Emergency admissions' diagnoses and risk of in-hospital death according to the primary ICD-10 chapter assigned at discharge and the National Early Warning Score on admission.

BACKGROUND: The relationship between diagnosis, illness severity, and mortality risk for unselected emergency admissions is poorly defined. AIM: To define primary ICD-10 diagnostic chapters at discharge, admission illness severity by the National Early Warning Score, and in-hospital mortality for all unselected emergency admissions. METHOD: Retrospective, observational, cohort study of 122,259 unselected, adult emergency admissions to Salford Royal Hospital between 2014 and 2022. RESULTS: In-hospital mortality was 4.3% but most patients had an ICD-10 chapter associated with a lower risk of death. 60% of in-hospital deaths were in four chapters, infections, circulatory and respiratory diseases, or neoplasms. An admission NEWS ≥3 was associated with earlier mortality and an eight-fold increased risk of in-hospital mortality. 45% of all in-hospital deaths occurred in patients with an admission NEWS <3. CONCLUSION: Mortality in emergency hospital admissions is associated with illness severity and four diagnostic chapters. NEWS should not be the only arbiter of hospital admission, as for certain diagnostic chapters the risk of death is high even if vital signs on presentation are normal.

Acute Medicine: How will we grow? - An analysis of organisational capabilities for quality improvement, research & education from SAMBA 2021.

BACKGROUND: Education, research, and Quality Improvement (QI) are key enablers for high quality care. We aimed to map the capability of Acute Medical Units (AMUs) to facilitate excellence in these areas. METHODS: AMUs were surveyed in an organisational questionnaire within the Society for Acute Medicine Benchmarking Audit 2021. RESULTS: 143 units participated. 80 units had a QI lead, 24 had a research lead and 99 had a medical education lead. 15 units had all three leadership roles. Most QI work considered service structure rather than changes in processes or care outcomes. CONCLUSION: The organisational capability of AMUs in the strategic areas considered is variable. Improving leadership and disseminating learning could help build a strategic foundation for acute medicine to grow.

Targeting young driver emotions can reduce their cellphone distractions.

OBJECTIVE: This study sought to evaluate the relationship between young drivers' intention to engage in cellphone distractions while driving and their emotions towards the associated risks. First, we assessed whether the emotions of guilt, shame, and fear are associated with young drivers' intention to engage in cellphone distractions, through an extended Theory of Planned Behavior (TPB) model. Second, we evaluated whether road signs that may evoke these negative emotions reduce cellphone use intentions among young drivers. METHODS: An online survey was conducted with young drivers (18 to 25 years old) from Ontario, Canada. 403 responses were collected, of which, 99 responses were used to evaluate the first objective and all 403 responses were used to evaluate the second objective. RESULTS: Anticipating feelings of guilt, shame, and fear negatively predicted the intention to engage in cellphone distractions, above and beyond the standard TPB constructs (i.e., attitudes, subjective norms, and perceived behavioral control). When prompted with potentially emotion-evoking road signs (children crossing, my mom/dad works here), an increase in anticipated feelings of these emotions corresponded with lower intention to engage in cellphone distractions. CONCLUSION: Countermeasures that target young driver emotions toward distracted driving risks may be effective in reducing their distraction engagement. Future studies in more controlled environments can investigate causal relationships between emotions and distracted driving among young drivers.

Suitability of maize crop residue fermented by Pleurotus ostreatus as feed for edible crickets: growth performance, micronutrient content, and iron bioavailability.

Small-scale farming of edible insects could help combat public health challenges such as protein energy malnutrition and anemia, but reliable low-cost feeds for insects are needed. In resource-limited contexts, where grains such as maize are prohibitively costly for use as insect feed, the feasibility of insect farming may depend on finding alternatives. Here, we explore the potential to modify plentiful maize crop residue with edible mushroom mycelium to generate a low-cost feed adjunct for the farmed two-spotted cricket, Gryllus bimaculatus. Mushroom farming, like insect agriculture, is versatile; it can yield nutritious food while increasing system circularity by utilizing lignocellulosic residues from row crops as inputs. Pleurotus ostreatus, is an edible basidiomycete capable of being cultivated on corn stover (Zea mays). Mushroom harvest results in abundant "spent" substrate, which we investigated as a candidate feed ingredient. We created six cricket feeds containing fermented Pleurotus substrate plus an unfermented control, measuring cricket mass, mortality, and maturation weekly to evaluate cricket growth performance impacts of both fungal fermentation duration and mushroom formation. Pasteurized corn stover was inoculated with P. ostreatus mycelium and fermented for 0, 2, 3, 4, or 8 weeks. Some 4 and 8-week substrates were induced to produce mushrooms through manipulations of temperature, humidity, and light conditions. Dried fermented stover (40%) was added to a 1:1 corn/soy grain mix and fed to crickets ad libitum for 44 days. The unfermented control group showed higher survivorship compared to several fermented diets. Control group mass yield was higher for 2 out of 6 fermented diets. Little variation in cricket iron content was observed via ICP-spectrometry across feeds, averaging 2.46 mg/100 g. To determine bioavailability, we conducted in vitro Caco-2 human colon epithelial cell absorption assays, showing that iron in crickets fed fruiting-induced substrates was more bioavailable than in unfruited groups. Despite more bioavailable iron in crickets reared on post-fruiting substrates, we conclude that Pleurotus-fermented stover is an unsuitable feed ingredient for G. bimaculatus due to high mortality, variability in growth responses within treatments, and low mass yield.

Connectomic Basis for Tremor Control in Stereotactic Radiosurgical Thalamotomy.

BACKGROUND AND PURPOSE: Given the increased use of stereotactic radiosurgical thalamotomy and other ablative therapies for tremor, new biomarkers are needed to improve outcomes. Using resting-state fMRI and MR tractography, we hypothesized that a "connectome fingerprint" can predict tremor outcomes and potentially serve as a targeting biomarker for stereotactic radiosurgical thalamotomy. MATERIALS AND METHODS: We evaluated 27 patients who underwent unilateral stereotactic radiosurgical thalamotomy for essential tremor or tremor-predominant Parkinson disease. Percentage postoperative improvement in the contralateral limb Fahn-Tolosa-Marin Clinical Tremor Rating Scale (TRS) was the primary end point. Connectome-style resting-state fMRI and MR tractography were performed before stereotactic radiosurgery. Using the final lesion volume as a seed, "connectivity fingerprints" representing ideal connectivity maps were generated as whole-brain R-maps using a voxelwise nonparametric Spearman correlation. A leave-one-out cross-validation was performed using the generated R-maps. RESULTS: The mean improvement in the contralateral tremor score was 55.1% (SD, 38.9%) at a mean follow-up of 10.0 (SD, 5.0) months. Structural connectivity correlated with contralateral TRS improvement (r = 0.52; P = .006) and explained 27.0% of the variance in outcome. Functional connectivity correlated with contralateral TRS improvement (r = 0.50; P = .008) and explained 25.0% of the variance in outcome. Nodes most correlated with tremor improvement corresponded to areas of known network dysfunction in tremor, including the cerebello-thalamo-cortical pathway and the primary and extrastriate visual cortices. CONCLUSIONS: Stereotactic radiosurgical targets with a distinct connectivity profile predict improvement in tremor after treatment. Such connectomic fingerprints show promise for developing patient-specific biomarkers to guide therapy with stereotactic radiosurgical thalamotomy.

"We are the forgotten grievers": Bereaved family members' experiences of support and mental ill-health following a road traffic collision.

Road traffic collisions (RTCs) are a global public health concern; however, research on the impact of bereavement on families remains limited. A critical realist approach was adopted to explore experiences of families suffering bereavement following RTCs, using interviews with 14 participants in the United Kingdom (UK) who have lost a family member. Three key themes were identified: (1) worsening mental health following bereavement, (2) negative impact of an RTC-related bereavement upon family members, (3) limited support following an RTC. Findings highlighted the requirement for appropriate support for bereaved families, and outlined significant flaws within the UK legal system, sentencing, and treatment of families.

Rates and Reasons for Readmission after Hospitalisation on the Acute Medical Unit.

INTRODUCTION: Readmission after hospital discharge is an ongoing challenge that healthcare systems face worldwide, with multimorbidity increasing the readmission risk significantly. Identifying higher risk groups of patients allows for safety netting at discharge to be implemented to prevent harm. The aim of this study was to compare readmission rates and reasons across common diagnostic groups presenting to the acute medical unit. METHOD: A retrospective analysis was performed on an anonymous dataset extracted from Salford Royal Hospital from 2014 - 2022 covering all non-elective inpatient admissions to AMU or medical same day emergency care where the patient survived to discharge. Episodes were grouped according to ICD-10 diagnostic codes, with readmission rates and reasons at 30 and 90 day calculated and compared using descriptive statistics. Further subgroups were evaluated according to demographic and co-morbid features. RESULTS: There were 89,897 admissions to AMU and SDEC where patients survived to discharge: age 68±19 years, 53% female. 5,880 episodes were excluded due to inpatient death. The most common first admission reasons were pneumonia (n=9,121), COPD (4,800) and sepsis (3,440). The overall 30 day readmission rate was 12.3%, with the highest rates being found where first admission episode was due to liver disease (21.9%), chronic obstructive pulmonary disease (COPD, 21.1%), and falls (17.9%). 6% of all patients were readmitted within 30 days due to recurrence of the primary presenting illness, representing 49% of all readmissions. After primary illness recurrence, pneumonia was the second most common readmission reason in 17 of 22 diagnostic groups and accounted for 25% of all readmissions excluding primary illness recurrence. Overall 90 day readmission rate was 24.2% with the same 3 most common diagnostic groups (liver disease 44%, COPD 39% and falls 34%). For 90 day readmission reasons according to specified comorbidities, the highest rates were seen in heart failures (34.1%) and COPD (33.1%). The highest readmission reason in the diagnostic groups was 41.4% of heart failure patients being readmitted with respiratory causes. Heart failure was the most impactful co-morbid factor associated with higher likelihood of 90 day readmission in other disease presentations (34.4% with heart failure, 22.8% without). DISCUSSION: Readmission rates vary significantly between diagnostic and co-morbid groups meaning that targeting high risk groups for safety netting may be possible using only simple admission details.

Improving and Sustaining the Quality of Discharge Summaries.

High quality discharge information communication has been linked to a reduction in the incidence of adverse events, decreasing the risk of prescription errors and lost follow up. In this paper we describe how our trust-wide quality improvement project, led by acute physicians, successfully improved discharge documentation. We demonstrate how we identified obstacles to continued success, and the interventions we implemented. We recommend how discharge summary quality can be optimised through training of junior doctors, recruitment of local champions, and use of novel methods to preserve engagement, such as gamification.

Implementation of a Night-Float Curriculum: Impact on Intern Confidence over Time.

OBJECTIVES: Formal nighttime education is becoming increasingly necessary as more internal medicine (IM) residency programs adopt night-float rotations (NFRs); however, the efficacy of an NFR curriculum throughout an academic year and which topics in an NFR curriculum increase trainee confidence are unknown. We implemented a 12-module, self-paced NFR curriculum for 76 postgraduate year-1 residents at an academic IM residency program. We evaluated the impact of this curriculum on postgraduate year-1 residents' clinical confidence, as well as longitudinal efficacy of the curriculum. METHODS: Night-float interns' (NFIs) clinical confidence regarding specific curricular topics was evaluated overall and during specific timeframes within the academic year. Pre- and post-NFR surveys using Likert scales for each topic were administered to NFIs from June 24, 2020 to March 2, 2021, representing 32 week-long NFR cycles. RESULTS: NFIs' pre- and postrotation confidence in managing clinical scenarios significantly improved for all 12 topics in the NFR curriculum. The NFR curriculum resulted most significantly in improved confidence during the first 4 months of the academic year, with 11 of 12 curricular topics reaching the threshold for statistical significance. Modules on altered mental status, hypotension, narrow-complex tachyarrhythmias, new fever, and sepsis and antibiotic escalation maintained their efficacy for the longest periods of time. CONCLUSIONS: It may be especially important to emphasize an NFR curriculum at the beginning of the academic year. IM residency programs also may wish to carefully consider that certain topics may maintain their efficacy throughout the year, whereas other topics should potentially be replaced with more complex modules as the academic year progresses.

Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure.

Premature closure is often described as a significant contributor to diagnostic error. Therefore, developing strategies to mitigate premature closure could reduce diagnostic errors and improve patient care. Here we propose the novel concept of pursuit of an "endpoint diagnosis" as a cognitive forcing strategy (CFS) for avoiding premature diagnostic closure. We define an "endpoint diagnosis" as an underlying causative explanation for a patient's signs, symptoms, and laboratory and radiographic data that exhausts additional relevant diagnostic evaluation. We have observed four contexts in which the error of not pursuing an endpoint diagnosis most often occurs: (1) diagnoses that appear to result in the same treatment regardless of etiology, (2) cases that are particularly complex, (3) clinical scenarios that are vulnerable to systems errors, and (4) situations in which patients' problems are attributed to uncontrolled underlying risk factors or an exacerbation of a known condition. Additionally, we address why we believe endpoint diagnoses are not universally pursued, delineate when this approach might be particularly useful, attempt to reconcile the potential conflict between accepting diagnostic ambiguity in certain instances and pursuing endpoint diagnoses, and outline possible concerns that might arise with using this CFS, including the possibility of lengthy evaluations resulting in overdiagnosis and overtreatment. Our overarching goal is for this CFS to help clinicians in their daily clinical practice as they seek to optimize their diagnostic skill and patient care.

Developing priorities for quality improvement in acute medicine using a modified Delphi method A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI).

INTRODUCTION: The SAM Quality Improvement Committee (SAM-QI), set up in 2016, has worked over the last year to determine the priority Acute Medicine QI topics. They have also discussed and put forward proposals to improve QI training for Acute Medicine professionals. METHODS: A modified Delphi process was completed over four rounds to determine priority QI topics. Online meetings were also used to develop proposals for QI training. RESULTS: Same Day Emergency Care (SDEC) was chosen as the priority topic for QI work within Acute Medicine. CONCLUSION: The SAM-QI group settled on SDEC being the priority topic for Acute Medicine QI development. Throughout the Delphi process SAM-QI has also developed proposals for QI training that will help Acute Medicine professionals deliver coordinated meaningful improvements in care.

Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21): assessing national performance of acute medicine services.

INTRODUCTION: The Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21) took place on 17th June 2021, providing the first assessment of performance against the Society for Acute Medicine's Clinical Quality Indicators (CQIs) within acute medical units since the start of the COVID-19 pandemic. METHODS: All acute hospitals in the UK were invited to participate. Data were collected on unit structure, and for patients admitted to acute medicine services over a 24-hour period, with follow-up at 7 days. RESULTS: 158 units participated in SAMBA21, from 156 hospitals. 8973 patients were included. The number of admissions per unit had increased compared to SAMBA19 (Sign test p<0.005). An early warning score was recorded within 30 minutes of hospital arrival in 77.4% of patients. 87.4% of unplanned admissions were seen by a tier 1 clinician within 4 hours of arrival. Overall, the medical team performed the initial clinician assessment for 36.4% of unplanned medical admissions. More than a third of medical admissions had their initial assessment in Same Day Emergency Care (SDEC) in 25.4% of hospitals. 62.1% of unplanned admissions were seen by two other clinical decision makers prior to consultant review. Of those unplanned admissions requiring consultant review, 67.8% were seen within the target time. More than a third of unplanned admissions were discharged the same day in 41.8% of units. CONCLUSION: Performance against the CQIs for acute medicine was maintained in comparison to previous rounds of SAMBA, despite increased admissions. There remains considerable variation in unit structure and performance within acute medical services.

Length of stay in Acute Medical Admissions: Analysis from the Society for Acute Medicine Benchmarking Audit.

INTRODUCTION: Medical admissions to hospital represent a diverse range of patients, from those managed on ambulatory pathways through Same Day Emergency Care (SDEC) services, to those requiring prolonged inpatient admission. An understanding of current patterns of admission through acute medicine services and patient factors associated with longer hospital admission is needed to guide service planning and improvement. METHODS: Data from the Society for Acute Medicine Benchmarking Audit (SAMBA) 2021 were analysed. Patients admitted to acute medicine services during a 24-hour period on 17th June 2021 were included, with data recording patient demographics, frailty score, acuity and follow-up of outcomes after seven days. RESULTS: 8101 unplanned medical admissions were included, from 156 hospitals. 31.6% were discharged without overnight admission; the median hospital performance was 30.1% (IQR 19.3-39.3%). 22.1% of patients remained in hospital for more than 7 days. Those remaining in hospital for more than 48 hours and for more than seven days were more likely to be aged over 70, to be frail, or to have a NEWS2 of 3 or more on arrival to hospital. CONCLUSION: The proportion of acute medical attendances receiving overnight admission varies between hospitals. Length of stay is impacted by patient factors and illness acuity. Strategies to reduce inpatient service pressures must ensure effective care for older patients and those with frailty.

Comparing an augmented reality navigation display to an electronic map for military reconnaissance.

The next generation of displays for soldiers may include augmented reality capabilities. One such display, called Mirror in the Sky (MitS), presents survey information in the upper visual field. Using a virtual reality simulation of a military reconnaissance scenario, we compared a MitS prototype to a familiar electronic 2D north-up map. Participants (24 soldiers) were told to follow a prescribed route, detect potential threats, and reroute around them. They also performed a secondary task as a measure of mental workload. At the end of the route, the soldiers were asked to recall the locations of threats and route changes. Participants made better reroute decisions with the north-up map than with MitS, although no differences were observed for threat detection or mental workload. They also scored higher on recall with the north-up map than with MitS. Practitioner Summary: An augmented reality navigation aid was compared to an electronic north-up map in a military reconnaissance scenario, in a virtual reality simulation. Participants made better route decisions and had better recall with the north-up map, but no mental workload differences were found between displays.

A mirror in the sky: the effects of map format and user expertise on navigation performance and mental workload.

A novel map display concept named Mirror in the Sky (MitS) has been introduced to improve performance and reduce workload in navigation tasks. However, this display will be novel to most users and as such, an evaluation of MitS in comparison with more conventional map formats is warranted. This study investigated the effects of map display format (MitS vs. north-up and track-up maps) and user expertise on mental workload (MWL) and performance, using both soldiers (experts) and civilians (novices) as participants. Participants followed a prescribed route to a destination in a virtual environment (route following task) while also performing a secondary task (detection response task). Soldiers generally performed better than civilians. Soldiers reported a higher MWL with MitS than with the north-up map, whereas civilians reported a higher MWL with MitS than with the track-up map. Regardless of user expertise, there were performance and workload challenges with MitS, despite its potential. Practitioner summary: A new map display concept called Mirror in the Sky (MitS) was compared with two conventional map formats: a north-up and track-up map. The experiment tested soldier and civilian users in a route following task. Both groups got further into the route and had fewer obstacle collisions with north-up and track-up maps than they did with the MitS map. MWL measures generally indicated higher workload with MitS. Abbreviations: MitS: mirror in the sky; FFOV: forward field of view; AR: augmented reality; MWL: mental workload; VR: virtual reality; HF: human factors; HR: heart rate; HRV: heart rate variability; DRT: detection response task; DRDC: defence research and development Canada; VE: virtual environment; RT: response time; ANOVA: analysis of variance.

Guest Editorial - Acute Medicine and Pandemics: Getting It Right Next Time!

For those of you who are not aware of what GIRFT (Getting It Right First Time) is, let me start by saying it is a brilliant idea, genius perhaps. The vision of its founder, Professor Tim Briggs CBE, was to optimise orthopaedic care by using the most clinically and cost effective treatments, minimising waste, reducing variation and eliminating poor practice. Since 2014 in orthopaedics alone, operational and financial opportunities to save the NHS £696 million have been generated. Acute medicine, coupled with general medicine, has been part of the GIRFT programme since 2017. The mischievous reader might question the name, as clearly this is about getting things right at the second time of asking at the very earliest. Apart from that pedantic note, GIRFT is a force for good.

Quality: What does it mean in Acute Medicine and how do we measure it?

Acute Medicine is a specialty that is not defined by a single organ system and sits at the interface between primary and secondary care. In order to document improvements in the quality of care delivered a system of metrics is required. A number of frameworks for measurements exist to quantify quality of care at the level of patients, teams and organisations, such as measures of population health, patient satisfaction and cost per patient. Measures can capture whether care is safe, effective, patient-centred, timely, efficient and equitable. Measurement in Acute Medicine is challenged by the often-transient nature of the contact between Acute Medicine clinicians and patients, the lack of diagnostic labels, a low degree of standardisation and difficulties in capturing the patient experience in the context. In a time of increasing ecological and financial constraints, reflecting about the most appropriate metrics to document the impact of Acute Medicine is required.

Snow on Arctic Sea Ice in a Warming Climate as Simulated in CESM.

Earth system models are valuable tools for understanding how the Arctic snow-ice system and the feedbacks therein may respond to a warming climate. In this analysis, we investigate snow on Arctic sea ice to better understand how snow conditions may change under different forcing scenarios. First, we use in situ, airborne, and satellite observations to assess the realism of the Community Earth System Model (CESM) in simulating snow on Arctic sea ice. CESM versions one and two are evaluated, with V1 being the Large Ensemble experiment (CESM1-LE) and V2 being configured with low- and high-top atmospheric components. The assessment shows CESM2 underestimates snow depth and produces overly uniform snow distributions, whereas CESM1-LE produces a highly variable, excessively-thick snow cover. Observations indicate that snow in CESM2 accumulates too slowly in autumn, too quickly in winter-spring, and melts too soon and rapidly in late spring. The 1950-2050 trends in annual mean snow depths are markedly smaller in CESM2 (-0.8 cm decade-1) than in CESM1-LE (-3.6 cm decade-1) due to CESM2 having less snow overall. A perennial, thick sea-ice cover, cool summers, and excessive summer snowfall facilitate a thicker, longer-lasting snow cover in CESM1-LE. Under the SSP5-8.5 forcing scenario, CESM2 shows that, compared to present-day, snow on Arctic sea ice will: (1) undergo enhanced, earlier spring melt, (2) accumulate less in summer-autumn, (3) sublimate more, and (4) facilitate marginally more snow-ice formation. CESM2 also reveals that summers with snow-free ice can occur ∼30-60 years before an ice-free central Arctic, which may promote faster sea-ice melt.

The Nazi Analogy Muddles Our Thinking About Physician Aid-in-Dying in the US.

What has become known in bioethics as "the Nazi analogy" likens a change's potential to precipitate moral deterioration to Nazi atrocities of the mid-20th century. This analogy has been applied in physician aid-in-dying (PAD) deliberations by those fearful that a physician's role in enabling a patient's death is too similar to Nazi physicians' roles in systematic murders during the Holocaust. This article suggests the importance of carefully distinguishing between when the Nazi analogy is aptly applied and when its use is limited to urging great caution about abuse or inequity.

Ovine Hemisection Model of Spinal Cord Injury.

INTRODUCTION: We are developing ovine models of spinal cord injury to test novel neuromodulation-based methods on spasticity. The hemisection has been reported in a number of large animal studies. Our aim is to duplicate a hemisection injury in the sheep. Our effort is explored here. Methods and Results: Three sheep underwent hemi-sectioning of the spinal cord. Quantitative gait analysis was completed both pre- and post-injury. While measurable differences in most of the 20 gait metrics were observed, relatively few were above the predicted thresholds based on error levels expected from the data. Variations in severity of injury across the three sheep were observed. Conclusions: The hemisection ovine model of spinal cord injury shows promise as a large-animal platform for developing new therapies for treating spinal cord injuries. While variability in injury severity was observed across animals, as has been observed with weight drop-based SCI models, the hemi-section approach has the advantages of procedural ease and reduced technical complexity.