time less than 4 h was not associated with altered 90-day mortality, although this should be interpreted with caution due to study limitations.

Time to change direction in training load monitoring in elite football? The application of MEMS accelerometers for the evaluation of movement requirements.

In elite football, the emphasis is placed on monitoring the output from the Global Positioning Systems (GPS) component of a Micro-Electro-Mechanical Systems (MEMS) device; however, this does not comprehensively overview the total demands due to the intermittent multidirectional nature. The aim of the study was to investigate the application of accelerometer data provided by MEMS, to evaluate movement requirements in elite football. A two-staged research approach, involving an effectiveness and efficacy stage, was deployed. The effectiveness stage examined two MEMS-accelerometer variables (PlayerLoadTM (PL) and PlayerLoadTM per meter (PL.m-1)) for four years and four months. Ninety-nine English Premier League outfield football players' participated. In the efficacy stage, 26 elite outfield football players completed three different training modalities (running, possession and dribbling) and a range of MEMS-accelerometer variables were analysed. In the effectiveness stage, the mean difference in PL for all training activities other than Set Pieces were similar to Matches (-283 to -246au). Model coefficients for PL.m-1 were smallest in Team Shape (-0.00114au), Attacking (0.00025au) and Games (0.00196au), and largest for Possession (0.03356AU), Defending (0.03182au) and Skills Games (0.03106au) compared to Matches. The findings suggest that PL.m-1 but not PL may be effective at describing differences in movement requirements. In the efficacy stage, PL.m-1 and inertial movement analysis (IMA) efforts were the only variables that had greater mean differences in the smaller conditions, confirming PL.m-1's suitability in evaluating movement requirements of different training activities and pitch dimensions. The findings suggest such a variable offers value in a monitoring strategy in football.

Comparison of supine and upright face-to-face cadaver intubation.

INTRODUCTION: Optimal patient positioning during intubation improves laryngeal view and first pass success, as well as reducing incidence of hypoxia. In certain pre-hospital situations, it may be impractical or impossible for the operator to stand behind the patient. OBJECTIVE: We compared intubation in the supine and upright face-to-face positions, with regards to time to intubate and the view of the vocal cords obtained. METHODS: This was a pilot comparison study. One investigator intubated 25 cadavers with the use of a bougie in the supine and upright face-to-face positions. Each attempt was recorded on a video laryngoscope. Recordings of each attempt were reviewed by five blinded emergency physicians, who allocated both a percentage of glottic opening (POGO) score and Cormack-Lehane (CL) grade. Time to insertion of the endotracheal tube (ETT) through the vocal cords was measured from the video. RESULTS: The median intubation time was 1 s longer for upright cadavers than for supine cadavers, with greater variation in intubation times for upright cadavers compared with supine cadavers (IQR 9.0 vs 3.5 excluding the outlier case). The mean POGO score (averaged across raters) was 4.7% lower for upright intubation attempts (excluding the outlier case) with a moderate-to-good degree of inter-rater reliability, however this difference was not statistically significant. The median CL grade (averaged across raters) was 0.2 higher for upright intubation attempts (excluding the outlier case) with a poor-to-moderate degree of inter-rater reliability, and this difference was also not statistically significant. CONCLUSIONS: This pilot study suggests that upright, face-to-face intubation may be clinically similar to supine intubation in terms of time to intubation and difficulty. Further studies utilising a larger number of operators and cadaver types are indicated.

A 6-mRNA host response classifier in whole blood predicts outcomes in COVID-19 and other acute viral infections.

Predicting the severity of COVID-19 remains an unmet medical need. Our objective was to develop a blood-based host-gene-expression classifier for the severity of viral infections and validate it in independent data, including COVID-19. We developed a logistic regression-based classifier for the severity of viral infections and validated it in multiple viral infection settings including COVID-19. We used training data (N = 705) from 21 retrospective transcriptomic clinical studies of influenza and other viral illnesses looking at a preselected panel of host immune response messenger RNAs. We selected 6 host RNAs and trained logistic regression classifier with a cross-validation area under curve of 0.90 for predicting 30-day mortality in viral illnesses. Next, in 1417 samples across 21 independent retrospective cohorts the locked 6-RNA classifier had an area under curve of 0.94 for discriminating patients with severe vs. non-severe infection. Next, in independent cohorts of prospectively (N = 97) and retrospectively (N = 100) enrolled patients with confirmed COVID-19, the classifier had an area under curve of 0.89 and 0.87, respectively, for identifying patients with severe respiratory failure or 30-day mortality. Finally, we developed a loop-mediated isothermal gene expression assay for the 6-messenger-RNA panel to facilitate implementation as a rapid assay. With further study, the classifier could assist in the risk assessment of COVID-19 and other acute viral infections patients to determine severity and level of care, thereby improving patient management and reducing healthcare burden.

Diagnoses and trends in use of imaging for low back pain in four Australian emergency departments between 2012 and 2019.

OBJECTIVE: We aimed to determine, in those who present to the ED with low back pain (LBP): (i) the prevalence of four key diagnostic categories, (ii) trends in lumbar imaging from 2015 to 2019 and (iii) the effect of a new model of care on lumbar imaging in the ED. METHODS: We conducted a retrospective analysis of routinely collected medical data of four tertiary hospitals in Sydney, Australia. We analysed ED presentations for LBP between January 2012 and October 2019. Outcomes were the prevalence of four key diagnostic categories of LBP and use of lumbar imaging. We examined trends in lumbar imaging over time and used interrupted time series analysis to determine the impact of model of care implementation on imaging use. RESULTS: There were 31 168 presentations for LBP of which 64.5% were non-specific LBP, 27.2% were problems beyond the spine, 5.3% were LBP with neurological signs and 2.3% were serious spinal conditions. 28.9% received lumbar imaging; use did not change substantially between 2012 and 2019. Patients diagnosed with serious spinal conditions were more likely to receive imaging (59%) than those diagnosed with non-specific LBP (29%). Implementation of a state-wide model of care in November 2016 did not appear to influence imaging use. CONCLUSION: Most presentations to the ED for LBP are for non-specific LBP. Around 2% will have specific spinal pathology. Use of imaging in those diagnosed with non-specific LBP remains high and was unaffected by implementation of a state-wide model of care.

The Prevent Alcohol and Risk-related Trauma in Youth (P.A.R.T.Y.) Program Questionnaire Validation Study (PQVS).

The Prevent Alcohol and Risk-related Trauma in Youth (P.A.R.T.Y.) program is an immersive hospital-based education program designed to reduce trauma in adolescents. The efficacy of the program in reducing risk-taking attitudes and preventing traumatic injuries has been proven through various methodologies. However, there is currently no study that has investigated the efficacy of the program using a validated, multi-domain questionnaire. This study outlines the design of the P.A.R.T.Y. Program Questionnaire (PPQ) and validates it through examining its construct and criterion validity as well as its internal consistency. Its capacity to risk-stratify participants was compared against the RT-18, a robust, 18-item risk-profiling instrument. The PPQ and the RT-18 were completed by New South Wales school students (N = 458) aged 15 to 18. The PPQ was designed in consultation with relevant field experts to optimise engagement and sensitivity. Examination of the construct validity of the PPQ was performed through exploratory factor analysis which demonstrated the presence of two underlying factors which aligned with the constructed two-scenario questionnaire format. The PPQ was shown to be internally consistent with a Cronbach's alpha of 0.77. Individual scenarios were shown to be internally consistent as well (α = 0.69, α = 0.66). The PPQ also identified high risk and low risk participants effectively as demonstrated by comparison against the risk stratification performed with the RT-18 (p-value < 0.001). This suggests the PPQ demonstrates criterion validity. Hence, the PPQ is an effective and valid tool for assessing risk-taking attitudes in adolescent populations.

Mapping haemodynamic changes with rapid sequence induction agents in the emergency department.

OBJECTIVE: Patients intubated in the ED are at an increased risk of post-intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. METHODS: This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre- and post-intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre- and post-intubation was the primary measure of haemodynamic stability. RESULTS: From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre-intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose-dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. CONCLUSION: Propofol was associated with post-intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post-intubation hypotension.

Clinical screening tools for obstructive sleep apnea in a population with atrial fibrillation: a diagnostic accuracy trial.

STUDY OBJECTIVES: Although obstructive sleep apnea (OSA) is a known risk factor for atrial fibrillation (AF), there is a paucity of data around its diagnosis and management in patients with AF. The objectives of this study were to compare the diagnostic accuracy of commonly used OSA screening tools in an AF population, including a level 3 portable sleep study device, and to examine the epidemiology of OSA in a hospital cohort with AF. METHODS: One hundred seven patients with AF recruited from 2 tertiary centers underwent a panel of OSA screening tools and in-laboratory polysomnography in randomized order. RESULTS: Oxygen desaturation index derived from a level 3 portable sleep study device performed best for moderate to severe and severe OSA, with excellent diagnostic accuracy (area under the curve, 0.899; 95% confidence interval, 0.838-0.960 and area under the curve, 0.925; 95% confidence interval, 0.859-0.991, respectively). Sixty-seven patients (62.6%) were newly diagnosed with OSA (31.8% mild, 18.7% moderate, 12.1% severe). CONCLUSIONS: Undiagnosed OSA is highly prevalent in a hospital AF cohort. However, it is characterized by a relative paucity of symptoms, markedly limiting the usefulness of history or screening questionnaires. This is the first study to find that a level 3 home sleep study device shows excellent diagnostic accuracy in patients with AF. This finding may inform AF management guidelines. CLINICAL TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Registry; Name: The validity and reliability of a portable device for the diagnosis of Obstructive Sleep Apnoea in patients with Atrial Fibrillation; URL:https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371024; Identifier: ACTRN12616001016426.

The Clinical Application of Polarization Pattern Perception.

Purpose: Determine the repeatability of and optimum stimulus parameters for testing polarization pattern perception in a real-world clinical population, and assess the ability of polarization perception to distinguish normal from abnormal eyes. Methods: Polarization perception was evaluated in staff and patients attending ophthalmology clinics at Warwick Hospital, UK. A series of visual stimuli were presented in pseudorandom order using a liquid-crystal-display-based polarization pattern generator. Stimuli included geometric patterns, gratings, checkerboards, and optotypes. Participants had one or both eyes diagnosed as normal or abnormal following ophthalmic examination, optical coherence tomography, and measures of visual acuity. Measurement scores were assigned to the eye(s) of each participant depending on the total number of stimuli perceived or identified. Results: Stimuli covered the range of spatial scales resolvable within polarization perception by normal and abnormal eyes. Different stimuli had different saliencies. For each stimulus type, polarization perception in the abnormal group was significantly reduced compared with normal eyes (P < 0.001). Relative stimulus salience was broadly similar for normal-eye and abnormal-eye viewing groups, being greatest for radially symmetric patterns and least for optotypes. Checkerboard pattern salience had an inverse logarithmic relationship with check fundamental spatial frequency. A devised metric covering the dynamic range of polarization perception was repeatable, and the score derived from the metric was reduced in the abnormal group compared with the normal group (P < 0.001). Conclusions: Clinically useful metrics of polarization perception distinguish between normal and abnormal eyes. Translational Relevance: Perception of spatial patterns formed of non-uniform polarization fields has potential as a quantitative clinical diagnostic measurement.

Challenges in the acute identification of mild traumatic brain injuries: results from an emergency department surveillance study.

OBJECTIVES: To establish the proportion of mild traumatic brain injury (mTBI) diagnosis among people presenting to an emergency department (ED), to determine the accuracy of recorded ED diagnoses. We also aimed to describe challenges in mTBI case identification and its acute hospital management. DESIGN AND SETTING: A retrospective chart review of all ED attendances to a major trauma hospital, over a 9-month period (June 2015-February 2016). PARTICIPANTS: Adults aged 18-65 years consecutively presenting to an ED. PRIMARY OUTCOME MEASURES: Proportion of mTBI diagnosis among ED attendances (ie, confirmed mTBI based on the WHO criteria or indeterminate mTBI based on secondary criteria), and proportion of accurately recorded mTBI diagnosis by ED clinicians (ie, 'mTBI', 'concussion'). RESULTS: Of 30 479 ED attendances, 351 (1.15%) confirmed mTBI diagnosis and 180 (0.6%) indeterminate diagnosis were identified. Only 81 (23.1%) individuals with a confirmed mTBI had a 'mTBI diagnosis' clearly recorded in the medical notes. Of the allocated discharge diagnosis codes to the two identified cohorts, 89.8% were not indicative of mTBI. Intracranial injuries were found in 31 (8.5%) confirmed cases. Glasgow Coma Scale scores were consistently assessed in the ED but identified only 117 (33.3%) confirmed mTBI cases. Post-traumatic amnesia (PTA) testing was able to confirm acute cognitive impairment in 113 (62.1%) of those who were tested (182, 51.3%). CONCLUSIONS: mTBI is a common, but an under-recognised cause for ED attendance. Despite challenges, the use of an operational definition such as the WHO diagnostic criteria can improve accuracy in mTBI identification. Acute management may be enhanced by rapid assessment of PTA.

Defining the Process of a Cardiovascular Risk Assessment Program: Lessons Learned From Cardiac Assessment of Elite Soccer Players in the United Kingdom.

OBJECTIVE: Retrospectively analyze the cardiac assessment process for elite soccer players, and provide team physicians with a systematic guide to managing longitudinal cardiac risk. DESIGN: Descriptive Epidemiology Study. SETTING: Cardiac assessments incorporating clinical examination, 12-lead ECG, echocardiography, and health questionnaire. PARTICIPANTS: Soccer players at 5 professional clubs in England, the United Kingdom. INTERVENTION: Data was retrospectively collected, inspected, and analyzed to determine their clinical management and subsequent follow-up. RESULTS: Over 2 years, 265 soccer players, aged 13 to 37 years with 66% of white European ethnicity, were included in the cohort. Eleven percent had "not-normal" assessments, of these assessments, 83% were considered gray screens, falling into three broad categories: structural cardiac features (including valvular abnormalities), functional cardiac features, and electrocardiogram changes. After cardiology consultation, all assessments were grouped into low, enhanced and high-risk categories for ongoing longitudinal risk management. Overall clear-cut pathology was identified in 2%. CONCLUSIONS: Cardiovascular assessment is a vital tool in identifying athletes at risk of sudden cardiac death to mitigate their risk through surveillance, intervention, or participation restriction. The decision whether a player is fit to play or not requires a robust risk assessment followed by input from a multidisciplinary team that includes both the team physician and cardiologist. This educational article proposes a clinical management pathway to aid clinicians with this process. CLINICAL RELEVANCE: Sudden cardiac death is the important medical cause of death during exercise. The team physician should assume responsibility for the management of the longitudinal risk of their players' cardiac assessments in conjunction with sports cardiologist.

Neutrophils-related host factors associated with severe disease and fatality in patients with influenza infection.

Severe influenza infection has no effective treatment available. One of the key barriers to developing host-directed therapy is a lack of reliable prognostic factors needed to guide such therapy. Here, we use a network analysis approach to identify host factors associated with severe influenza and fatal outcome. In influenza patients with moderate-to-severe diseases, we uncover a complex landscape of immunological pathways, with the main changes occurring in pathways related to circulating neutrophils. Patients with severe disease display excessive neutrophil extracellular traps formation, neutrophil-inflammation and delayed apoptosis, all of which have been associated with fatal outcome in animal models. Excessive neutrophil activation correlates with worsening oxygenation impairment and predicted fatal outcome (AUROC 0.817-0.898). These findings provide new evidence that neutrophil-dominated host response is associated with poor outcomes. Measuring neutrophil-related changes may improve risk stratification and patient selection, a critical first step in developing host-directed immune therapy.

Biomarkers of autonomic regulation for predicting psychological distress and functional recovery following road traffic injuries: protocol for a prospective cohort study.

INTRODUCTION: Psychological distress is a prevalent condition often overlooked following a motor vehicle crash (MVC), particularly when injuries are not severe. The aim of this study is to examine whether biomarkers of autonomic regulation alone or in combination with other factors assessed shortly after MVC could predict risk of elevated psychological distress and poor functional recovery in the long term, and clarify links between mental and physical health consequences of traffic injury. METHODS AND ANALYSIS: This is a controlled longitudinal cohort study, with follow-up occurring at 3, 6 and 12 months. Participants include up to 120 mild to moderately injured MVC survivors who consecutively present to the emergency departments of two hospitals in Sydney and who agree to participate, and a group of up to 120 non-MVC controls, recruited with matched demographic characteristics, for comparison. WHO International Classification of Functioning is used as the framework for study assessment. The primary outcomes are the development of psychological distress (depressive mood and anxiety, post-traumatic stress symptoms, driving phobia, adjustment disorder) and biomarkers of autonomic regulation. Secondary outcomes include indicators of physical health (presence of pain/fatigue, physical functioning) and functional recovery (quality of life, return to function, participation) as well as measures of emotional and cognitive functioning. For each outcome, risk will be described by the frequency of occurrence over the 12 months, and pathways determined via latent class mixture growth modelling. Regression models will be used to identify best predictors/biomarkers and to study associations between mental and physical health. ETHICS AND DISSEMINATION: Ethical approvals were obtained from the Sydney Local Health District and the research sites Ethics Committees. Study findings will be disseminated to health professionals, related policy makers and the community through peer-reviewed journals, conference presentations and health forums. TRIAL REGISTRATION NUMBER: ACTRN12616001445460.

Donor white blood cell survival and cytokine profiles following red blood cell transfusion in Australian major trauma patients.

BACKGROUND: The potential for the co-existence of genetically disparate cells (microchimerism) and associated cytokine profiles following red blood cell (RBC) transfusion in trauma patients has not been well characterized to date. This study investigated the incidence of surviving donor white blood cells (known as transfused-associated microchimerism (TAM)) and cytokine changes following blood transfusion in trauma patients. STUDY DESIGN AND METHODS: Trauma patients with an injury severity score (ISS) >12 who had been transfused between 2012-2016 with at least 5 units of RBC units over a 4 h period were recruited. Trauma patients with ISS > 12 who did not require blood transfusion were recruited as controls. The incidence of TAM was determined using a panel of insertion/deletion (InDel) bi-allelic polymorphisms. Selected pro- and anti-inflammatory cytokine profiles were analyzed using cytometric bead array. RESULTS: The transfused cohort (n = 40) had median ISS of 28 [12-66], received a median of 11 RBC units [4-114] and had median hospital length of stay of 35 days [1-152]. Only 11 (27.5%) patients returned for follow-up blood sampling after discharge. Of these, one patient showed an InDel pattern indicating the presence of TAM. No patients in the control cohort (n = 49) showed TAM. Cytokines IL-10 and IL-6 were found to be elevated in the transfused trauma patients. CONCLUSION: In this cohort, TAM was found to occur in one patient of the 11 who received a blood transfusion. Elevated IL-6 and IL-10 cytokines were detected in those patients who were transfused. However, the incidence of TAM could not be correlated with the elevated cytokine profiles for this cohort.

Lower limb muscle injuries: The good, the bad and the ugly.

Injuries to the lower limb muscles are a common cause of absence from training and competition in athletes. The different muscular groups of the thigh and leg are involved in various activities with kicking and sprinting being responsible for the largest number of injuries. The muscle acts on bone through the tendon and the fascia. The failure of one or more of these structures results in various degrees of loss of function of the muscle(s) involved. Usually, the point of weakness is the interface between different structures with different elastic properties (myofascial, myotendinous, avulsion). Diagnostic imaging is best performed by MRI that provides valuable information about the severity of the injury and its anatomical extent. In this article, we will review the MRI features of muscle injuries which can be used to guide return to play. We will emphasize the clinical implications of the MRI findings by dividing the muscle injuries into three categories "The Good, The Bad and The Ugly" to help the clinician in the planning of the most appropriate rehabilitation strategy.

A surveillance study to determine the accuracy of mild traumatic brain injury diagnosis in an emergency department: protocol for a retrospective cohort study.

INTRODUCTION: Previous literature confirms that a mild traumatic brain injury (mTBI) may result in long-term emotional impacts and, in vulnerable subgroups, cognitive deficits. The accurate diagnosis of mTBI and its written documentation is an important first step towards providing appropriate and timely clinical care. Surveillance studies involving emergency department (ED) and hospital-based data need to be prioritised as these provide incident mTBI estimates. This project will advance existing research findings by estimating the occurrence of mTBI among those attending an ED and quantifying the accuracy of mTBI diagnoses recorded by ED staff through a comprehensive audit of ED records. METHODS AND ANALYSIS: Retrospective chart reviews (between June 2015 and June 2016) of electronic clinical records from an ED in Sydney (New South Wales, Australia) will be conducted. The study population will include persons aged 18-65 years who attended the ED with any clinical features potentially indicative of mTBI. The WHO operational criteria for the clinical identification of mTBI cases is the presence of: (1) a Glasgow Coma Scale (GCS) of 13-15 after 30 min postinjury or on presentation to hospital; (2) one or more of the following: post-traumatic amnesia (PTA) of less than 24 hours' duration, confusion or disorientation, a witnessed loss of consciousness for ≤30 min and/or a positive CT brain scan. We estimate that 30 000 ED attendances will be screened and that a sample size of 500 cases with mTBI will be identified during this 1-year period, which will provide reliable estimates of mTBI occurrence in the ED setting. ETHICS AND DISSEMINATION: The study was approved by the Northern Sydney Local Health District Ethics Committee. The committee deemed this study as low risk in terms of ethical issues. The written papers from this study will be submitted for publication in quality peer-reviewed medical and health journals. Study findings will be disseminated via presentations at national/international conferences and peer-reviewed journals.

A novel immune biomarker IFI27 discriminates between influenza and bacteria in patients with suspected respiratory infection.

Host response biomarkers can accurately distinguish between influenza and bacterial infection. However, published biomarkers require the measurement of many genes, thereby making it difficult to implement them in clinical practice. This study aims to identify a single-gene biomarker with a high diagnostic accuracy equivalent to multi-gene biomarkers.In this study, we combined an integrated genomic analysis of 1071 individuals with in vitro experiments using well-established infection models.We identified a single-gene biomarker, IFI27, which had a high prediction accuracy (91%) equivalent to that obtained by multi-gene biomarkers. In vitro studies showed that IFI27 was upregulated by TLR7 in plasmacytoid dendritic cells, antigen-presenting cells that responded to influenza virus rather than bacteria. In vivo studies confirmed that IFI27 was expressed in influenza patients but not in bacterial infection, as demonstrated in multiple patient cohorts (n=521). In a large prospective study (n=439) of patients presented with undifferentiated respiratory illness (aetiologies included viral, bacterial and non-infectious conditions), IFI27 displayed 88% diagnostic accuracy (AUC) and 90% specificity in discriminating between influenza and bacterial infections.IFI27 represents a significant step forward in overcoming a translational barrier in applying genomic assay in clinical setting; its implementation may improve the diagnosis and management of respiratory infection.