Recognising and managing eating disorders in the emergency department.

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

Recognising and managing eating disorders in the emergency department.

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

Cross-cultural adaptation and its impact on research in emergency care.

The perspective of patients is increasingly recognised as important to care improvement and innovation. Patient questionnaires such as patient-reported outcome measures may often require cross-cultural adaptation (CCA) to gather their intended information most effectively when used in cultures and languages different to those in which they were developed. The use of CCA could be seen as a practical step in addressing the known problems of inclusion, diversity and access in medical research.An example of the recent adaptation of a patient-reported outcome measure for use with ED patients is used to explore some key features of CCA, introduce the importance of CCA to emergency care practitioners and highlight the limitations of CCA.

Long-term cardiovascular risk prediction in the emergency department: a mixed-methods study protocol.

INTRODUCTION: Cardiovascular disease (CVD) remains one of the leading causes of preventable death in Europe, therefore any opportunity to intervene and improve care should be maximised. Known CVD risk factors are routinely collected in the emergency department (ED), yet they are often not acted on. If the risk factors have prognostic value and a pathway can be created, then this would provide more holistic care for patients and reduce health system inefficiency. METHODS AND ANALYSIS: In this mixed-methods study, we will use quantitative methods to investigate the prognostic characteristics of routinely collected data for long-term CVD outcomes, and qualitative methods to investigate how to use and implement this knowledge. The quantitative arm will use a database of approximately 21 000 chest pain patient episodes with a mean follow-up of 7.3 years. We will use Cox regression to evaluate the prognostic characteristics of routinely collected ED data for long-term CVD outcomes. We will also use a series of semi-structured interviews to co-design a prototype care pathway with stakeholders via thematic analysis. To enable the development of prototypes, themes will be structured into a logic model consisting of situation, inputs, outputs and mechanism. ETHICS AND DISSEMINATION: This work has been approved by Research Ethics Committee (Wales REC7) and the Human Research Authority under reference 19/WA/0312 and 19/WA/0311. It has also been approved by the Confidentiality Advisory Group reference 19/CAG/0209. Dissent recorded in the NHS' opt-out scheme will be applied to the dataset by NHS Digital. This work will be disseminated through peer-review publication, conference presentation and a public dissemination strategy. TRIAL REGISTRATION NUMBER: ISRCTN41008456. PROTOCOL VERSION: V.1.0-7 June 2021.

Advanced cardiovascular risk prediction in the emergency department: updating a clinical prediction model - a large database study protocol.

BACKGROUND: Patients presenting with chest pain represent a large proportion of attendances to emergency departments. In these patients clinicians often consider the diagnosis of acute myocardial infarction (AMI), the timely recognition and treatment of which is clinically important. Clinical prediction models (CPMs) have been used to enhance early diagnosis of AMI. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid is currently in clinical use across Greater Manchester. CPMs have been shown to deteriorate over time through calibration drift. We aim to assess potential calibration drift with T-MACS and compare methods for updating the model. METHODS: We will use routinely collected electronic data from patients who were treated using TMACS at two large NHS hospitals. This is estimated to include approximately 14,000 patient episodes spanning June 2016 to October 2020. The primary outcome of acute myocardial infarction will be sourced from NHS Digital's admitted patient care dataset. We will assess the calibration drift of the existing model and the benefit of updating the CPM by model recalibration, model extension and dynamic updating. These models will be validated by bootstrapping and one step ahead prequential testing. We will evaluate predictive performance using calibrations plots and c-statistics. We will also examine the reclassification of predicted probability with the updated TMACS model. DISCUSSION: CPMs are widely used in modern medicine, but are vulnerable to deteriorating calibration over time. Ongoing refinement using routinely collected electronic data will inevitably be more efficient than deriving and validating new models. In this analysis we will seek to exemplify methods for updating CPMs to protect the initial investment of time and effort. If successful, the updating methods could be used to continually refine the algorithm used within TMACS, maintaining or even improving predictive performance over time. TRIAL REGISTRATION: ISRCTN number: ISRCTN41008456.

Systematic literature search, review and dissemination methodology for the COVID-19 pandemic.

Purpose of the study: SARS-CoV-2 has caused healthcare systems globally to reorganise. A pandemic paradox emerged; while clinicians were desperate for information on a new disease, they had less time to find and evaluate the vast volume of publications at times of significant strain on healthcare systems.A multidisciplinary team undertook a weekly literature search capturing all COVID-19 publications. We also monitored free open access medical education (FOAMed) sources for emerging themes. Title and abstract screening pooled the most relevant papers for emergency medicine. Three summary types were created, a 'Top 5 Flash Update', a journal club and a rapid response to emerging FOAMed themes. From these summaries, three modes of dissemination were used: short written summaries, blogs and podcasts. These were amplified through social media. Study design: A retrospective review was conducted assessing the impact of this knowledge dissemination strategy for the period of March to September 2020. Results: In total, 64 687 papers were identified and screened. Of the papers included in the 'Top 5', 28.3% were on epidemiology, 23.6% treatment, 16.7% diagnostics, 12% prognosis, 8.7% pathophysiology with the remaining 10.7% consisting of PPE, public health, well-being and 'other'. We published 37 blogs, 17 podcasts and 18 Top 5 Flash Updates. The blogs were read 138 343 times, the Top 5 Flash Updates 68 610 times and the podcasts had 72 501 listens. Conclusion: A combination of traditional academic and novel social media approaches can address the pandemic paradox clinicians are facing.