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Background Low back pain (LBP) is a leading cause of disability worldwide and has posed numerous health and socioeconomic challenges. This study compared whether nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with tramadol, tizanidine or placebo would be the best treatment regime to improve the Roland Morris Disability Questionnaire (RMDQ) scores at 1 week. Methods This was a multi-center, double-blind, randomized, and placebo-controlled trial including adult patients with acute LBP and sciatica in three emergency departments in Hong Kong. Patients were randomized to the receive tramadol 50 mg, tizanidine 2 mg, or placebo every 6 hours for 2 weeks in a 1:1:1 ratio. The RMDQ and other secondary outcomes were measured at baseline, Day 2, 7, 14, 21, and 28. Data were analyzed on an intention to treat basis. Crude and adjusted mean differences in the changes of RMDQ and NRS scores from baseline to Day 7 between tizanidine/tramadol and placebo were determined with 95% confidence intervals. Results Two hundred and ninety-one patients were analyzed with the mean age of 47.4 years and 57.7% were male. The primary outcome of mean difference in RMDQs on Day 7 (compared with baseline) was non-significant for tizanidine compared with placebo (adjusted mean difference − 0.56, 95% CI -2.48 to 1.37) and tramadol compared with placebo (adjusted mean difference − 0.85, 95% CI -2.80 to 1.10). Only 23.7% were fully compliant to the treatment allocated. Complier Average Causal Effect analysis also showed no difference in the primary outcome for the tizanidine and tramadol versus placebo. Conclusion Among patients with acute LBP and sciatica presenting to the ED, adding tramadol or tizanidine to diclofenac did not improve functional recovery. What is already known on this topic There was no clear evidence of efficacy for cyclobenzaprine, methocarbamol, and metaxalone in addition to nonsteroidal anti-inflammatory drugs alone in patients with acute low back pain in the emergency department setting. What this study adds Among Chinese patients with acute low back pain and sciatica presenting to the emergency department, adding tramadol or tizanidine to diclofenac did not improve functional recovery at one week. The compliance to the analgesic drugs were low in this trial, with only 23.7% has taken at least 75% of the recommended doses, and 53.6% of patients has taken less than 25% of the recommended doses. Significant adverse events related to tramadol and tizanidine were found, with the most common being sleepiness and dizziness. How this study might affect research, practice or policy The lack of compliance would drive the effect estimate towards the null hypothesis (i.e. no difference), and further studies on relevant drugs should take into account of these low compliance rates. [ABSTRACT FROM AUTHOR]

Background: With the increasing threat of hazardous events at local, national, and global levels, an effective workforce for health emergency and disaster risk management (Health EDRM) in local, national, and international communities is urgently needed. However, there are no universally accepted competencies and curricula for Health EDRM. This study aimed to identify Health EDRM competencies and curricula worldwide using literature reviews and a cross-sectional survey. Methods: Literature reviews in English and Japanese languages were performed. We searched MEDLINE, EMBASE, CINAHL (English), and the ICHUSHI (Japanese) databases for journal articles published between 1990 and 2020. Subsequently, a cross-sectional survey was sent to WHO Health EDRM Research Network members and other recommended experts in October 2021 to identify competency models and curricula not specified in the literature search. Results: Nineteen studies from the searches were found to be relevant to Health EDRM competencies and curricula. Most of the competency models and curricula were from the US. The domains included knowledge and skills, emergency response systems (including incident management principles), communications, critical thinking, ethical and legal aspects, and managerial and leadership skills. The cross-sectional survey received 65 responses with an estimated response rate of 25%. Twenty-one competency models and 20 curricula for managers and frontline personnel were analyzed; managers' decision-making and leadership skills were considered essential. Conclusion: An increased focus on decision-making and leadership skills should be included in Health EDRM competencies and curricula to strengthen the health workforce. [ABSTRACT FROM AUTHOR]

Background: With the increasing threat of hazardous events at local, national, and global levels, an effective workforce for health emergency and disaster risk management (Health EDRM) in local, national, and international communities is urgently needed. However, there are no universally accepted competencies and curricula for Health EDRM. This study aimed to identify Health EDRM competencies and curricula worldwide using literature reviews and a cross-sectional survey. Methods: Literature reviews in English and Japanese languages were performed. We searched MEDLINE, EMBASE, CINAHL (English), and the ICHUSHI (Japanese) databases for journal articles published between 1990 and 2020. Subsequently, a cross-sectional survey was sent to WHO Health EDRM Research Network members and other recommended experts in October 2021 to identify competency models and curricula not specified in the literature search. Results: Nineteen studies from the searches were found to be relevant to Health EDRM competencies and curricula. Most of the competency models and curricula were from the US. The domains included knowledge and skills, emergency response systems (including incident management principles), communications, critical thinking, ethical and legal aspects, and managerial and leadership skills. The cross-sectional survey received 65 responses with an estimated response rate of 25%. Twenty-one competency models and 20 curricula for managers and frontline personnel were analyzed; managers' decision-making and leadership skills were considered essential. Conclusion: An increased focus on decision-making and leadership skills should be included in Health EDRM competencies and curricula to strengthen the health workforce. [ABSTRACT FROM AUTHOR]

Objective: To examine whether a 2-week or 4-week virtual patient simulation program can improve clinical competence for undergraduate emergency medicine education during COVID-19. Methods: This randomized controlled trial was conducted between October and December 2021. Final-year medical students were randomized into a 2-week short exposure group and a 4-week long exposure group on a 1:1 allocation. They were assessed using a virtual case with structured scoring system before and after the virtual patient simulation learning program. An end-of-program questionnaire on learners' perceptions was also administered. Results: A total of 138 students were recruited. After the virtual patient simulation program, the virtual case score increment in the long exposure group was significantly higher than in the short exposure group with a mean score difference of 18/100 (95% confidence interval = 9.8 to 26.3). Questionnaire showed generally positive perceptions toward the use of virtual patient simulation program for emergency medicine teaching. Conclusion: Virtual reality learning of 2 and 4 weeks' duration may be beneficial for improving emergency medicine clinical competence for final-year medical students, especially during periods of limited clinical exposure like the COVID-19 pandemic. A longer 4-week virtual patient simulation program may produce a better learning effect on clinical competence. [ABSTRACT FROM AUTHOR]

Background: Several early warning scores have been designed to optimize acute care by identifying patients at risk of deterioration. Methods: In this post hoc dual center study, we analyzed the performance of six clinical scores (the Goodacre score, Groarke, Worthing Physiological Score, Rapid Acute Physiology Score, Rapid Emergency Medicine Score, United Kingdom National Early Warning Score. The primary outcome is 30-day all-cause mortality after inclusion and data were obtained from previous studies performed at two different emergency departments on two continents (Denmark, Europe, and Hong Kong, Asia). Results: We included 2952 people; 1482 (50.2%) were male, mean age (standard deviation) was 65.7 (18.3) years, and 109 (3.7%) died within 30 days. Mortality rate increased steadily with increasing scores for all six scoring systems in Hong Kong while this was less obvious in Denmark. In all patients, Rapid Acute Physiology Score had the lowest discriminatory power while National Early Warning Score had the highest. National Early Warning Score performed best in Hong Kong while Worthing performed marginally better in Denmark. Discussion: Surprisingly, the performance of the scoring systems varied considerably, but were largely unaffected by location, and none of them performed close to what clinicians would normally require for predicting 30-day all-cause mortality Conclusion: All scores performed similarly across both centers, with poor prediction of 30-day all-cause mortality. Based on these findings, we believe that clinical scores must be supplemented by either biochemical values or global markers of physiological reserve to reflect reality and to be of true value. [ABSTRACT FROM AUTHOR]

Background: Acute pyelonephritis is a bacterial infection of the upper urinary tract. Patients can be admitted to a variety of wards for treatment. However, at the Prince of Wales Hospital in Hong Kong, they are managed initially in the emergency medicine ward. The aim of the study is to identify the risk factors that are associated with a prolonged hospital length of stay. Methods: This was a retrospective cohort study conducted in Prince of Wales Hospital. The study recruited patients who were admitted to the emergency medicine ward between 1 January 2014 and 31 December 2017. These patients presented with clinical features of pyelonephritis, received antibiotic treatment and had a discharge diagnosis of pyelonephritis. The length of stay was measured and any length of stay over 72 h was considered to be prolonged. Results: There were 271 patients admitted to the emergency medicine ward, and 118 (44%) had a prolonged hospital length of stay. Univariate and multivariate analyses showed that the only statistically significant predictor of prolonged length of stay was a raised C-reactive protein (odds ratio 1.01; 95% confidence 1.01–1.02; p < 0.0001). Out of 271 patients, 261 received antibiotics in the emergency department. All 10 patients (8.5%) who did not receive antibiotics in emergency department had a prolonged length of stay (p = 0.0002). Conclusion: In this series of acute pyelonephritis treated in the emergency medicine ward, raised C-reactive protein levels were predictive for prolonged length of stay. Patients who did not receive antibiotics in the emergency department prior to emergency medicine ward admission had prolonged length of stay. [ABSTRACT FROM AUTHOR]

Background: Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as 'thunderclap' undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation.Methods: This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test.Results: 644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases-significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p<0.001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p<0.001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache.Conclusions: Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation. [ABSTRACT FROM AUTHOR]

Purpose: Trauma remains a major cause of morbidity and disability worldwide; however, reliable data on the health status of an urban Asian population after injury are scarce. The aim was to evaluate 1-year post-trauma return to work (RTW) status in Hong Kong. Methods: This was a prospective, multi-center cohort study involving four regional trauma centers from 2017 to 2019 in Hong Kong. Participants included adult patients entered into the trauma registry who were working or seeking employment at the time of injury. The primary outcome was the RTW status up to 1 year. The Extended Glasgow Outcome Scale, 12-item Short Form (SF-12) survey and EQ5D were also obtained during 1-, 3-, 6-, 9-, and 12-month follow-ups. Multivariable Cox proportional hazards regression analysis was used for analysis. Results: Six hundred and seven of the 1115 (54%) recruited patients had RTW during the first year after injury. Lower physical requirements (p = 0.003, HR 1.51) in pre-injury job nature, higher educational levels (p < 0.001, HR 1.95), non-work-related injuries (p < 0.001, HR 1.85), shorter hospital length of stay (p = 0.007, HR 0.98), no requirement for surgery (p = 0.006, HR 1.34), and patients who could be discharged home (p = 0.006, HR 1.43) were associated with RTW within 12 months post-injury. In addition, 1-month outcomes including extended Glasgow Outcome Scale ≥ 6 (p = 0.001, HR 7.34), higher mean SF-12 physical component summary (p = 0.002, HR 1.02) and mental component summary (p < 0.001, HR 1.03), and higher EQ5D health index (p = 0.018, HR 2.14) were strongly associated with RTW. Conclusions: We have identified factors associated with failure to RTW during the first year following in Hong Kong including socioeconomic factors, injury factors and treatment-related factors and 1-month outcomes. Future studies should focus on the interventions that can impact on RTW outcomes. Trial registration: ClinicalTrials.gov Identifier NCT03219424. [ABSTRACT FROM AUTHOR]

Purpose: The purpose was to investigate long-term health impacts of trauma and the aim was to describe the functional outcome and health status up to 7 years after trauma. Methods: We conducted a prospective, multi-centre cohort study of adult trauma patients admitted to three regional trauma centres with moderate or major trauma (ISS ≥ 9) in Hong Kong (HK). Patients were followed up at regular time points (1, 6 months and 1, 2, 3, 4, 5, 6, and 7 years) by telephone using extended Glasgow Outcome Scale (GOSE) and the Short-Form 36 (SF36). Observed annual mortality rate was compared with the expected mortality rate estimated using the HK population cohort. Linear mixed model (LMM) analyses examined the changes in SF36 with subgroups of age ≥ 65 years, ISS > 15, and GOSE ≥ 5 over time. Results: At 7 years, 115 patients had died and 48% (138/285) of the survivors responded. The annual mortality rate (AMR) of the trauma cohort was consistently higher than the expected mortality rate from the general population. Forty-one percent of respondents had upper good recovery (GOSE = 8) at 7 years. Seven-year mean PCS and MCS were 45.06 and 52.06, respectively. LMM showed PCS improved over time in patients aged < 65 years and with baseline GOSE ≥ 5, and the MCS improved over time with baseline GOSE ≥ 5. Higher mortality rate, limited functional recovery and worse physical health status persisted up to 7 years post-injury. Conclusion: Long-term mortality and morbidity should be monitored for Asian trauma centre patients to understand the impact of trauma beyond hospital discharge. [ABSTRACT FROM AUTHOR]

Purpose: Hong Kong (HK) trauma registries have been using the Trauma and Injury Severity Score (TRISS) for audit and benchmarking since their introduction in 2000. We compare the mortality prediction model using TRISS and Revised Injury Severity Classification, version II (RISC II) for trauma centre patients in HK. Methods: This was a retrospective cohort study with all five trauma centres in HK. Adult trauma patients with Injury Severity Score (ISS) > 15 suffering from blunt injuries from January 2013 to December 2015 were included. TRISS models using the US and local coefficients were compared with the RISC II model. The primary outcome was 30-day mortality and the area under the receiver operating characteristic curve (AUC) for tested models. Results: 1840 patients were included, of whom 1236/1840 (67%) were male. Median age was 59 years and median ISS was 25. Low falls were the most common mechanism of injury. The 30-day mortality was 23%. RISC II yielded a superior AUC of 0.896, compared with the TRISS models (MTOS: 0.848; PATOS: 0.839; HK: 0.858). Prespecified subgroup analyses showed that all the models performed worse for age ≥ 70, ASA ≥ III, and low falls. RISC II had a higher AUC compared with the TRISS models in all subgroups, although not statistically significant. Conclusion: RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult blunt major trauma patients. RISC II may be useful when performing future audit or benchmarking exercises for trauma in Hong Kong. [ABSTRACT FROM AUTHOR]

Background: As health systems across the world respond to the coronavirus disease 2019 (COVID-19), there is rising concern that patients without COVID-19 are not receiving timely emergency care, resulting in avoidable deaths. This study examined patterns of self-reported health service utilization, their socio-demographic determinants and association with avoidable deaths during the COVID-19 outbreak. Methods: A cross-sectional telephone survey was conducted between March 22 and April 1, 2020, during the peak rise in confirmed COVID-19 cases in Hong Kong. Cantonese-speaking Hong Kong residents over 18-years-old were recruited using a computerised random digital dialling (RDD) system. The RDD method used stratified random sampling to ensure a representative sample of the target population by age, gender, and residential district. A structured self-reported questionnaire was used. Results: Out of 1738 placed calls, 765 subjects responded to the questionnaire (44.0% response rate). The factors associated with avoiding medical consultation included being female (37.2% vs. 22.5%, P < .001), married (32.8% vs. 27%, P = .044), completing tertiary education (35.3% vs. 27.7% (secondary) vs. 14.8% (primary), P = .005), and those who reported a "large/very large" impact of COVID-19 on their mental health (36.1% vs 30.5% (neutral) vs. 19.7% (very small/small), P = .047) using logistic regression analysis. Conclusion: Married females with both higher educational attainment and concern about COVID-19 were associated with avoiding healthcare services. Timely public communication to encourage and promote early health seeking treatment even during extreme events such as pandemics are needed. [ABSTRACT FROM AUTHOR]

Background: Emergency nurse practitioners have traditionally been reluctant to treat acute red eyes in Hong Kong emergency departments. The Edinburgh Red Eye Diagnostic Algorithm is the only validated tool to assist non-ophthalmologists to make diagnoses. Objectives: This study investigates the utility of a modified version used by emergency nurse practitioners. Methods: This is a prospective single-centre cohort study in a university hospital emergency department in Hong Kong, comparing red eye patients seen by emergency nurse practitioners with the aid of the algorithm to patients seen by emergency doctors. Data on patient-reported symptom severity were obtained on the day of consultation and information on resolution of symptoms at 1 week following emergency department attendance via telephone interviews. Results: A convenience sample of 50 patients was recruited to the emergency nurse practitioner group and 130 patients were recruited to the doctors' group over 9 weeks. Reductions in symptom severity were seen in both groups (>70% in both groups reported moderate to very severe discomfort on day 0; ~90% in both groups reported none or mild discomfort on day 7). There was no difference between the two groups (p = 0.55, analysis of covariance). Symptom resolution was reported in 96% in the emergency nurse practitioner group and 98.5% in the doctor's group, which was not statistically significant (p = 0.31, χ 2 test). Conclusion: Emergency nurse practitioners using the Edinburgh Red Eye Algorithm to manage red eye patients in a Hong Kong emergency department achieve similar patient-reported outcomes compared to emergency department doctor consultations. [ABSTRACT FROM AUTHOR]

Objective: To describe the characteristics, assessment and management of older emergency department (ED) patients with non‐traumatic headache. Methods: Planned sub‐study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non‐traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. Results: A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). Conclusions: Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non‐traumatic headache. [ABSTRACT FROM AUTHOR]

Background and Aim: Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. Methods: This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. Results: The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. Conclusions: This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required. [ABSTRACT FROM AUTHOR]

Background The impact of a pandemic on unplanned hospital attendance has not been extensively examined. The aim of this study is to report the nationwide consequences of the COVID-19 pandemic on unplanned hospital attendances in Denmark for 7 weeks after a 'shelter at home' order was issued. Methods We merged data from national registries (Civil Registration System and Patient Registry) to conduct a study of unplanned (excluding outpatient visits and elective surgery) hospital-based healthcare and mortality of all Danes. Using data for 7 weeks after the 'shelter at home' order, the incidence rate of unplanned hospital attendances per week in 2020 was compared with corresponding weeks in 2017-2019. The main outcome was hospital attendances per week as incidence rate ratios. Secondary outcomes were general population mortality and risk of death in-hospital, reported as weekly mortality rate ratios (MRRs). Results From 2 438 286 attendances in the study period, overall unplanned attendances decreased by up to 21%; attendances excluding COVID-19 were reduced by 31%; non-psychiatric by 31% and psychiatric by 30%. Out of the five most common diagnoses expected to remain stable, only schizophrenia and myocardial infarction remained stable, while chronic obstructive pulmonary disease exacerbation, hip fracture and urinary tract infection fell significantly. The nationwide general population MRR rose in six of the recorded weeks, while MRR excluding patients who were COVID-19 positive only increased in two. Conclusion The COVID-19 pandemic and a governmental national 'shelter at home' order was associated with a marked reduction in unplanned hospital attendances with an increase in MRR for the general population in two of 7 weeks, despite exclusion of patients with COVID-19. The findings should be taken into consideration when planning for public information campaigns. [ABSTRACT FROM AUTHOR]

Objective: To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). Background: Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. Methods: An international, multicenter, observational, cross‐sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re‐presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. Results: We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%–75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non‐SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti‐inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In‐hospital mortality was 0.3% (11/4526). Conclusion: Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment. [ABSTRACT FROM AUTHOR]

Objective: To describe the patterns of opioid use in patients presenting to the emergency department (ED) with nontraumatic headache by severity and geography. Background: International guidelines recognize opioids are ineffective in treating primary headache disorders. Globally, many countries are experiencing an opioid crisis. The ED can be a point of initial exposure leading to tolerance for patients. More geographically diverse data are required to inform practice. Methods: This was a planned, multicenter, cross‐sectional, observational substudy of the international Headache in Emergency Departments (HEAD) study. Participants were prospectively identified throughout March 2019 from 67 hospitals in Europe, Asia, Australia, and New Zealand. Adult patients with nontraumatic headache were included as identified by the local site investigator. Results: Overall, 4536 patients were enrolled in the HEAD study. Opioids were administered in 1072/4536 (23.6%) patients in the ED, and 386/3792 (10.2%) of discharged patients. High opioid use occurred prehospital in Australia (190/1777, 10.7%) and New Zealand (55/593, 9.3%). Opioid use in the ED was highest in these countries (Australia: 586/1777, 33.0%; New Zealand: 221/593, 37.3%). Opioid prescription on discharge was highest in Singapore (125/442, 28.3%) and Hong Kong (12/49, 24.5%). Independent predictors of ED opioid administration included the following: severe headache (OR 4.2, 95% CI 3.1–5.5), pre‐ED opioid use (OR 1.42, 95% CI 1.11–1.82), and long‐term opioid use (OR 1.80, 95% CI 1.26–2.58). ED opioid administration independently predicted opioid prescription at discharge (OR 8.4, 95% CI 6.3–11.0). Conclusion: Opioid prescription for nontraumatic headache in the ED and on discharge varies internationally. Severe headache, prehospital opioid use, and long‐term opioid use predicted ED opioid administration. ED opioid administration was a strong predictor of opioid prescription at discharge. These findings support education around policy and guidelines to ensure adherence to evidence‐based interventions for headache. [ABSTRACT FROM AUTHOR]

Background: Trauma remains a leading cause of death and effective trauma management within a well-developed trauma system has been shown to reduce morbidity and mortality. A trauma registry, as an integral part of a mature trauma system, can be used to monitor the quality of trauma care and to provide a means to compare local versus international standards. Hong Kong and Germany both have highly developed health care services. We compared the performance of trauma systems including outcomes among major trauma victims (ISS > 15) over a 3-year period (2013–2015) in both settings using trauma registry data. Methods: This study was a retrospective analysis of prospectively collected data from trauma registries in Hong Kong and Germany. Data from 01/2013 to 12/2015 were extracted from the trauma registries of the five trauma centers in Hong Kong and the TraumaRegister DGU® (TR-DGU). The study cohort included adults (≥ 18 years) with major trauma (ISS > 15). Data related to patient characteristics, nature of the injury, prognostic parameters to calculate the RISC II score, outcomes and clinical management were collected and compared. Results: Datasets from 1,864 Hong Kong and 10,952 German trauma victims were retrieved from respective trauma registries. The unadjusted mortality in Hong Kong (22.4%) was higher compared to Germany (19.2%); the difference between observed and expected mortality was higher in Hong Kong (+ 2.7%) than in Germany (– 0.5%). The standardized mortality ratio (SMR) in Hong Kong and Germany were 1.138 (95% CI 1.033–1.252) and 0.974 (95% CI 0.933–1.016), respectively, and the adjusted death rate in Hong Kong was significantly higher compared to the calculated RISC II data. However, patients in Hong Kong were significantly older, had more pre-trauma co-morbidities, more head injuries, shorter hospital and ICU stays and lower ICU admission rates. Conclusion: Hong Kong had a higher mortality rate and a statistically significantly higher standardized mortality ratio (SMR) after RISC II adjustment. However, multiple differences existed between trauma systems and patient characteristics. [ABSTRACT FROM AUTHOR]

This document is a correction notice for an article titled "Mapping study for health emergency and disaster risk management competencies and curricula: literature review and cross-sectional survey." The original article was published with the wrong license, and it has now been corrected to the Creative Commons Attribution 3.0 IGO License. The publisher apologizes for any inconvenience caused. The article was authored by Kevin K. C. Hung, Makiko K. MacDermot, Theresa S. I. Hui, Suet Yi Chan, Sonoe Mashino, Catherine P. Y. Mok, Pak Ho Leung, Ryoma Kayano, Jonathan Abrahams, Chi Shing Wong, Emily Y. Y. Chan, and Colin A. Graham. [Extracted from the article]

Background: Truly patient-centred care needs to be aligned with what patients consider important, and is highly desirable in the first 24 h of an acute admission, as many decisions are made during this period. However, there is limited knowledge on what matters most to patients in this phase of their hospital stay. The objective of this study was to identify what mattered most to patients in acute care and to assess the patient perspective as to whether their treating doctors were aware of this.Methods: This was a large-scale, qualitative, flash mob study, conducted simultaneously in sixty-six hospitals in seven countries, starting November 14th 2018, ending 50 h later. One thousand eight hundred fifty adults in the first 24 h of an acute medical admission were interviewed on what mattered most to them, why this mattered and whether they felt the treating doctor was aware of this.Results: The most reported answers to "what matters most (and why)?" were 'getting better or being in good health' (why: to be with family/friends or pick-up life again), 'getting home' (why: more comfortable at home or to take care of someone) and 'having a diagnosis' (why: to feel less anxious or insecure). Of all patients, 51.9% felt the treating doctor did not know what mattered most to them.Conclusions: The priorities for acutely admitted patients were ostensibly disease- and care-oriented and thus in line with the hospitals' own priorities. However, answers to why these were important were diverse, more personal, and often related to psychological well-being and relations. A large group of patients felt their treating doctor did not know what mattered most to them. Explicitly asking patients what is important and why, could help healthcare professionals to get to know the person behind the patient, which is essential in delivering patient-centred care.Trial Registration: NTR (Netherlands Trial Register) NTR7538 . [ABSTRACT FROM AUTHOR]

Background: Truly patient-centred care needs to be aligned with what patients consider important, and is highly desirable in the first 24 h of an acute admission, as many decisions are made during this period. However, there is limited knowledge on what matters most to patients in this phase of their hospital stay. The objective of this study was to identify what mattered most to patients in acute care and to assess the patient perspective as to whether their treating doctors were aware of this. Methods: This was a large-scale, qualitative, flash mob study, conducted simultaneously in sixty-six hospitals in seven countries, starting November 14th 2018, ending 50 h later. One thousand eight hundred fifty adults in the first 24 h of an acute medical admission were interviewed on what mattered most to them, why this mattered and whether they felt the treating doctor was aware of this. Results: The most reported answers to "what matters most (and why)?" were 'getting better or being in good health' (why: to be with family/friends or pick-up life again), 'getting home' (why: more comfortable at home or to take care of someone) and 'having a diagnosis' (why: to feel less anxious or insecure). Of all patients, 51.9% felt the treating doctor did not know what mattered most to them. Conclusions: The priorities for acutely admitted patients were ostensibly disease- and care-oriented and thus in line with the hospitals' own priorities. However, answers to why these were important were diverse, more personal, and often related to psychological well-being and relations. A large group of patients felt their treating doctor did not know what mattered most to them. Explicitly asking patients what is important and why, could help healthcare professionals to get to know the person behind the patient, which is essential in delivering patient-centred care. Trial registration: NTR (Netherlands Trial Register) NTR7538. [ABSTRACT FROM AUTHOR]

Objective: Lower respiratory tract infection (LRTI) is a frequent cause of dyspnoea in EDs, and is associated with considerable morbidity and mortality. We described and compared the management of this disease in Europe and Oceania/South‐East Asia (SEA) cohorts. Methods: We conducted a prospective cohort study with three time points in Europe and Oceania/SEA. We included in this manuscript patients presenting to EDs with dyspnoea and a diagnosis of LRTI in ED. We collected comorbidities, chronic medication, clinical signs at arrival, laboratory parameters, ED management and patient outcomes. Results: A total of 1389 patients were included, 773 in Europe and 616 in SEA. The European cohort had more comorbidities including chronic heart failure, obesity, chronic obstructive pulmonary disease and smoking. Levels of inflammatory markers were higher in Europe. There were more patients with inflammatory markers in Europe and more hypercapnia in Oceania/SEA. The use of antibiotics was higher in SEA (72.2% vs 61.8%, P < 0.001) whereas intravenous diuretics, non‐invasive and invasive ventilation were higher in Europe. Intensive care unit admission rate was 9.9% in Europe cohort and 3.4% in Oceania/SEA cohort. ED mortality was 1% and overall in‐hospital mortality was 8.7% with no differences between regions. Conclusions: More patients with LRTI in Europe presented with cardio‐respiratory comorbidities, they received more adjunct therapies and had a higher intensive care unit admission rate than patients from Oceania/SEA, although mortality was similar between the two cohorts. [ABSTRACT FROM AUTHOR]

Background: Hong Kong rates of bystander cardiopulmonary resuscitation are very low by international standards. Several Hong Kong secondary schools have begun incorporating cardiopulmonary resuscitation training into their curriculums for teachers and students. Objective: This study aimed to explore secondary school cardiopulmonary resuscitation programs and better understand school principals' attitudes toward cardiopulmonary resuscitation training. Methods: A cross-sectional survey was sent to all Hong Kong secondary school principals (public and private, except for special education schools) between December 2017 and March 2018. A self-administered questionnaire of 20 items focusing on school characteristics, details of any in-school cardiopulmonary resuscitation materials or training, attitudes toward teaching cardiopulmonary resuscitation, and any barriers or ways to promote school cardiopulmonary resuscitation training was given to all school principals in the territory. This study was approved by the Survey and Behavioural Research Ethics committee of the Chinese University of Hong Kong on September 13, 2017. Results: Out of the 506 schools contacted, 110 completed surveys were returned (21.7%). Cardiopulmonary resuscitation training was offered in 33.6% (37/110), while 92.7% (102/110) had an automatic external defibrillator. A majority (69.1% (76/110)) agreed or strongly agreed that cardiopulmonary resuscitation training should be compulsory for secondary school students. In schools where cardiopulmonary resuscitation was taught, most cardiopulmonary resuscitation students were aged 15–17 years, and most courses ran for < 5 h. Increased funding could encourage more schools to offer cardiopulmonary resuscitation training to students in the future. Conclusion: One-third (33.6%) of Hong Kong secondary schools offer cardiopulmonary resuscitation training. Increased funding may support school-based cardiopulmonary resuscitation instruction and improve rates of bystander cardiopulmonary resuscitation in the future. [ABSTRACT FROM AUTHOR]

Background: Similar to many Asian cities, there is no statutory provision for the determination of the duty borne by bystander first aiders when assisting victims in Hong Kong. Objectives: The aim of this study was to explore the views of a Good Samaritan Law by first-aid learners in Hong Kong. Methods: A cross-sectional survey was conducted among first-aid course participants from the two largest training providers in Hong Kong using a self-administered questionnaire. Results: In total, 1223 questionnaires were completed and returned. Only 12.1% (147/1211) of participants have ever heard of Good Samaritan Law. After a short description of Good Samaritan Law was provided, 71.4% (848/1188) agreed or strongly agreed on a Likert-type scale that a Good Samaritan Law is necessary; 95.2% (1148/1223) support the enactment of a Good Samaritan Law in Hong Kong. Conclusion: The majority of first-aid learners in Hong Kong supported the enactment of Good Samaritan Law. Overcoming the fear of litigation and improving bystander cardiopulmonary resuscitation rate is a priority for improving survival rates from sudden cardiac arrest in Hong Kong. [ABSTRACT FROM AUTHOR]

Objectives To describe the epidemiology and outcomes of non-traumatic dyspnoea in patients aged 75 years or older presenting to emergency departments (EDs) in the Asia-Pacific region. Methods A substudy of a prospective interrupted time series cohort study conducted at three time points in EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia of patients presenting to the ED with dyspnoea as a main symptom. Data were collected over three 72-h periods and included demographics, co-morbidities, mode of arrival, usual medications, ED investigations and treatment, ED diagnosis and disposition, and outcome. The primary outcomes of interest are the epidemiology and outcome of patients aged 75 years or older presenting to the ED with dyspnoea. Results 1097 patients were included. Older patients with dyspnoea made up 1.8% [95% confidence interval (CI) 1.7–1.9%] of ED presentations. The most common diagnoses were heart failure (25.3%), lower respiratory tract infection (25.2%) and chronic obstructive pulmonary disease (17.6%). Hospital ward admission was required for 82.6% (95% CI 80.2–84.7%), with 2.5% (95% CI 1.7–3.6%) requiring intensive care unit (ICU) admission. In-hospital mortality was 7.9% (95% CI 6.3–9.7%). Median length of stay was 5 days (interquartile range 2–8 days). Conclusion Older patients with dyspnoea make up a significant proportion of ED case load, and have a high admission rate and significant mortality. Exacerbations or worsening of pre-existing chronic disease account for a large proportion of cases which may be amenable to improved chronic disease management. [ABSTRACT FROM AUTHOR]

Objectives: Guideline recommended treatments for chronic conditions are thought to reduce ED presentations. Method: We used data from 1958 ED patients with dyspnoea to describe medication use in patients with chronic conditions. Results: A total of 1233 (63.5%) patients had one or more of: chronic obstructive pulmonary disease 547 (28%), asthma 454 (23%), atrial fibrillation 368 (19%) or heart failure 401 (21%). Approximately, 70% were prescribed appropriate preventative medication for their chronic condition when they presented to ED with dyspnoea. Conclusion: Prescription of guideline recommended therapies for chronic conditions in patients presenting to the ED in Australasia with acute dyspnoea is similar or higher than reported previously. [ABSTRACT FROM AUTHOR]

We aim to compare the prognostic value of Quick Sepsis-Related Organ Failure Assessment (qSOFA) and the previous Systemic Inflammatory Response Syndrome (SIRS) criteria, the National Early Warning Score (NEWS) and along with their combinations in the emergency department (ED). This single-centre prospective study recruited a convenience sample of unselected ED patients triaged as category 2 (Emergency) and 3 (Urgent). Receiver Operating Characteristic analyses were performed to determine the Area Under the Curve (AUC), along with sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios for the various scores. Of 1253 patients recruited, overall 30-day mortality was 5.7%. The prognostic value for prediction of 30-day mortality, with AUCs for qSOFA ≥2, SIRS ≥2, NEWS ≥5, qSIRS (qSOFA + SIRS) ≥2 and NSIRS (NEWS + SIRS) ≥5 of 0.56 (95%CI 0.53–0.58), 0.61 (95%CI 0.58–0.64), 0.61 (95%CI 0.58–0.64), 0.64 (95%CI 0.62–0.67) and 0.61 (95%CI 0.58–0.63), respectively. Using pairwise comparisons of ROC curves, NEWS ≥5 and qSIRS ≥2 were better than qSOFA ≥2 at predicting 30-day mortality. Among unselected emergency and urgent ED patients, the prognostic value for NEWS and qSIRS were greater than qSOFA, Combinations of qSOFA and SIRS could improve the predictive value for 30-day mortality for ED patients. NEWS ≥5 and qSIRS ≥2 were better than qSOFA ≥2 at predicting 30-day mortality in ED patients. Combinations of qSOFA and SIRS could improve the predictive value for 30-day mortality for ED patients. [ABSTRACT FROM AUTHOR]

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Introduction: A prepared and well-trained workforce is essential to reducing the loss of lives from health emergencies. However, it is uncertain what should be included in the common set of core competencies for the health emergency and disaster risk management (Health EDRM) workforce. The objective of the study is to provide evidence mapping for the competencies in existing professional development programs and courses in Health EDRM. Method: A survey conducted using an online platform (Survey Monkey) was conducted from October to November 2021. Experts in the Health EDRM Research Network including experts identified for the Delphi studies were invited to join the study. Participants should be ≥ 18 years of age, and had relevant experience in Health EDRM and in disaster education and training programs. A self designed questionnaire containing 28 questions in four domains including competencies; curriculum; evidence gaps; work and personal details were used. Results: There were 65 respondents from 20 countries participating in the survey. Most of the respondents worked in academic institutions (60%), followed by government employees (19%), and non-governmental organizations (7%). These organizations have roles throughout the disaster cycle with 95% in the preparedness phase. For management skills, EDRM managers should be competent in planning, organizing, applying management processes, establishing effective communication systems and providing effective leadership. For technical competencies, emergency communications, hazard specific knowledge, communicable diseases were essential for frontline workers. In terms of designing the competency matrix, WHO resources were frequently used for the competencies and the curriculum design. Conclusion: Health EDRM managers are expected to master a large number of managerial and technical skills, including the increasingly recognized leadership and decision-making skills for effective planning and implementation. These competencies need to be established for the development of a Health EDRM workforce. [ABSTRACT FROM AUTHOR]

Objective: Asthma exacerbations are common presentations to ED. Key guideline recommendations for management include administration of inhaled bronchodilators, systemic corticosteroids and titrated oxygen therapy. Our aim was to compare management and outcomes between patients treated for asthma in Europe (EUR) and South East Asia/Australasia (SEA) and compliance with international guidelines. Methods: In each region, prospective, interrupted time series studies were performed including adult (age >18 years) patients presenting to ED with the main complaint of dyspnoea during three 72 h periods. This was a planned sub‐study that included those with an ED primary diagnosis of asthma. Data was collected on demographics, clinical features, treatment in ED, diagnosis, disposition and in‐hospital outcome. The results of interest were differences in treatment and outcome between EUR and SEA cohorts. Results: Five hundred and eighty‐four patients were identified from 112 EDs (66 EUR and 46 SEA). The cohorts had similar demographics and co‐morbidity patterns, with 89% of the cohort having a previous diagnosis of asthma. There were no significant differences in treatment between EUR and SEA patients – inhaled beta‐agonists were administered in 86% of cases, systemic corticosteroids in 66%, oxygen therapy in 44% and antibiotics in 20%. Two thirds of patients were discharged home from the ED. Conclusion: The data suggests that compliance with guideline‐recommended therapy in both regions, particularly corticosteroid administration, is sub‐optimal. It also suggests over‐use of antibiotics. [ABSTRACT FROM AUTHOR]

Objectives Capillary blood lactate testing with handheld analysers has great advantages to reduce the time needed for clinical decisions, and for extended use in the prehospital setting. We investigated the agreement of capillary lactate measured using handheld analysers (CL-Nova and CL-Scout+ measured by Nova and Lactate Scout+ analyzers) and the reference venous level assessed using a point-of-care testing (POCT) blood gas analyser (VL-Ref). Design A prospective observational study. Setting A university teaching hospital emergency department in Hong Kong. Participants Patients triaged as 'urgent' (Category 3 of a 5-point scale), aged ≥18 years during 2016 were eligible. 240 patients (mean age 69.9 years) were recruited. Primary and secondary outcome measures The primary outcome measure was the agreement of the capillary blood lactate level measured by handheld lactate analyser when compared with the reference standard technique, namely venous blood samples obtained by venepuncture and analysed using the blood gas analyser. The secondary outcome measure was the difference in values of venous lactate using blood gas analysers and handheld lactate analysers. Results The results of VL-Ref ranged from 0.70 to 5.38 mmol/L (mean of 1.96 mmol/L). Regarding capillary lactate measurements, the bias (mean difference) between VL-Ref and CL-Scout+ was -0.22 with 95% limits of agreement (LOA) of -2.17 to 1.73 mmol/L and the bias between VL-Ref and CL-Nova was 0.46, with LOA of -1.08 to 2.00 mmol/L. For venous lactate, results showed the bias between VL-Ref and VL-Scout+ was 0.22 with LOA being -0.46 to 0.90 mmol/L, and the bias between VL-Ref and VL-Nova was 0.83 mmol/L with LOA -0.01 to 1.66 mmol/L. Conclusion Our study shows poor agreement between capillary lactate and reference values. The study does not support the clinical utility of capillary lactate POCT. However, venous lactate measured by Scout+ handheld analyser may have potential for screening patients who may need further testing. Trial registration number NCT02694887. [ABSTRACT FROM AUTHOR]

This article analyzes the points made in the study "Towards a Framework for Not-for-Profit Accounting," by Haim Falk. The objectives of his work are to analyze theoretical explanations for not-for-profit (NFP) organizations, distinguish between those organizations and profit entities and propose an accounting framework that is consistent with both the economic nature of NFP entities and the nature of the donation. However, the author disagrees with Falk that organizational structure and its products instead of the type of transaction that determines accounting and control systems.

Objective: To develop comprehensive guidance that captures international impacts, causes, and solutions related to emergency department crowding and access block Methods: Emergency physicians representing 15 countries from all IFEM regions composed the Task Force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020. Results: A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the Task Force. Conclusions: The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic has produced significant changes in emergency medicine patient volumes, clinical practice, and has accelerated a number of systems‐level developments. Many of these changes produced efficiencies in emergency care systems and contributed to a reduction in crowding and access block. In this paper, we explore these changes, analyse their risks and benefits and examine their sustainability for the future to the extent that they may combat crowding. We also examine the necessity of a system‐wide approach in addressing ED crowding and access block. [ABSTRACT FROM AUTHOR]

ABSTRACT: Background and objective: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common presentation to emergency departments (ED) but data regarding its epidemiology and outcomes are scarce. We describe the epidemiology, clinical features, treatment and outcome of patients treated for AECOPD in ED. Methods: This was a planned sub‐study of patients with an ED diagnosis of AECOPD identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. The AANZDEM was a prospective, interrupted time series cohort study conducted in 46 ED in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72‐h periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality). Results: Forty‐six ED participated. There were 415 patients with an ED primary diagnosis of AECOPD (13.6% of the overall cohort; 95% CI: 12.5–14.9%). Median age was 73 years, 60% males and 65% arrived by ambulance. Ninety‐one percent had an existing COPD diagnosis. Eighty percent of patients received inhaled bronchodilators, 66% received systemic corticosteroids and 57% of those with pH < 7.30 were treated with non‐invasive ventilation (NIV). Seventy‐eight percent of patients were admitted to hospital, 7% to an intensive care unit. In‐hospital mortality was 4% and median LOS was 4 days (95% CI: 2–7). Conclusion: Patients treated in ED for AECOPD commonly arrive by ambulance, have a high admission rate and significant in‐hospital mortality. Compliance with evidence‐based treatments in ED is suboptimal affording an opportunity to improve care and potentially outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Shortness of breath is a common presenting symptom to the emergency department (ED) that can arise from a myriad of possible diagnoses. Asthma is one of the major causes. Objective: The aim of this study was to describe the demographic features, clinical characteristics, management and outcomes of adults with an ED diagnosis of asthma who presented to an ED in the Asia Pacific region with a principal symptom of dyspnea. Methods: Planned sub‐study of patients with an ED diagnosis of asthma identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. AANZDEM was a prospective cohort study conducted in 46 EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72 hour periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality). Results: Of the 3044 patients with dyspnea, 387 (12.7%) patients had an ED diagnosis of asthma. The median age was 45 years, 60.1% were female, 16.1% were active or recent smokers and 30.4% arrived by ambulance. Inhaled bronchodilator therapy was initiated in 88.1% of patients, and 66.9% received both inhaled bronchodilators and systemic corticosteroids. After treatment in the ED, 65.4% were discharged. No death was reported. Conclusion: Asthma is common among patients presenting with a principal symptom of dyspnea in the ED of the Asia Pacific region. There was a suboptimal adherence to international guidelines on investigations and treatments of acute asthma exacerbations presenting an opportunity to improve the efficiency of care. [ABSTRACT FROM AUTHOR]

Background: Hong Kong (HK) and Guangzhou (GZ) are cities in China with different healthcare systems. This study aimed to compare 30-day and 6-month mortality and characteristics of patients with suspected cardiac chest pain admitted to two emergency departments (ED) in HK and GZ.Methods: A prospective observational study enrolled patients with suspected cardiac chest pain presenting to EDs in the Prince of Wales Hospital (PWH), HK and the Second Affiliated Hospital of Guangzhou Medical University (AHGZMU),GZ. The primary outcome was 30-day and 6-month mortality.Results: In total, 996 patients were recruited, 407 cases from GZ and 589 cases from HK.The 30-day and 6-month mortality of chest patients were 3.7% and 4.7% in GZand 0.3% and 1.9% in HK, respectively. Serum creatinine level (Cr) was an independent factor for 30-day mortality whilst Cr and systolic blood pressure (SBP) were independent factors for 6-month mortality. In Cox regression analysis, unadjusted and adjusted hazard ratios for 30-day and 6-month mortality in GZ were significantly increased.Conclusion: The 30-day and 6-month mortality of patients with suspected cardiac chest pain in Guangzhou were higher than in Hong Kong due to due to different baseline clinical characteristics of patients and different distributions of diagnoses, which were associated with different healthcare systems. Serum creatinine and SBP were independent factors for 30-day and 6-month mortality. [ABSTRACT FROM AUTHOR]

Background: Soft tissue injuries commonly present to the emergency department (ED), often with acute pain. They cause significant suffering and morbidity if not adequately treated. Paracetamol and ibuprofen are commonly used analgesics, but it remains unknown if either one or the combination of both is superior for pain control. Objectives: To investigate the analgesic effect of paracetamol, ibuprofen and the combination of both in the treatment of soft tissue injury in an ED, and the side effect profile of these drugs. Methods: Double-blind, double dummy, placebo-controlled randomised controlled trial. 782 adult patients presenting with soft tissue injury without obvious fractures attending the ED of a university hospital in the New Territories of Hong Kong were recruited. Patients were randomised using a random number table into three parallel arms of paracetamol only, ibuprofen only and a combination of paracetamol and ibuprofen in a 1:1:1 ratio. The primary outcome measure was pain score at rest and on activity in the first 2 hours and first 3 days. Data was analysed on an intention to treat basis. Results: There was no statistically significant difference in pain score in the initial two hours between the three groups, and no clinically significant difference in pain score in the first three days. Conclusion: There was no difference in analgesic effects or side effects observed using oral paracetamol, ibuprofen or a combination of both in patients with mild to moderate pain after soft tissue injuries attending the ED. Trial registration: The study is registered with ClinicalTrials.gov (no. ). [ABSTRACT FROM AUTHOR]

A foreword to "Crumpled metal and A Gift of a Melon: The Future in Northern Irish Culture" is presented.