Emergency Medicine Journal最新文献

Older people living with frailty are frequent users of emergency care and have multiple and complex problems. Typical evidence-based guidelines and protocols provide guidance for the management of single and simple acute issues. Meanwhile, person-centred care orientates interventions around the perspectives of the individual. Using a case vignette, we illustrate the potential pitfalls of applying exclusively either evidence-based or person-centred care in isolation, as this may trigger inappropriate clinical processes or place undue onus on patients and families. We instead advocate for delivering a combined evidence-based, person-centred approach to healthcare which considers the person's situation and values, apparent problem and available options.

Background: D-dimer is the only biomarker currently recommended in guidelines for the diagnosis of acute aortic syndrome (AAS). We undertook a systematic review to determine whether any alternative biomarkers could be useful in AAS diagnosis.

Methods: We searched electronic databases (including MEDLINE, EMBASE and the Cochrane Library) from inception to February 2024. Diagnostic studies were eligible if they examined biomarkers other than D-dimer for diagnosing AAS compared with a reference standard test in people presenting to the ED with symptoms of AAS. Case-control studies were identified but excluded due to high risk of bias. Selection of studies, data extraction and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool were undertaken independently by at least two reviewers. We used narrative synthesis to summarise the findings.

Results: We identified 2017 citations, included 13 cohort studies (n=76-999), and excluded 38 case-control studies. Methodological quality was variable, with most included studies having unclear or high risk of bias and applicability concerns in at least one item of the QUADAS-2 tool. Only two studies reported biomarkers with sensitivity and specificity comparable to D-dimer (ie, >90% and >50%, respectively). Wang et al reported 99.1% sensitivity and 84.9% specificity for soluble ST2; however, these findings conflicted with estimates of 58% sensitivity and 70.8% specificity reported in another study. Chun and Siu reported 95.6% sensitivity and 56.1% specificity for neutrophil count, but this has not been confirmed elsewhere.

Conclusion: There are many potential alternative biomarkers for AAS but few have been evaluated in more than one study, study designs are often weak and reported biomarker accuracy is modest or inconsistent between studies. Alternative biomarkers to D-dimer are not ready for routine clinical use.

Prospero registration number: CRD42022252121.

Background: The Emergency Department(ED) team need to make sense of an ever-changing dynamic environment. The stories people tell about everyday occurrences are central to how sense-making occurs. These stories also contribute to organisational culture, with the frequently told narratives maintaining organisational identity and shaping behaviour. By capturing stories in the ED, valuable insights can be gained into organisational culture and identity.

Methods: Non-random purposive sampling was used to recruit doctors and nurses from EDs in five hospitals in Cape Town. Data collection took place over 8 weeks between June and August 2018. Participants were asked to tell a short descriptive narrative, provide a title for their story and create a metaphor to describe working in the ED. Data were captured using the SenseMaker Collector tool, and stories were exported into a Microsoft Excel spreadsheet for analysis. An inductive thematic analysis was undertaken to discover the dominant themes.

Results: Stories were collected from 89 participants. Five did not meet the inclusion criteria and were excluded. Four themes were identified. The theme 'the usual chaos' included stories about everyday challenges, clinical situations and the difficulties in managing patients with acute behavioural disturbance and those with mental health disorders in the ED. 'There is no help' included stories about a perceived lack of support from the rest of the hospital and healthcare system, whereas 'set up to fail' referred to characteristics of the ED, including crowding and boarders. The fourth theme demonstrated a pervasive 'war-like mentality' shared among professional groups in the ED.

Conclusion: Considering the ED as a socially constructed verbal system, we identified stories that used war-like metaphors, and related staff feelings of being unsupported and disconnected. The findings are concerning from an organisational perspective. The next step is to facilitate a participative process to strategically shape future narratives.

The use of dock leaves to ease the discomfort of nettle stings is a well-known folk remedy in the British Isles, yet has never been tested in a clinical trial. A group of Emergency Department doctors designed and conducted the Nettle-induced Urticaria Treatment Study (NUTS) as a research training and team-building exercise to address this gap in the Emergency Medicine evidence base.

A shortcut review of the literature was carried out to examine whether the measurement of neuron-specific enolase (NSE) can be used as a marker to exclude spinal cord, cauda equina or other significant spinal nerve root compression. 132 papers were found of which 4 included data on patients relevant to the clinical question, these are discussed in the paper. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. The clinical bottom line is that to date there is no evidence to suggest that measurement of NSE would be beneficial in clinical practice to rule out compression.