UNASSIGNED: Distinguishing between ruptured and non-ruptured acute appendicitis presents a significant challenge. This study aimed to validate the accuracy of RAMA-WeRA Risk Score in predicting ruptured appendicitis (RA) in emergency department.
UNASSIGNED: This study was a multicenter diagnostic accuracy study conducted across six hospitals in Thailand from February 1, 2022, to January 20, 2023. The eligibility criteria included individuals aged >15 years suspected of acute appendicitis, presenting to the ED, and having an available pathology report following appendectomy or intraoperative diagnosis by the surgeon. We assessed the screening performance characteristics of RAMA-WeRA Risk Score, in detecting the ruptured appendicitis (RA) cases.
UNASSIGNED: 860 patients met the study criteria. 168 (19.38%) had RA and 692 (80.62%) patients had non-RA. The area under the receiver operating characteristic curve (AuROC) of RAMA-WeRA Risk Score was 75.11% (95% CI: 71.10, 79.11). The RAMA-WeRA Risk Score > 6 points (high-risk group) demonstrated a positive likelihood ratio (LR) of 3.22 in detecting the ruptured cases. The sensitivity and specificity of score in > 6 cutoff point was 43.8% (95%CI: 36.2, 51.6) and 86.4% (95%CI: 83.6, 88.9), respectively.
UNASSIGNED: The RAMA-WeRA Risk Score can predict rupture in patients presenting with suspected acute appendicitis in the emergency department with total accuracy of 75% for high-risk cases.

BACKGROUND: Traumatic brain injury (TBI) is a common presentation in the prehospital environment. At present, paramedics do not routinely use tools to identify low-risk patients who could be left at scene or taken to a local hospital rather than a major trauma centre. The Canadian CT Head Rule (CCHR) was developed to guide the use of CT imaging in hospital. It has not been evaluated in the prehospital setting. We aim to address this gap by evaluating the feasibility and acceptability of implementing the CCHR to patients and paramedics, and the feasibility of conducting a full-scale clinical trial of its use.
METHODS: We will recruit adult patients who are being transported to an emergency department (ED) by ambulance after suffering a mild TBI. Paramedics will prospectively collect data for the CCHR. All patients will be transported to the ED, where deferred consent will be taken and the treating clinician will reassess the CCHR, blinded to paramedic interpretation. The primary clinical outcome will be neurosurgically significant TBI. Feasibility outcomes include recruitment and attrition rates. We will assess acceptability of the CCHR to paramedics using the Ottawa Acceptability of Decision Rules Instrument. Interobserver reliability of the CCHR will be assessed between paramedics and the treating clinician in the ED. Participating paramedics and patients will be invited to participate in semistructured interviews to explore the acceptability of trial processes and facilitators and barriers to the use of the CCHR in practice. Data will be analysed thematically. We anticipate recruiting approximately 100 patients over 6 months.
BACKGROUND: This study was approved by the Health Research Authority and the Research Ethics Committee (REC reference: 22/NW/0358). The results will be published in a peer-reviewed journal, presented at conferences and will be incorporated into a doctoral thesis.
BACKGROUND: ISRCTN92566288.

BACKGROUND: Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department.
METHODS: In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children\'s emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child\'s neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330.
RESULTS: Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays.
CONCLUSIONS: Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments.
BACKGROUND: The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

In Acute Admission Wards, vital signs are commonly measured only intermittently. This may result in failure to detect early signs of patient deterioration and impede timely identification of patient stability, ultimately leading to prolonged stays and avoidable hospital admissions. Therefore, continuous vital sign monitoring may improve hospital efficacy. The objective of this randomized controlled trial was to evaluate the effect of continuous monitoring on the proportion of patients safely discharged home directly from an Acute Admission Ward. Patients were randomized to either the control group, which received usual care, or the sensor group, which additionally received continuous monitoring using a wearable sensor. The continuous measurements could be considered in discharge decision-making by physicians during the daily bedside rounds. Safe discharge was defined as no unplanned readmissions, emergency department revisits or deaths, within 30 days after discharge. Additionally, length of stay, the number of Intensive Care Unit admissions and Rapid Response Team calls were assessed. In total, 400 patients were randomized, of which 394 completed follow-up, with 196 assigned to the sensor group and 198 to the control group. The proportion of patients safely discharged home was 33.2% in the sensor group and 30.8% in the control group (p = 0.62). No significant differences were observed in secondary outcomes. The trial was terminated prematurely due to futility. In conclusion, continuous monitoring did not have an effect on the proportion of patients safely discharged from an Acute Admission Ward. Implementation challenges of continuous monitoring may have contributed to the lack of effect observed. Trial registration: https://clinicaltrials.gov/ct2/show/NCT05181111 . Registered: January 6, 2022.

OBJECTIVE: We tested a previously developed clinical prediction tool-a nomogram consisting of four patient measures (lower patient-expected benefit, lower patient-reported knee function, greater knee varus angle and severe medial knee radiological degeneration) that were related to poor response to non-surgical management of knee osteoarthritis. This study sought to prospectively evaluate the predictive validity of this nomogram to identify patients most likely to respond poorly to non-surgical management of knee osteoarthritis.
METHODS: Multisite prospective longitudinal study.
METHODS: Advanced practice physiotherapist-led multidisciplinary service across six tertiary hospitals.
METHODS: Participants with knee osteoarthritis deemed appropriate for trial of non-surgical management following an initial assessment from an advanced practice physiotherapist were eligible for inclusion.
METHODS: Baseline clinical nomogram scores were collected before a trial of individualised non-surgical management commenced.
METHODS: Clinical outcome (Global Rating of Change) was collected 6 months following commencement of non-surgical management and dichotomised to responder (a little better to a very great deal better) or poor responder (almost the same to a very great deal worse). Clinical nomogram accuracy was evaluated from receiver operating characteristics curve analysis and area under the curve, and sensitivity/specificity and positive/negative likelihood ratios were calculated.
RESULTS: A total of 242 participants enrolled. Follow-up scores were obtained from 210 participants (87% response rate). The clinical nomogram demonstrated an area under the curve of 0.70 (p<0.001), with greatest combined sensitivity 0.65 and specificity 0.64. The positive likelihood ratio was 1.81 (95% CI 1.32 to 2.36) and negative likelihood ratio 0.55 (95% CI 0.41 to 0.75).
CONCLUSIONS: The knee osteoarthritis clinical nomogram prediction tool may have capacity to identify patients at risk of poor response to non-surgical management. Further work is required to determine the implications for service delivery, feasibility and impact of implementing the nomogram in clinical practice.

UNASSIGNED: MONTH Difficult Laryngoscopy Score was developed for effectively identifying difficult intubations in the emergency department (ED). This study aimed to evaluate the accuracy of MONTH Score in predicting difficult intubations in ED.
UNASSIGNED: We prospectively collected data on all patients undergoing intubation in the ED of Ramathibodi Hospital, Bangkok, Thailand. The screening performance characteristics of the MONTH score in identifying the difficult intubation in ED were analyzed. All data were analyzed using STATA software version 18.0.
UNASSIGNED: 324 intubated patients with the median age of 73 (63-82) years were studied (63.58% male). The proportion of difficult intubations was 19.44%. The sensitivity and specificity of MONTH in predicting difficult intubations were 74.6% (95% CI: 61.6%-85.0%) and 92.8% (95% CI: 89.0%-95.6%), respectively. These measures in subgroup of patients with Intubation Difficulty Scale (IDS) score ≥ 6 were 44.1% (95%CI: 31.2-57.6) and 98.5% (95% CI: 96.2%- 99.6%), respectively. The area under the receiver operation characteristic (ROC) curve of MONTH in predicting difficult intubations was 0.895 (95% CI: 0.856- 0.926).
UNASSIGNED: It seems that the MONTH Difficult Laryngoscopy Score could be considered as a tool with high specificity and positive predictive values in identifying cases with difficult intubations in ED.

BACKGROUND: The risk of venous thromboembolism (VTE) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is 1.0% to 1.5%, despite uniform thromboprophylaxis.
OBJECTIVE: To develop and validate a prediction model for 90-day VTE risk.
METHODS: A multinational cohort study was performed. For model development, records were used from the Oxford Royal College of General Practitioners Research and Surveillance Centre linked to Hospital Episode Statistics and Office of National Statistics UK routine data. For external validation, data were used from the Danish Hip and Knee Arthroplasty Registry, the National Patient Registry, and the National Prescription Registry. Binary multivariable logistic regression techniques were used for development.
RESULTS: In the UK data set, 64 032 THA/TKA procedures were performed and 1.4% developed VTE. The prediction model consisted of age, body mass index, sex, cystitis within 1 year before surgery, history of phlebitis, history of VTE, presence of varicose veins, presence of asthma, history of transient ischemic attack, history of myocardial infarction, presence of hypertension and THA or TKA. The area under the curve of the model was 0.65 (95% CI, 0.63-0.67). Furthermore, 36 169 procedures were performed in the Danish cohort, of whom 1.0% developed VTE. Here, the area under the curve was 0.64 (95% CI, 0.61-0.67). The calibration slope was 0.92 in the validation study and 1.00 in the development study.
CONCLUSIONS: This clinical prediction model for 90-day VTE risk following THA and TKA performed well in both development and validation data. This model can be used to estimate an individual\'s risk for VTE following THA/TKA.

OBJECTIVE: To derive a clinical decision rule to exclude cerebral venous sinus thrombosis (CVST) in the ED. A secondary aim was to derive a rule that incorporated clinical parameters and the non-contrast CT brain.
METHODS: Single-centre, retrospective cohort study. Patients suspected of CVST were identified from the radiology database for CT/MR venograms. Clinical features included in the rule were determined by literature review. The presence of these features in participants was determined by chart review. Variables were tested for univariate association with CVST using logistic regression. Variable selection was accomplished using a forward-stepwise process, calculating the sensitivity/specificity of a rule containing the variable of most significance, then repeating the process after adding the next most significant variable.
RESULTS: Forty-five out of 912 participants had confirmed CVST. The primary clinical rule was answering \'no\' to all the following: any prothrombotic risk factor, age ≥54 years, confusion: sensitivity 95.6% (95% confidence interval [CI] 84.9-99.5%), specificity 40.9% (95% CI 37.6-44.2%), negative predictive value 99.4% (95% CI 97.9-99.9%) and positive predictive value 7.7% (95% CI 7.1-8.3%). The rule classified 39.5% of participants as CVST ruled out. The rule incorporating the non-contrast CT brain was answering \'no\' to all the following: abnormal non-contrast CT brain, any prothrombotic risk-factor, age ≥54 years, confusion: sensitivity 100.0% (95% CI 91.6-100.0%), specificity 42.0% (95% CI 38.7-45.4%), negative predictive value 100.0% (95% CI not calculated) and positive predictive value 7.8% (95% CI 7.4-8.2%). The rule classified 40.0% of participants as CVST ruled out.
CONCLUSIONS: A clinical decision rule was derived to rule out CVST. These results require validation before adoption into clinical practice.

UNASSIGNED: Various scores have been developed to predict sepsis mortality. This Study aimed to evaluate the accuracy of the quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), National Early Warning Score (NEWS) and Ramathibodi Early Warning Score (REWS) for predicting severity and 28-day mortality of elderly suspected sepsis cases in emergency department (ED).
UNASSIGNED: This prognostic accuracy study was performed using data obtained from patients aged ≥ 60 years with suspected sepsis who visited the Ramathibodi Hospital ED between May and December 2019. The accuracy of NEWS, SIRS, REWS, and qSOFA in predicting the studied outcomes were evaluated using the receiver operating characteristic (ROC) curve analysis.
UNASSIGNED: A total of 531 cases with the mean age of 77.6 ± 9.39 (range: 60-101) years were evaluated (45% male). The overall 28-day mortality was 11.6%. The area under ROC curve of qSOFA scores ≥2 showed moderate discrimination (0.66, 95% confidence interval [CI]: 0.59-0.73) in predicting mortality, which was significantly higher than SIRS ≥2 (ROC: 0.56, 95% CI: 0.50-0.63; p=0.04), NEWS ≥5 (ROC: 0.56, 95% CI: 0.50-0.63; p=0.01), and REWS ≥4 (ROC: 0.56, 95% CI: 0.50-0.63; p<0.01).
UNASSIGNED: qSOFA score ≥2 was superior to SIRS ≥2, NEWS ≥5, and REWS ≥4 in predicting 28-day mortality and septic shock in elderly patients with suspected sepsis in the ED. However, the predictive performance of qSOFA ≥2 was only moderate (AUC<0.8). Therefore, to reduce mortality and improve outcomes, we suggest the use of qSOFA ≥2 combined with clinical or other early warning scores, or the development of new prediction scores for screening, triage, and prediction of mortality and of severity of sepsis in elderly patients with suspected sepsis in the ED.

BACKGROUND: We aimed to identify patients at low risk of bloodstream infection (BSI) in the ED.
METHODS: We derived and validated a prediction model to rule out BSI in the ED without the need for laboratory testing by determining variables associated with a positive blood culture (BC) and assigned points according to regression coefficients. This retrospective study included adult patients suspected of having BSI (defined by at least one BC collection) from two European ED between 1 January 2017 and 31 December 2019. The primary end point was the BSI rate in the validation cohort for patients with a negative Bacteremia Rule Out Criteria (BAROC) score. The effect of adding laboratory variables to the model was evaluated as a second step in a two-step diagnostic strategy.
RESULTS: We analysed 2580 patients with a mean age of 64 years±21, of whom 46.1% were women. The derived BAROC score comprises 12 categorical clinical variables. In the validation cohort, it safely ruled out BSI without BCs in 9% (58/648) of patients with a sensitivity of 100% (95% CI 95% to 100%), a specificity of 10% (95% CI 8% to 13%) and a negative predictive value of 100% (95% CI 94% to 100%). Adding laboratory variables (creatinine ≥177 µmol/L (2.0 mg/dL), platelet count ≤150 000/mm3 and neutrophil count ≥12 000/mm3) to the model, ruled out BSI in 10.2% (58/570) of remaining patients who had been positive on the BAROC score. The BAROC score with laboratory results had a sensitivity of 100% (95% CI 94% to 100%), specificity of 11% (95% CI 9% to 14%) and negative predictive value of 100% (95% CI 94 to 100%). In the validation cohort, there was no evidence of a difference in discrimination between the area under the receiver operating characteristic for BAROC score with versus without laboratory testing (p=0.6).
CONCLUSIONS: The BAROC score safely identified patients at low risk of BSI and may reduce BC collection in the ED without the need for laboratory testing.