Assertive community treatment for high-utilizing alcohol misuse patients: a before-and-after cohort study protocol.

BACKGROUND: The challenge posed by Alcohol-Related Frequent Attenders (ARFAs) in Emergency Departments (EDs) is growing in Singapore, marked by limited engagement with conventional addiction treatment pathways. Recognizing this gap, this study aims to explore the potential benefits of Assertive Community Treatment (ACT) - an innovative, community-centered, harm-reduction strategy-in mitigating the frequency of ED visits, curbing Emergency Medical Services (EMS) calls, and uplifting health outcomes across a quartet of Singaporean healthcare institutions. METHODS: Employing a prospective before-and-after cohort design, this investigation targeted ARFAs aged 21 years and above, fluent in English or Mandarin. Eligibility was determined by a history of at least five ED visits in the preceding year, with no fewer than two due to alcohol-related issues. The study contrasted health outcomes of patients integrated into the ACT care model versus their experiences under the exclusive provision of standard emergency care across Hospitals A, B, C and D. Following participants for half a year post-initial assessment, the evaluation metrics encompassed socio-demographic factors, ED, and EMS engagement frequencies, along with validated health assessment tools, namely Christo Inventory for Substance-misuse Services (CISS) scores, University of California, Los Angeles (UCLA) Loneliness scores, and Centre for Epidemiologic Studies Depression Scale Revised (CESD-R-10) scores. DISCUSSION: Confronted with intricate socio-economic and medical challenges, the ARFA cohort often grapples with heightened vulnerabilities in relation to alcohol misuse. Pioneering the exploration of ACT's efficacy with ARFAs in a Singaporean context, our research is anchored in a patient-centered approach, designed to comprehensively address these multifaceted clinical profiles. While challenges, like potential high attrition rates and sporadic data collection, are anticipated, the model's prospective contribution towards enhancing patient well-being and driving healthcare efficiencies in Singapore is substantial. Our findings have the potential to reshape healthcare strategies and policy recommendations. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04447079. Initiated on 25 June 2020.

Implementation of Prediction Models in the Emergency Department from an Implementation Science Perspective-Determinants, Outcomes, and Real-World Impact: A Scoping Review.

STUDY OBJECTIVE: Prediction models offer a promising form of clinical decision support in the complex and fast-paced environment of the emergency department (ED). Despite significant advancements in model development and validation, implementation of such models in routine clinical practice remains elusive. This scoping review aims to survey the current state of prediction model implementation in the ED and to provide insights on contributing factors and outcomes from an implementation science perspective. METHODS: We searched 4 databases from their inception to May 20, 2022: MEDLINE (through PubMed), Embase, Scopus, and CINAHL. Articles that reported implementation outcomes and/or contextual determinants under the Reach, Effectiveness, Adoption, Implementation Maintenance (RE-AIM)/Practical, Robust, Implementation, and Sustainability Model (PRISM) framework were included. Characteristics of studies, models, and results of the RE-AIM/PRISM domains were summarized narratively. RESULTS: Thirty-six reports on 31 implementations were included. The most common prediction models implemented were early warning scores. The most common implementation strategies used were training stakeholders, infrastructural changes, and using evaluative or iterative strategies. Only one report examined ED patients' perspectives, whereas the rest were focused on the experience of health care workers or organizational stakeholders. Key determinants of successful implementation include strong stakeholder engagement, codevelopment of workflows and implementation strategies, education, and usability. CONCLUSION: Examining ED prediction models from an implementation science perspective can provide valuable insights and help guide future implementations.

Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review.

BACKGROUND: Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method. METHODS: MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use. RESULTS: 1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA. CONCLUSION: Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.

Trends of chronic illness in emergency department admissions among elderly adults in a tertiary hospital over ten years.

BACKGROUND: This study aimed to determine to what extent an aging population and shift to chronic illness has contributed to emergency admissions at a tertiary care hospital over ten years. METHODS: This was a retrospective observational study performed using a database of all emergency admissions from the Emergency Department (ED) at a single tertiary hospital in Singapore during a ten-year period (January 1st, 2008 to December 31st, 2017). Emergency admissions were defined as ED visits with inpatient admission as the disposition. This study analyzed the trends of demographics, pre-existing comorbidities, chronic conditions or ambulatory care sensitive conditions (ACSC) of all patients who underwent emergency admissions in Singapore General Hospital. RESULTS: A total of 446,484 emergency records were included. For elderly patients, the proportions of them had pre-existing multimorbidity at the time of undergoing emergency admissions were found to be lower at the end the 10-year study period relative to the beginning of the study period. The proportions of emergency admissions whose ED primary diagnoses were categorized as chronic conditions and certain chronic ACSC including chronic obstructive pulmonary disease, congestive heart failure, diabetes complications, and epilepsy also decreased for elderly patients over the 10-year study period. CONCLUSIONS: In Singapore, despite a rapidly aging population, there have been surprisingly lower proportions of chronic conditions, pre-existing comorbidities, and chronic ACSC among the elderly emergency admissions. This is possibly consistent with an overall improved management of the chronic conditions among the elderly population. Future studies should include similar studies at the national level and comparison with other healthcare settings in different countries.

Coronavirus disease 2019 (COVID-19): an evidence map of medical literature.

BACKGROUND: Since the beginning of the COVID-19 outbreak in December 2019, a substantial body of COVID-19 medical literature has been generated. As of June 2020, gaps and longitudinal trends in the COVID-19 medical literature remain unidentified, despite potential benefits for research prioritisation and policy setting in both the COVID-19 pandemic and future large-scale public health crises. METHODS: In this paper, we searched PubMed and Embase for medical literature on COVID-19 between 1 January and 24 March 2020. We characterised the growth of the early COVID-19 medical literature using evidence maps and bibliometric analyses to elicit cross-sectional and longitudinal trends and systematically identify gaps. RESULTS: The early COVID-19 medical literature originated primarily from Asia and focused mainly on clinical features and diagnosis of the disease. Many areas of potential research remain underexplored, such as mental health, the use of novel technologies and artificial intelligence, pathophysiology of COVID-19 within different body systems, and indirect effects of COVID-19 on the care of non-COVID-19 patients. Few articles involved research collaboration at the international level (24.7%). The median submission-to-publication duration was 8 days (interquartile range: 4-16). CONCLUSIONS: Although in its early phase, COVID-19 research has generated a large volume of publications. However, there are still knowledge gaps yet to be filled and areas for improvement for the global research community. Our analysis of early COVID-19 research may be valuable in informing research prioritisation and policy planning both in the current COVID-19 pandemic and similar global health crises.

Omega-3 fatty acids for dialysis vascular access outcomes in patients with chronic kidney disease.

BACKGROUND: Maintaining long-term vascular access patency is necessary for high quality haemodialysis (HD) treatment of patients with the terminal and most serious stage of chronic kidney disease (CKD) - end-stage kidney disease (ESKD). Oral supplementation with omega-3 fatty acids (ω-3FA) may help to prevent blockage of the vascular access by reducing the risk of thrombosis and stenosis. OBJECTIVES: To evaluate the efficacy and safety of ω-3FA supplementation versus placebo or no treatment for maintaining vascular access patency in ESKD patients undergoing HD. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 23 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA: Randomised controlled trials (RCTs) of omega-3 fatty acids versus placebo that assessed the patency of arteriovenous fistula (AVF) or arteriovenous graft (AVG) types of vascular access in ESKD patients. DATA COLLECTION AND ANALYSIS: We assessed the risk of bias of each eligible study using the Cochrane Risk of Bias tool and made separate overall risk of bias judgments for the efficacy and safety outcomes. The certainty of evidence was assessed using the GRADE approach. The primary efficacy outcome was loss of vascular patency and the primary safety outcomes were occurrences of serious adverse events (e.g. death, hospitalisation, cardiovascular events, major bleeding). Secondary outcomes were the occurrence of non-serious adverse events (e.g. minor bleeding, gastrointestinal events and other adverse events). Efficacy effects were reported as risk ratios (RR) and safety effects as risk differences (RD) with 95% confidence intervals (CI). Studies were pooled separately by type of vascular access using a random-effects model. MAIN RESULTS: Five studies (833 participants) were included; one was a very small pilot study of 7 participants. All studies compared oral ω-3FA supplements against placebo. Four studies enrolled participants with arteriovenous grafts (AVGs), and the other had participants with arteriovenous fistulas (AVFs). The risk of bias for both efficacy and safety outcomes was unclear for all studies, due mainly to incomplete reporting for allocation concealment and incompleteness of study follow-up.In AVF patients, ω-3FA supplementation probably makes little or no difference to the 12-month risk of patency loss (1 study, 536 participants: RR 1.01, 95% CI 0.84 to 1.21; moderate certainty evidence), risk of death (1 study, 567 participants: RD 0.00, 95% CI -0.03 to 0.02; moderate certainty evidence) and risk of hospitalisation (1 study, 567 participants: RD 0.00, 95% CI -0.08 to 0.08; low certainty evidence). There was no information on cardiovascular events and major bleeding.In AVG patients, it is very uncertain whether ω-3FA supplementation reduces the risk of patency loss within 6 months (2 studies, 41 participants: RR 0.91, 95% CI 0.36 to 2.28; very low certainty evidence) or 12 months (2 studies, 220 participants: RR 0.59, 95% CI 0.27 to 1.31; very low certainty evidence). ω-3FA supplementation may make little or no difference to the risk of death within 6 to 12 months in AVG patients (4 studies, 261 participants: RD 0.01, 95% CI -0.05 to 0.07; low certainty evidence). It is very uncertain if ω-3FA supplementation increases the risk of hospitalisation (3 studies, 65 participants: RD 0.08, 95% CI -0.11 to 0.28; very low certainty evidence), changes the risk of cardiovascular events (4 studies, 261 participants: RD -0.02, 95% CI -0.11 to 0.07; very low certainty evidence), or increases the risk of major bleeding (3 studies, 65 participants: RD 0.08, 95% CI -0.11 to 0.28; very low certainty evidence) within 6 to 12 months in AVG patients. There may be an increase in the risk of mild gastrointestinal adverse reactions (3 studies, 65 participants: RD 0.25, 95% CI 0.07 to 0.43; low certainty evidence) such as a sensation of bloatedness, gas or a fishy aftertaste. AUTHORS' CONCLUSIONS: In CKD patients with an AVF, there is moderate certainty that ω-3FA supplementation makes little or no difference to preventing patency loss; and in patients with an AVG, it is very uncertain that ω-3FA supplementation prevents patency loss within 12 months.

Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour.

BACKGROUND: Childbirth may cause the most severe pain some women experience in their lifetime. Epidural analgesia is an effective form of pain relief during labour and is considered to be the reference standard. Traditionally epidural analgesia has been delivered as a continuous infusion via a catheter in the epidural space, with or without the ability for the patient to supplement the analgesia received by activating a programmable pump to deliver additional top-up doses, known as patient-controlled epidural analgesia (PCEA). There has been interest in delivering maintenance analgesic medication via bolus dosing (automated mandatory bolus - AMB) instead of the traditional continuous basal infusion (BI); recent randomized controlled trials (RCTs) have shown that the AMB technique leads to improved analgesia and maternal satisfaction. OBJECTIVES: To assess the effects of automated mandatory bolus versus basal infusion for maintaining epidural analgesia in labour. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, the World Health Organization International Clinial Trials Registry Platform (WHO-ICTRP) and ClinicalTrials.gov on 16 January 2018. We screened the reference lists of all eligible trials and reviews. We also contacted authors of included studies in this field in order to identify unpublished research and trials still underway, and we screened the reference lists of the included articles for potentially relevant articles. SELECTION CRITERIA: We included all RCTs that compared the use of bolus dosing AMB with continuous BI for providing pain relief during epidural analgesia for labour in women. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: risk of breakthrough pain with the need for anaesthetic intervention; risk of caesarean delivery; risk of instrumental delivery. Secondary outcomes included: duration of labour; local anaesthetic consumption. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included 12 studies with a total of 1121 women. Ten studies enrolled healthy nulliparous women only and two studies enrolled healthy parous women at term as well. All studies excluded women with complicated pregnancies. There were variations in the technique of initiation of epidural analgesia. Seven studies utilized the combined spinal epidural (CSE) technique, and the other five studies only placed an epidural catheter without any intrathecal injection. Seven studies utilized ropivacaine: six with fentanyl and one with sufentanil. Two studies used levobupivacaine: one with sufentanil and one with fentanyl. Three used bupivacaine with or without fentanyl. The overall risk of bias of the studies was low.AMB probably reduces the risk of breakthrough pain compared with BI for maintaining epidural analgesia for labour (from 33% to 20%; risk ratio (RR) 0.60; 95% confidence interval (CI) 0.39 to 0.92, 10 studies, 797 women, moderate-certainty evidence). AMB may make little or no difference to the risk of caesarean delivery compared to BI (15% and 16% respectively; RR 0.92; 95% CI 0.70 to 1.21, 11 studies, 1079 women, low-certainty evidence).AMB may make little or no difference in the risk of instrumental delivery compared to BI (12% and 9% respectively; RR 0.75; 95% CI 0.54 to 1.06, 11 studies, 1079 women, low-certainty evidence). There is probably little or no difference in the mean duration of labour with AMB compared to BI (mean difference (MD) -10.38 min; 95% CI -26.73 to 5.96, 11 studies, 1079 women, moderate-certainty evidence). There is probably a reduction in the hourly consumption of local anaesthetic with AMB compared to BI for maintaining epidural analgesia during labour (MD -1.08 mg/h; 95% CI -1.78 to -0.38, 12 studies, 1121 women, moderate-certainty evidence). Five out of seven studies reported an increase in maternal satisfaction with AMB compared to BI for maintaining epidural analgesia for labour; however, we did not pool these data due to their ordinal nature. Seven studies reported Apgar scores, though there was significant heterogeneity in reporting. None of the studies showed any significant difference between Apgar scores between groups. AUTHORS' CONCLUSIONS: There is predominantly moderate-certainty evidence that AMB is similar to BI for maintaining epidural analgesia for labour for all measured outcomes and may have the benefit of decreasing the risk of breakthrough pain and improving maternal satisfaction while decreasing the amount of local anaesthetic needed.

Hyperbaric versus isobaric bupivacaine for spinal anaesthesia for caesarean section.

BACKGROUND: Bupivacaine is an amide local anaesthetic used in hyperbaric and isobaric forms. These are administered intrathecally into the spine to provide regional anaesthesia for caesarean section. Several trials have compared hyperbaric and isobaric bupivacaine but none have conclusively shown the benefit of either. This review was first published in 2013 and updated in 2016. OBJECTIVES: Our objectives were to:1. Determine the effectiveness of hyperbaric bupivacaine compared to isobaric bupivacaine for spinal anaesthesia in women undergoing caesarean section;2. Determine the safety of hyperbaric bupivacaine compared to isobaric bupivacaine for spinal anaesthesia in women undergoing caesarean section. SEARCH METHODS: We originally searched the following databases to January 2011: CENTRAL, MEDLINE and Embase.For this update, we reran our search in the above databases from January 2011 to March 2016; two studies are awaiting a response from authors for assessment and will be dealt with when we next update the review.We imposed no language restriction. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) involving parturients undergoing spinal anaesthesia for elective caesarean section that compared the use of hyperbaric with isobaric bupivacaine. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data. The data that were extracted included the number of events and the sample sizes in both the intervention and control groups. For continuous outcomes, we extracted mean and standard deviation.We reported odds ratios (ORs) and risk ratios (RRs) for binary outcomes, and mean differences (MDs) for continuous outcomes. MAIN RESULTS: We included three new RCTs in this update, which now comprises 10 studies with a total of 614 participants. We judged most trials as having uncertain risk of bias regarding randomization. Other than this, the overall risk of bias was low. Most included trials had small sample sizes. All of the trials assessed the primary outcome of conversion to general anaesthesia. Ten trials comparing anaesthesia performed with hyperbaric and isobaric bupivacaine failed to show any difference in need for conversion to general anaesthesia (RR 0.33, 95% CI 0.09 to 1.17, 614 participants, very low quality of evidence). Nine trials also failed to show a difference in the need for supplemental analgesics (RR 0.61, 95% CI 0.26 to 1.41, 554 participants, very low quality of evidence). Four trials comparing requirement for ephedrine did not show any difference (RR 0.89, 95% CI 0.57 to 1.38, 256 participants, very low quality of evidence). Seven trials did not provide convincing evidence of difference in nausea and vomiting (RR 0.99, 95% CI 0.57 to 1.72, 433 participants, low quality of evidence). Three trials failed to show a difference in headache (OR 1.82, 95% CI 0.47 to 6.99, 234 participants, low quality of evidence). Two trials showed that the time until sensory block to the thoracic 4th (T4) spinal level was shorter with hyperbaric bupivacaine (MD -1.06 minutes, 95% CI -1.80 to -0.31, 128 participants, moderate quality of evidence). Six trials showed no difference in the amount of ephedrine used (RR 0.23, 95% CI -1.65 to 2.12, 386 participants, moderate quality of evidence). Three trials failed to show any difference in high block (RR 0.88, 95% CI 0.16 to 4.90, 205 participants). AUTHORS' CONCLUSIONS: Data are limited for some of the outcomes. Reporting of the included trials is less than optimal. For these reasons the overall quality of evidence is low or very low for most of the outcomes, based on the GRADE method of assessment. This review found that intrathecal hyperbaric bupivacaine had a more rapid onset of sensory blockade at the 4th thoracic vertebra (T4) level than isobaric bupivacaine. Hower, despite incorporating more data in the analysis, we found little evidence that the need for conversion to general anaesthesia and supplemental analgesia differed between the hyperbaric or isobaric bupivacaine groups. This is mainly due to the rarity of these outcomes, variability in the dose, use of adjuvant drugs and differences in the technique used for regional anaesthesia. There were no differences in the adverse effects studied. Any possible advantage of hyperbaric bupivacaine needs to be confirmed in larger randomized trials. In future research, criteria for conversion to general anaesthesia need to be defined objectively and applied uniformly.

Hyperbaric versus plain bupivacaine for spinal anesthesia for cesarean delivery.

BACKGROUND: Bupivacaine is an amide local anesthetic used in hyperbaric and plain forms administered as spinal anesthesia for cesarean delivery. In this systematic review, we summarized the effectiveness and safety of hyperbaric versus plain bupivacaine in providing anesthesia for cesarean delivery. We considered the adequacy of anesthesia for completion of cesarean delivery and the need for interventions to treat complications. METHODS: We searched the CENTRAL, MEDLINE, and EMBASE databases. We imposed no language restriction. We included all randomized controlled trials involving patients undergoing spinal anesthesia for elective cesarean delivery that compared the use of hyperbaric bupivacaine with plain bupivacaine. RESULTS: We included 6 studies with a total of 394 patients in this review. These studies have small sample size, few observed events, differences in methodology, and insufficient information pertaining to assessment of risk of bias. This prevented us from calculating pooled estimates. Results show that there is no compelling evidence in favor of the use of intrathecal plain or hyperbaric bupivacaine for spinal anesthesia for cesarean delivery. CONCLUSIONS: There is a lack of clear evidence regarding the superiority of hyperbaric compared with plain bupivacaine for spinal anesthesia for cesarean delivery. The need for conversion to general anesthesia because of failed spinal anesthesia is an important clinical outcome, but current data are insufficient to compare spinal anesthesia induced with hyperbaric compared with plain bupivacaine for this outcome. Further research is required.

Early versus late initiation of epidural analgesia for labour.

BACKGROUND: Pain during childbirth is arguably the most severe pain some women may experience in their lifetime. Epidural analgesia is an effective form of pain relief during labour. Many women have concerns regarding its safety. Furthermore, epidural services and anaesthetic support may not be available consistently across all centres. Observational data suggest that early initiation of epidural may be associated with an increased risk of caesarean section, but the same findings were not seen in recent randomised controlled trials. More recent guidelines suggest that in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labour. The choice of analgesic technique, agent, and dosage is based on many factors, including patient preference, medical status, and contraindications. There is no systematically reviewed evidence on the maternal and foetal outcomes and safety of this practice. OBJECTIVES: This systematic review aimed to summarise the effectiveness and safety of early initiation versus late initiation of epidural analgesia in women. We considered the obstetric and fetal outcomes relevant to women and side effects of the treatments, including risk of caesarean section, instrumental birth and time to birth. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (12 February 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE (January 1966 to February 2014), Embase (January 1980 to February 2014) and reference lists of retrieved studies. SELECTION CRITERIA: We included all randomised controlled trials involving women undergoing epidural labour analgesia that compared early initiation versus late initiation of epidural labour analgesia. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, extracted the data and assessed the trial quality. Data were checked for accuracy. MAIN RESULTS: We included nine studies with a total of 15,752 women.The overall risk of bias of the studies was low, with the exception of performance bias (blinding of participants and personnel).The nine studies showed no clinically meaningful difference in risk of caesarean section with early initiation versus late initiation of epidural analgesia for labour (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.96 to 1.08, nine studies, 15,499 women, high quality evidence). There was no clinically meaningful difference in risk of instrumental birth with early initiation versus late initiation of epidural analgesia for labour (RR 0.93; 95% CI 0.86 to 1.01, eight studies, 15,379 women, high quality evidence). The duration of second stage of labour showed no clinically meaningful difference between early initiation and late initiation of epidural analgesia (mean difference (MD) -3.22 minutes; 95% CI -6.71 to 0.27, eight studies, 14,982 women, high quality evidence). There was significant heterogeneity in the duration of first stage of labour and the data were not pooled.There was no clinically meaningful difference in Apgar scores less than seven at one minute (RR 0.96; 95% CI 0.84 to 1.10, seven studies, 14,924 women, high quality evidence). There was no clinically meaningful difference in Apgar scores less than seven at five minutes (RR 0.96; 95% CI 0.69 to 1.33, seven studies, 14,924 women, high quality evidence). There was no clinically meaningful difference in umbilical arterial pH between early initiation and late initiation (MD 0.01; 95% CI -0.01 to 0.03, four studies, 14,004 women, high quality evidence). There was no clinically meaningful difference in umbilical venous pH favouring early initiation (MD 0.01; 95% CI -0.00 to 0.02, four studies, 14,004 women, moderate quality evidence). AUTHORS' CONCLUSIONS: There is predominantly high-quality evidence that early or late initiation of epidural analgesia for labour have similar effects on all measured outcomes. However, various forms of alternative pain relief were given to women who were allocated to delayed epidurals to cover that period of delay, so that is it hard to assess the outcomes clearly. We conclude that for first time mothers in labour who request epidurals for pain relief, it would appear that the time to initiate epidural analgesia is dependent upon women's requests.

Towards advancing Out-of-Hospital cardiac arrest (OHCA) registries globally: Considerations from the global OHCA registry (GOHCAR) collaborative.

A growing number out-of-hospital cardiac arrest (OHCA) registries have been developed across the globe. A few of these are national, while others cover larger geographical regions. These registries have common objectives; continuous quality improvement, epidemiological research and providing infrastructure for clinical trials. OHCA registries make performance comparison across Emergency Medical Services systems possible for benchmarking, hypothesis generation and further research. Changes in OHCA incidence and outcomes provide insights about the effects of secular trends or health services interventions. These registries, therefore, have become a mainstay of OHCA management and research. However, developing and maintaining these registries is challenging. Coordination of different service providers to support data collection, sustainable resourcing, data quality and data security are the key challenges faced by these registries. Despite all these challenges, noteworthy progress has been made and further standardization and co-ordination across registries can result in great international benefit. In this paper we present a 'why' and 'how to' model for setting up OHCA registries, and suggestions for better international co-ordination through a Global OHCA Registries Collaborative (GOHCAR). We draw together the knowledge of a cohort of international researchers, with experience and expertise in OHCA registry development, management, and data synthesis.

Efficacy and safety of MLC601 (NeuroAiD®), a traditional Chinese medicine, in poststroke recovery: a systematic review.

BACKGROUND: Subsequent to a pooled analysis of 2 trials, several more studies have been published assessing the benefit of MLC601 in stroke patients. Hence, it is timely to conduct an updated meta-analysis to frame the interpretation of the results of an ongoing large multicenter, randomized, double-blind, placebo-controlled study. Therefore, we conducted a systematic review of the efficacy of MLC601 in improving the recovery of stroke patients. METHODS: PubMed® and the Cochrane Library® databases were searched for trials evaluating MLC601 in stroke patients. Primary outcome was functional independence, assessed by the Barthel Index or the Diagnostic Therapeutic Effects of Apoplexy scoring system, item 8. Secondary outcomes were improvement in functional independence scores, motor recovery, reduction in visual field defect and increase in cerebral blood flow. Two authors performed the article selection, appraisal and data extraction while resolving differences through discussion or consulting a third author. Data were analyzed in RevMan5®. Meta-analysis was conducted using a random effects model. RESULTS: This review included 6 studies with overall low risk of bias but some clinical heterogeneity. MLC601 increased the chances of achieving functional independence after stroke compared to control treatments (risk ratio, 2.35; 95% CI, 1.31-4.23). No deaths and 4 serious adverse events were reported in the MLC601 group, although detail was sparse with inconsistent reporting. CONCLUSIONS: There is evidence that MLC601 as an add-on to standard treatment could be effective in improving functional independence and motor recovery and is safe for patients with primarily nonacute stable stroke.

Use of hyperbaric versus isobaric bupivacaine for spinal anaesthesia for caesarean section.

BACKGROUND: Bupivacaine is an amide local anaesthetic used in hyperbaric and isobaric forms. These are administered intrathecally into the spine to provide regional anaesthesia for caesarean section. Several trials have compared hyperbaric and isobaric bupivacaine but none have conclusively shown benefit of either. OBJECTIVES: This systematic review aimed to summarize the effectiveness and safety of hyperbaric versus isobaric bupivacaine in providing anaesthesia for caesarean section. We considered the adequacy of anaesthesia for completion of caesarean section and the need for interventions to treat complications. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), MEDLINE (January 1966 to May 2011) and EMBASE (January 1980 to May 2011). We handsearched journals. We imposed no language restriction. We reran our search in the above databases from January 2011 to January 2013; the studies are awaiting assessment and will be dealt with when we update the review. SELECTION CRITERIA: We included all randomized controlled trials involving parturients undergoing spinal anaesthesia for elective caesarean section that compared the use of hyperbaric with isobaric bupivacaine. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data. The data that were extracted included the number of events and the sample sizes in both the intervention and control groups. For continuous outcomes, we extracted mean and standard deviation.We reported odds ratios and risk ratios (RR) for binary outcomes and mean differences (MD) for continuous outcomes. MAIN RESULTS: We included six studies with a total of 394 patients in this review. Anaesthesia performed with hyperbaric bupivacaine appeared to be less likely to need conversion to general anaesthesia (two studies, 158 patients included in meta-analysis; RR 0.17, 95% confidence interval (CI) 0.03 to 0.94). There was no difference in the need for supplemental analgesics. The time till sensory block to the T4 level was also shorter with hyperbaric bupivacaine (two studies, 126 patients; MD -1.06 minutes, 95% CI -1.80 to -0.31). There were no other significant differences between the two anaesthetics. AUTHORS' CONCLUSIONS: The criteria for conversion to general anaesthesia should be clearly defined in future research. This review found that intrathecal hyperbaric bupivacaine had a more rapid onset of sensory blockade at the T4 level than isobaric bupivacaine. It may also result in less need for conversion to general anaesthesia and supplemental analgesia. However, due to the rarity of this outcome, variability in the dose, use of adjuvant drugs and differences in the technique used for regional anaesthesia the evidence is weak. Any apparent advantage of hyperbaric bupivacaine needs to be confirmed in larger randomized trials. There were no differences in the adverse effects studied.

Artificial intelligence and machine learning in prehospital emergency care: A scoping review.

Our scoping review provides a comprehensive analysis of the landscape of artificial intelligence (AI) applications in prehospital emergency care (PEC). It contributes to the field by highlighting the most studied AI applications and identifying the most common methodological approaches across 106 included studies. The findings indicate a promising future for AI in PEC, with many unique use cases, such as prognostication, demand prediction, resource optimization, and the Internet of Things continuous monitoring systems. Comparisons with other approaches showed AI outperforming clinicians and non-AI algorithms in most cases. However, most studies were internally validated and retrospective, highlighting the need for rigorous prospective validation of AI applications before implementation in clinical settings. We identified knowledge and methodological gaps using an evidence map, offering a roadmap for future investigators. We also discussed the significance of explainable AI for establishing trust in AI systems among clinicians and facilitating real-world validation of AI models.

Risk of wound infection with use of sterile versus clean gloves in wound repair at the Emergency Department: A systematic review and meta-analysis.

STUDY OBJECTIVE: Sterile gloves are widely used during wound repair procedures in Emergency Departments (ED) worldwide. It is unclear whether sterile gloves protect against postoperative wound infections. We conducted a systematic review and meta-analysis to determine if sterile gloves offer significant protection against wound infections compared to clean gloves for wound repair in the ED. METHODS: Ovid MEDLINE, Ovid Embase, Cochrane Library and Web Of Science were searched for randomised controlled trials (RCTs) or non-randomized studies of intervention (NRSIs) from their dates of inception to January 2023. RCTs or NRSIs comparing sterile (control) vs. clean/no (intervention) glove use for wound repair procedures in the ED and reporting postoperative wound infections were included. Two investigators independently extracted data and assessed risk-of-bias of each report on a standardised form. Wound infection incidence was pooled using a random effects model. Subgroup analysis was performed to explore heterogeneity. RESULTS: 7 studies were included in the review, with 6 included in the meta-analysis. Of 3227 patients, 115/1608 (7.2%) patients in the intervention group and 135/1619 (8.3%) patients in the control group had postoperative wound infections. Overall RR was 0.86 (95% CI,0.67-1.10, I2=3.6%), and of high evidence certainty (GRADE). Absence of a protective effect was invariant in sensitivity analyses, leave-one-out analysis and subgroup analyses. CONCLUSION: No evidence of additional protection against wound infections with the use of sterile gloves for wound repair in the ED compared to clean gloves was found. However, the review was limited by nonreporting of antibiotic history and time between wound repair and follow-up amongst included studies. Considering the ergonomics, potential cost-savings and environmental impact, clean gloves are a viable alternative to sterile gloves, without compromising wound infection risk in this setting.

Technology activated community first responders in Singapore: Real-world care delivery & outcome trends.

BACKGROUND: Community first responders (CFRs) strengthen the Chain of Survival for out-of-hospital cardiac arrest (OHCA) care. Considerable efforts have been invested in Singapore's CFR program, during the years 2016-2020, by developing an app-based activation system called myResponder. This paper reports on national CFR response indicators to evaluate the real-world impact of these efforts. METHODS: We matched data from the Singapore Civil Defence Force's CFR registry with the Pan Asian Resuscitation Outcomes Study (PAROS) registry data to calculate performance indicators. These included the number of CFRs receiving and accepting an issued alert per OHCA event. Also calculated were the fraction of OHCA events where CFRs received an issued alert, or accepted the alert, and arrived at the scene either before or after EMS. We also present trends of these indicators and compare the prevalence of these fractions between the CFR-attended and CFR-unattended OHCA events. RESULTS: Of 6577 alerted OHCA events, 42.7% accepted an alert, 50% of these arrived at the scene and 71% of them arrived before EMS. Almost all CFR response indicators improved over time even for the pandemic year (2020). The fraction of OHCA events where >2 CFRs received an alert increased from 62% to 96%; the same figure for accepting an alert did not change much but >2 CFRs arriving at the scene increased from 0% to 7.5%. The fraction of OHCA events with an automated external defibrillator applied and defibrillation performed by CFR increased from 4.2% to 10.3% and 1.6% to 3%, respectively. Statistically significant differences were observed in these indicators when CFR-attended and CFR-unattended OHCA events were compared. CONCLUSION: This real-world study shows that activating CFRs using mobile technology can improve community response to OHCA and are bearing fruit in Singapore at a national level. Some targets for improvement and future research are highlighted in this report.

Impact of time-to-compression on out-of-hospital cardiac arrest survival outcomes: A national registry study.

OBJECTIVE: We aimed to quantify the association of no-flow interval in out-of-hospital cardiac arrests (OHCA) with the odds of neurologically favorable survival and survival to hospital discharge/ 30th day. Our secondary aim was to explore futility thresholds to guide clinical decisions, such as prehospital termination of resuscitation. METHODS: All OHCAs from 2012 to 2017 in Singapore were extracted. We examined the association between no-flow interval (continuous variable) and survival outcomes using univariate and multivariable logistic regressions. The primary outcome was survival with favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1/2), the secondary outcome was survival to hospital discharge/ 30th day if not discharged. To determine futility thresholds, we plotted the adjusted probability of good neurological outcomes to no-flow interval. RESULTS: 12,771 OHCAs were analyzed. The per-minute adjusted OR when no-flow interval was incorporated as a continuous variable in the multivariable model was: good neurological function- aOR 0.98 (95%CI: 0.97-0.98); survival to discharge- aOR 0.98 (95%CI: 0.98-0.99). Taking the 1% futility of survival line gave a no-flow interval cutoff of 12 mins (NPV 99%, sensitivity 85% and specificity 42%) overall and 7.5 mins for witnessed arrests. CONCLUSION: We demonstrated that prolonged no-flow interval had a significant effect on lower odds of favorable neurological outcomes, with medical futility occurring when no-flow interval was >12 mins (>7.5 mins for witnessed arrest). Our study adds to the literature of the importance of early CPR and EMS response and provided a threshold beyond traditional 'down-times', which could aid clinical decisions in TOR or OHCA management.

Dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing thyroidectomy: meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common complication after thyroidectomy. Steroids effectively reduce nausea, pain, and inflammation; therefore, preoperative administration of steroids ought to improve these surgical outcomes. METHODS: We conducted a systematic review of randomized controlled trials (RCTs) that compared preoperative single-dose administration of dexamethasone with no dexamethasone in patients undergoing thyroidectomy. The primary outcome was occurrence of PONV within 24 h, and the secondary outcomes were pain, use of analgesics, and steroid-related complications. RESULTS: Five RCTs were included with a total of 497 patients. A statistically and clinically significant difference in the incidence of PONV was found in favor of dexamethasone [relative risk (RR) 0.38; 95% confidence interval (CI) 0.30-0.49). The visual analog pain score was significantly diminished (weighted mean difference, WMD)-1.50; 95% CI-2.54 to -0.46) at 24 h. The incidence of analgesics use was also reduced (RR 0.61; 95% CI 0.41-0.90) in the dexamethasone group. No steroid-related complications were noted. CONCLUSIONS: A single preoperative administration of dexamethasone reduced the incidence of PONV and analgesic requirements in patients undergoing thyroidectomy. Prophylactic use of steroids for patients undergoing thyroidectomy is safe and should be considered for routine clinical practice.

Implementation of prediction models in the emergency department from an implementation science perspective-Determinants, outcomes and real-world impact: A scoping review protocol.

The number of prediction models developed for use in emergency departments (EDs) have been increasing in recent years to complement traditional triage systems. However, most of these models have only reached the development or validation phase, and few have been implemented in clinical practice. There is a gap in knowledge on the real-world performance of prediction models in the ED and how they can be implemented successfully into routine practice. Existing reviews of prediction models in the ED have also mainly focused on model development and validation. The aim of this scoping review is to summarize the current landscape and understanding of implementation of predictions models in the ED. This scoping review follows the Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. We will include studies that report implementation outcomes and/or contextual determinants according to the RE-AIM/PRISM framework for prediction models used in EDs. We will include outcomes or contextual determinants studied at any point of time in the implementation process except for effectiveness, where only post-implementation results will be included. Conference abstracts, theses and dissertations, letters to editors, commentaries, non-research documents and non-English full-text articles will be excluded. Four databases (MEDLINE (through PubMed), Embase, Scopus and CINAHL) will be searched from their inception using a combination of search terms related to the population, intervention and outcomes. Two reviewers will independently screen articles for inclusion and any discrepancy resolved with a third reviewer. Results from included studies will be summarized narratively according to the RE-AIM/PRISM outcomes and domains. Where appropriate, a simple descriptive summary of quantitative outcomes may be performed.

An Agile Systems Modeling Framework for Bed Resource Planning During COVID-19 Pandemic in Singapore.

Background: The COVID-19 pandemic has had a major impact on health systems globally. The sufficiency of hospitals' bed resource is a cornerstone for access to care which can significantly impact the public health outcomes. Objective: We describe the development of a dynamic simulation framework to support agile resource planning during the COVID-19 pandemic in Singapore. Materials and Methods: The study data were derived from the Singapore General Hospital and public domain sources over the period from 1 January 2020 till 31 May 2020 covering the period when the initial outbreak and surge of COVID-19 cases in Singapore happened. The simulation models and its variants take into consideration the dynamic evolution of the pandemic and the rapidly evolving policies and processes in Singapore. Results: The models were calibrated against historical data for the Singapore COVID-19 situation. Several variants of the resource planning model were rapidly developed to adapt to the fast-changing COVID-19 situation in Singapore. Conclusion: The agility in adaptable models and robust collaborative management structure enabled the quick deployment of human and capital resources to sustain the high level of health services delivery during the COVID-19 surge.