Global research highlights - December 2018

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.

The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease
From: Farrukh S, et al.  Ann Emerg Med. 2018 Dec;72(6):703-712.e1
Study objective
We evaluate the additive value of pelvic examinations in predicting sexually transmitted infection for young female patients with suspected cervicitis or pelvic inflammatory disease in a pediatric emergency department (ED).
Methods
This was a prospective observational study of female patients aged 14 to 20 years who presented to an urban academic pediatric ED with a complaint of vaginal discharge or lower abdominal pain. Enrolled patients provided a urine sample for chlamydia, gonorrhea, and trichomonas testing, which served as the criterion standard for diagnosis. A practitioner (pediatric ED attending physician, emergency medicine or pediatric resident, pediatric ED fellow, or advanced practice provider) obtained a standardized history from the patient to assess for cervicitis or pelvic inflammatory disease according to the Centers for Disease Control and Prevention criteria. They then recorded the likelihood of cervicitis or pelvic inflammatory disease on a 100-mm visual analog scale. The same practitioner then performed a pelvic examination and again recorded the likelihood of cervicitis or pelvic inflammatory disease on a visual analog scale with this additional information. Using the results of the urine sexually transmitted infection tests, the practitioner calculated and compared the test characteristics of history alone and history with pelvic examination.
Results
Two hundred eighty-eight patients were enrolled, of whom 79 had positive urine test results for chlamydia, gonorrhea, or trichomonas, with a sexually transmitted infection rate of 27.4% (95% confidence interval [CI] 22.6% to 32.8%). The sensitivity of history alone in diagnosis of cervicitis or pelvic inflammatory disease was 54.4% (95% CI 42.8% to 65.5%), whereas the specificity was 59.8% (95% CI 52.8% to 66.4%). The sensitivity of history with pelvic examination in diagnosis of cervicitis or pelvic inflammatory disease was 48.1% (95% CI 36.8% to 59.5%), whereas the specificity was 60.7% (95% CI 53.8% to 67.3%). The information from the pelvic examination changed management in 71 cases; 35 of those cases correlated with the sexually transmitted infection test and 36 did not.
Conclusion
For young female patients with suspected cervicitis or pelvic inflammatory disease, the pelvic examination does not increase the sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomonas compared with taking a history alone. Because the test characteristics for the pelvic examination are not adequate, its routine performance should be reconsidered.
Reproduced with permission

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Variability of renal colic management and outcomes in two Canadian cities
From: Innes G, et al. CJEM. 2018 Sep;20(5):702-712
Objectives
Some centres favor early intervention for ureteral colic while others prefer trial of spontaneous passage, and relative outcomes are poorly described.  Calgary and Vancouver have similar populations and physician expertise, but differing approaches to ureteral colic.  We studied 60-day hospitalization and intervention rates for patients having a first emergency department (ED) visit for ureteral colic in these diverse systems.
Methods
We used administrative data and structured chart review to study all Vancouver and Calgary patients with an index visit for ureteral colic during 2014. Patient demographics, arrival characteristics and triage category were captured from ED information systems, while ED visits and admissions were captured from linked regional hospital databases.  Laboratory results were obtained from electronic health records and stone characteristics were abstracted from diagnostic imaging reports.  Our primary outcome was hospitalization or urological intervention from 0-60 days. Secondary outcomes included ED revisits, readmissions and rescue interventions. Time to event analysis was conducted and Cox Proportional Hazards modeling was performed to adjust for covariate imbalance.
Results
We studied 3283 patients with CT-defined stones. Patient and stone characteristics were similar for the cities. Hospitalization or intervention occurred in 60.0% of Calgary patients and 31.3% of Vancouver patients (p<0.001). Calgary patients had higher index intervention rated (52.1% vs. 7.5%), and experienced more ED revisits and hospital readmissions during follow-up.  The data suggest that outcome events were associated with overtreatment of small stones in one city and undertreatment of large stones in the other.
Conclusions
An early interventional approach was associated with higher ED revisit, hospitalization and intervention rates. If these events are markers of patient disability, then a less interventional approach to small stones and earlier definitive management of large stones many reduce system utilization and improve outcomes for patients with acute ureteral colic.
Reproduced with permission

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Presentations at 29 conferences of the Spanish Society of Emergency Medicine (SEMES) from 1988 to 2017: a descriptive analysis
From: Fernández-Guerrero IM, et al. Emergencias. 2018;30:303-14
Objective
To gain greater understanding of the development of emergency medicine in Spain by analyzing the presentations at conferences of the Spanish Society of Emergency Medicine (SEMES) over the past 30 years (1988–2017).
Methods
We examined the programs of all SEMES conferences and described the characteristics of both presentations and presenters. We also analyzed changes occurring between 1988 and 2017 of some of the characteristics observed. The Web of Science was searched to evaluate the scientific productivity of the most frequent presenters and to calculate h-indexes for those presenters to assesstheir scientific relevance.
Results
SEMES did not hold a conference in 1992. The total of 29 conferences included 2182 presentations (112 listing presenters from abroad) given by 1410 presenters (89 from abroad). The presenters’ affiliations named 616 centers. The number of presentations and presenters increased linearly during the first period and then leveled off. The number increased exponentially in the final phase. Men gave 79.6% of the presentations; 70.6% of the presenters were physicians, 11.9% were nurses and 4.0% were ambulance staff. Specialists in emergency medicine accounted for 60.8% of the presenters who were physicians. Presenters from the Spanish autonomous community organizing the conference gave 29.8% of the presentations. The contributions of presenters from the local organizing community were nearly always more numerous than the average number of contributions from that community in all 29 conferences overall. Conference contributions from some autonomous communities (Extremadura, Andalusia, and Catalonia) were considerably fewer than would be expected given the scientific productivity of those communities. However, communities (Murcia, Balearic Islands, Asturias, Castile-Leon, Madrid), gave many more presentations tan their productivity metrics would predict. Analysis of the 59 most frequent presenters (at 5 conferences or more) showed that 64.4% of them had published at least 20 articles and that 71.2% had an h-index of 5 or higher. The number of women on the program increased significantly between 1988 and 2017. Likewise, geographic diversity increased significantly (presentations from centers outside the local organizing area) as did the participation of hospitalbased emergency medicine specialists.
Conclusions
SEMES conference programs have attracted significantly more presentations and presenters over the years. We also detected changes in descriptive characteristics. The analysis of those characteristics can help future SEMES conference planners to plan ways to correct aspects such as scarce geographic diversity, low international participation, and few women among presenters.
​Reproduced with permission

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Understanding better how emergency doctors work. Analysis of distribution of time and activities of emergency doctors: a systematic review and critical appraisal of time and motion studies
From: Abdulwahid MA, et al. Emerg Med J. 2018 Nov;35(11):692-700
Background
Optimising the efficiency and productivity of senior doctors is critical to ED function and delivery of safe patient care. Time and motion studies (TMS) can allow quantification of how these doctors spend their working time, identify inefficiencies in the current work processes and provide insights into improving working conditions, and enhancing productivity. Three questions were addressed: (1) How do senior emergency doctors spend their time in the ED? (2) How much of their time is spent on multitasking? (3) What is the number of tasks completed per hour?
Methods
The literature was systematically searched for TMS of senior emergency doctors. We searched for articles published in peer-reviewed journals in English language from 1998 to 2018 in the following databases: MEDLINE, EMBASE, Scopus, Web of Science and Cochrane. Studies were assessed for methodological quality using evidence-based quality criteria relevant for TMS including duration of observation, observer bias, Hawthorne effect and whether the task classification acknowledged any previous existing schemes. A narrative synthesis approach was followed.
Results
Fourteen TMS were included. The studies were liable to several biases including observer and Hawthorne bias. Overall, the time spent on direct face-to-face contact with the patient accounted for at least around 25%–40% of the senior doctors’ time. The remaining time was mostly spent on indirect clinical care such as communication (8%–44%), documentation (10%–28%) and administrative tasks (2%–20%). The proportion of time spent on multitasking ranged from 10% to 23%. When reported, the number of tasks performed per hour was generally high.
Conclusion
The review revealed that senior doctors spent a large percentage of their time on direct face-to-face contact with patients. The review findings provided a grounded understanding of how senior doctors spent their time in the ED and could be useful in implementing improvements to the emergency care system.
​Reproduced with permission

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The significance of National Early Warning Score for predicting prognosis and evaluating conditions of patients in resuscitation room
From: Wang Chang Yuan, et al. https://doi.org/10.1177/1024907918775879
Background
For critical patients in resuscitation room, the early prediction of potential risk and rapid evaluation of disease progression would help physicians with timely treatment, leading to improved outcome. In this study, it focused on the application of National Early Warning Score on predicting prognosis and conditions of patients in resuscitation room. The National Early Warning Score was compared with the Modified Early Warning Score) and the Acute Physiology and Chronic Health Evaluation II.
Objectives
To assess the significance of NEWS for predicting prognosis and evaluating conditions of patients in resuscitation rooms.
Methods
A total of 621 consecutive cases from resuscitation room of Xuanwu Hospital, Capital Medical University were included during June 2015 to January 2016. All cases were prospectively evaluated with Modified Early Warning Score, National Early Warning Score, and Acute Physiology and Chronic Health Evaluation II and then followed up for 28 days. For the prognosis prediction, the cases were divided into death group and survival group. The Modified Early Warning Score, National Early Warning Score, and Acute Physiology and Chronic Health Evaluation II results of the two groups were compared. In addition, receiver operating characteristic curves were plotted. The areas under the receiver operating characteristic curves were calculated for assessing and predicting intensive care unit admission and 28-day mortality.
Results
For the prognosis prediction, in death group, the National Early Warning Score (9.50 ± 3.08), Modified Early Warning Score (4.87 ± 2.49), and Acute Physiology and Chronic Health Evaluation II score (23.29 ± 5.31) were significantly higher than National Early Warning Score (5.29 ± 3.13), Modified Early Warning Score (3.02 ± 1.93), and Acute Physiology and Chronic Health Evaluation II score (13.22 ± 6.39) in survival group (p < 0.01). For the disease progression evaluation, the areas under the receiver operating characteristic curves of National Early Warning Score, Modified Early Warning Score, and Acute Physiology and Chronic Health Evaluation II were 0.760, 0.729, and 0.817 (p < 0.05), respectively, for predicting intensive care unit admission; they were 0.827, 0.723, and 0.883, respectively, for predicting 28-day mortality. The comparison of the three systems was significant (p < 0.05).
Conclusion
The performance of National Early Warning Score for predicting intensive care unit admission and 28-day mortality was inferior than Acute Physiology and Chronic Health Evaluation II but superior than Modified Early Warning Score. It was able to rapidly predict prognosis and evaluate disease progression of critical patients in resuscitation room.

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