Global research highlights - December 2017

Every quarter, the African Journal of Emergency Medicine, in partnership with several other regional emergency medicine journals, publishes abstracts from each respective journal. Abstracts are not necessarily linked to open access papers, but where green access is available it is linked to.  Click 'Read More' to read further.

Is the Pelvic Examination in Patients With Threatened Abortion Still Crucial in the Era of Readily Available Emergency Department Ultrasound? A Randomized Controlled Trial
From: Linden JA. Ann Emerg Med. 2017. http://dx.doi.org/10.1016/j.annemergmed.2017.07.487

​Study objective
We determine whether omitting the pelvic examination in emergency department (ED) evaluation of vaginal bleeding or lower abdominal pain in ultrasonographically confirmed early intrauterine pregnancy is equivalent to performing the examination.
Methods
We conducted a prospective, open-label, randomized, equivalence trial in pregnant patients presenting to the ED from February 2011 to November 2015. Patients were randomized to no pelvic examination versus pelvic examination. Inclusion criteria were aged 18 years or older, English speaking, vaginal bleeding or lower abdominal pain, positive β–human chorionic gonadotropin result, and less than 16-week intrauterine pregnancy by ultrasonography. Thirty-day record review and follow-up call assessed for composite morbidity endpoints (unscheduled return, subsequent admission, emergency procedure, transfusion, infection, and alternate source of symptoms). Wilcoxon rank sum tests were used to assess patient satisfaction and throughput times.
Results
Only 202 (of a planned 720) patients were enrolled, despite extension of the study enrollment period. The composite morbidity outcome was experienced at similar rates in the intervention (no pelvic examination) and control (pelvic examination) groups (19.6% versus 22.0%; difference –2.4%; 90% confidence interval [CI] –11.8% to 7.1%). Patients in the intervention group were less likely to report feeling uncomfortable or very uncomfortable during the visit (11.2% versus 23.7%; difference –12.5; 95% CI –23.0% to –2.0%).
Conclusion
Although there was only a small difference between the percentage of patients experiencing the composite morbidity endpoint in the 2 study groups (2.4%), the resulting 90% CI was too wide to conclude equivalence. This may have been due to insufficient power. Patients assigned to the pelvic examination group reported feeling uncomfortable more frequently.
Reproduced with permission

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Combined high-sensitivity copeptin and troponin T evaluation for the diagnosis of non-ST elevation acute coronary syndrome in the emergency department
From: Alquézar A. Emergencias. 2017;29:237-244

Objectives
To assess the diagnostic yield of a high-sensitivity copeptin (hs-copep) assay alone or in combination with a high-sensitivity cardiac troponin T (hs-cTnt) assay for the diagnosis of non-ST segment elevation acute coronary syndrome (NSTEMI) in patients with chest pain in the emergency department (ED). The secondary aim was to assess the 1-year prognostic utility of these biomarkers in this clinical context.
Material and methods
Retrospective observational study of a series of patients attended for chest pain suggesting myocardial ischemia in 5 Spanish ED. The first blood drawn in the ED was used for hs-copep and hs-cTnt assays, which were processed in a single laboratory serving all centers. Diagnostic utility was assessed by sensitivity, specificity, positive and negative predictive values and likelihood ratios, and the area under the receiver operating characteristic curve (ROC). We also performed a separate analysis with data for the subgroup of patients with early detection of symptoms (3 h of onset of symptoms). We recorded complications, mortality or reinfarction occurring within a year of the index event.
Results
We included 297 patients; 63 (21.2%) with NSTEMI. The median age was 69 years (interquartile range, 70–76 years), and 199 (67%) were men. The ROC was 0.89 (95% CI, 0.85–0.94) for the hs-cTnt assay, 0.58 (95% CI, 0.51–0.66) for the hscopep assay, and 0.90 (95% CI, 0.86–0.94) for the 2 assays combined. The ROC for the 2 assays combined was not significantly better than the ROC for the hs-cTnt by itself (P=.89). We saw the same pattern of results when we analyzed the subgroup of patients who presented early. Sixty percent of the complications occurred in patients with elevated findings on both assays. Elevated hs-copep findings did not provide prognostic information that was not already provided by hs-cTnt findings (P=.56).
Conclusion
The hs-copep assay does not increase the diagnostic or prognostic yield already provided by the hs-cTnt assay in patients suspected of myocardial infarction in the ED.
Reproduced with permission

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Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence?
From: Krage R. Emerg Med J. 2017;34:728-733

Background
Non-technical skills, such as task management, leadership, situational awareness, communication and decision-making refer to cognitive, behavioural and social skills that contribute to safe and efficient team performance. The importance of these skills during cardiopulmonary resuscitation (CPR) is increasingly emphasised. Nonetheless, the relationship between non-technical skills and technical performance is poorly understood. We hypothesise that non-technical skills become increasingly important under stressful conditions when individuals are distracted from their tasks, and investigated the relationship between non-technical and technical skills under control conditions and when external stressors are present.
Methods
In this simulator-based randomised cross-over study, 30 anaesthesiologists and anaesthesia residents from the VU University Medical Center, Amsterdam, the Netherlands, participated in two different CPR scenarios in random order. In one scenario, external stressors (radio noise and a distractive scripted family member) were added, while the other scenario without stressors served as control condition. Non-technical performance of the team leader and technical performance of the team were measured using the ‘Anaesthetists’ Non-technical Skill’ score and a recently developed technical skills score. Analysis of variance and Pearson correlation coefficients were used for statistical analyses.
Results
Non-technical performance declined when external stressors were present (adjusted mean difference 3.9 points, 95% CI 2.4 to 5.5 points). A significant correlation between non-technical and technical performance scores was observed when external stressors were present (r=0.67, 95% CI 0.40 to 0.83, p<0.001), while no evidence for such a relationship was observed under control conditions (r=0.15, 95% CI −0.22 to 0.49, p=0.42). This was equally true for all individual domains of the non-technical performance score (task management, team working, situation awareness, decision-making).
Conclusions
During CPR with external stressors, the team’s technical performance is related to the non-technical skills of the team leader. This may have important implications for training of CPR teams.
Reproduced with permission

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