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PurposeEmerging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants have impacted the in vitro activity of sotrovimab 500 mg, with reduced fold change in EC50for the Omicron BA.2 sublineage and onward. The correlation between this reduction and clinical efficacy outcomes is unknown. In the absence of clinical trials assessing the efficacy of sotrovimab against emerging variants, real-world evidence becomes a critical source of information. A systematic literature review (SLR) of published observational studies was undertaken to evaluate the effectiveness of sotrovimab on severe clinical outcomes during the Omicron BA.2 subvariant predominance period.MethodsSearches of indexed electronic databases for peer-reviewed journals, preprint articles, and conference abstracts published between January 1, 2022 and November 3, 2022 were undertaken using a combination of search terms for COVID-19, sotrovimab, and observational study design. Study quality was assessed using the Newcastle Ottawa Scale (NOS).ResultsFrom the 343 unique titles and abstracts identified, five studies were eligible for inclusion in the SLR. Included studies displayed heterogeneity in study design and population. The OpenSAFELY study, which received a high NOS score and had a sufficient sample of patients treated with sotrovimab during BA.2 predominance, demonstrated clinical effectiveness during both BA.1 (adjusted hazard ratio (HR) 0.54, 95% confidence interval (CI) 0.33–0.88;p= 0.014) and BA.2 (adjusted HR 0.44, 95% CI 0.27–0.71;p= 0.001) periods vs molnupiravir. Furthermore, a US-based study that also received a high NOS score reported that sotrovimab was associated with a lower risk of 30-day all-cause hospitalization or mortality compared with no monoclonal antibody treatment during the BA.2 subvariant surge in March (adjusted relative risk (RR) 0.41, 95% CI 0.27–0.62) and April 2022 (adjusted RR 0.54, 95% CI 0.08–3.54). Although only a limited number of studies evaluated sotrovimab during both the BA.1 and BA.2 periods, these demonstrated that clinical outcomes in patients with COVID-19 treated with sotrovimab were consistently low across both periods. One large study directly compared data from the two periods and found no evidence of a difference in the clinical outcomes of sotrovimab-treated patients with sequencing-confirmed BA.1 and BA.2 (HR 1.17, 95% CI 0.74–1.86).ConclusionThe observational data presented in this SLR provide evidence that the effectiveness of sotrovimab (IV 500 mg) is maintained against Omicron BA.2 in both ecological and sequencing-confirmed studies, either through the demonstration of low and comparable rates of severe clinical outcomes between the Omicron BA.1 and BA.2 periods, or by comparison against an active comparator or no treatment within the Omicron BA.2 period.Key pointsWhy carry out this study?Emerging SARS-CoV-2 variants have impacted the in vitro activity of sotrovimab 500 mg, with reduced fold change in EC50relative to wild-type for the Omicron BA.2 sublineage and onward; the clinical relevance of this difference on outcomes for BA.2 (and other variants) is unknown.Given the complexity of generating formal clinical trial data in the context of the constantly evolving SARS-CoV-2 landscape, real-world evidence is a key source of information with which to assess the effectiveness of treatments such as sotrovimab on newly predominant or emerging variants.We conducted a systematic literature review to evaluate the effectiveness of sotrovimab for the early treatment of COVID-19 on clinical outcomes during the period predominated by the Omicron BA.2 subvariant.What was learned from the study?Sotrovimab treatment was associated with low proportions of severe clinical outcomes (such as all-cause or COVID-19-related hospitalization or mortality) in patients infected during periods of Omicron BA.2 predominance, despite reduction in the in vitro neutralization activity of sotrovimab.These data support continued clinical effectiveness of sotrovimab during Omicron BA.2 predominance.

IntroductionThere is limited real-world evidence describing the effectiveness of early treatments for Coronavirus disease 2019 (COVID-19) during the period where Omicron was the dominant variant. Here we describe characteristics and acute clinical outcomes in patients with COVID-19 treated with a monoclonal antibody (mAb; presumed to be sotrovimab) across six distinct periods covering the emergence and subsequent dominance of Omicron subvariants (BA.1, BA.2 and BA.5) in England.MethodsRetrospective cohort study using data from Hospital Episode Statistics database between 1stJanuary – 31stJuly 2022. Included patients were aged ≥12 years and received a mAb delivered by a National Health Service (NHS) hospital as a day-case, for which the primary diagnosis was COVID-19. Patients were presumed to have received sotrovimab on the basis of available NHS data showing that 99.98% of individuals who received COVID-19 treatment during the period covered by the study were actually treated with sotrovimab. COVID-19-attributable hospitalisations were reported overall and across six distinct periods of Omicron sub-variant prevalence. A multivariate Poisson regression model was used to estimate incidence rate ratios for each period. Subgroup analyses were conducted in patients with severe renal disease and active cancer.ResultsIn total, 10,096 patients were included. The most common high-risk comorbidities were Immune-Mediated Inflammatory Disorders (43.0%;n= 4,337), severe renal disease (14.1%;n= 1,422), rare neurological conditions (10.4%;n= 1,053) and active cancer (9.0%;n= 910). The proportions of patients with a COVID-19-attributable hospitalisation was 1.0% (n= 96), or with a hospital visit due to any cause was 4.6% (n= 465) during the acute period. The percentage of patients who died due to any cause during the acute study period was 0.3% (n= 27). COVID-19-attributable hospitalisation rates were consistent among subgroups and no significant differences (p-values ranged from 0.13 to 0.64) were observed across periods of Omicron subvariants.ConclusionLow levels of COVID-19-attributable hospitalisations and deaths were recorded in mAb-treated patients. Results were consistent for patients with severe renal disease and active cancer. No evidence of differences in hospitalisation rates were observed whilst Omicron BA.1, and BA.2 or BA.5 subvariants were predominant, despite reported reductions in in vitro neutralisation activity of sotrovimab against BA.2 and BA.5.

Background Sotrovimab, a monoclonal antibody (mAb), received Emergency Use Authorization (EUA) for the treatment of high-risk outpatients with symptomatic COVID-19. The study objective was to evaluate real-world effectiveness of sotrovimab (500 mg intravenous) in reducing the risk of mortality or hospitalization during the SARS-CoV-2 Delta and initial Omicron variant waves in the US. Methods A retrospective analysis was conducted of de-identified patients (pts) diagnosed with COVID-19 (ICD-10: U07.1) from 9/1/2021 to 2/28/2022 in the FAIR Health FH NPIC® claims database. Pts were divided into 2 cohorts based on HCPCS codes: treated with sotrovimab and not treated with any mAb (no mAb). Pts meeting EUA high-risk criteria were identified via pre-specified ICD-10-CM diagnoses in records ≤ 24 months prior to their first COVID-19 diagnosis (index date). Facility-reported mortality (referred to as “mortality”), all cause hospitalizations and intensive care unit (ICU) admissions within 30 days of index were identified. Chi-square test, ANOVA, or t-tests were performed to statistically compare cohorts at a 0.05 level of significance (2-sided). P-values were not adjusted for multiplicity. Multivariable logistic regression was conducted to estimate the risk of mortality or hospitalization within 30 days, adjusting for demographic and clinical factors. Results Of the high-risk COVID-19 pts identified, 13,140 were treated with sotrovimab and 1,283,284 received no mAb therapy. Compared to the no mAb cohort, the sotrovimab cohort was older, had more baseline conditions, and were more likely to be female (all p < 0.0001). In the no mAb cohort, 0.59% died and 5.74% were hospitalized (of whom 30% in ICU). In the sotrovimab cohort, 0.08% died and 2.50% were hospitalized (of whom 15% in ICU). After adjusting for potential confounders, treatment with sotrovimab was associated with 83% reduced odds of 30-day mortality (OR: 0.17, 95% CI: 0.09-0.31) and 61% reduced odds of 30-day hospitalization or mortality (OR: 0.39, 95% CI: 0.35-0.43) among high-risk COVID-19 pts. Conclusion In this US real-world observational study of high-risk COVID-19 pts during the Delta and initial Omicron waves, treatment with sotrovimab was associated with reduced odds of mortality and hospitalization compared to no mAb treatment. Disclosures Mindy M. Cheng, PhD, Vir Biotechnology: Employee, Shareholder Daniel C. Gibbons, PhD, GlaxoSmithKline: Employee, GlaxoSmithKline GSK shareholder Helen Birch, PhD, GlaxoSmithKline: Employee, GlaxoSmithKline GSK shareholder Vishal Patel, MSc, GlaxoSmithKline: Employee, GlaxoSmithKline Christopher F. Bell, n/a, GlaxoSmithKline: Employee, GlaxoSmithKline GSK shareholder Myriam Drysdale, PhD, GlaxoSmithKline: Employee, GlaxoSmithKline GSK shareholder Sacha Satram, PhD, Vir Biotechnology: Employee, Vir Biotechnology Vir shareholder Carolina M. Reyes, PhD, Vir Biotechnology: Employee, Vir Biotechnology Vir shareholder.

Background Falls are the most commonly reported incident in the Health Service Executive (HSE). Inappropriate medications and polypharmacy in the elderly can contribute to increased falls risk. Our aim was to assess whether a medication review was being completed at the time of the post-fall clinician review. Methods We completed a retrospective chart review using an audit tool of consecutive inpatient falls, resulting in serious injury, from March–December 2019. Standards measured against were: HSE Guideline—Service User Falls: A Practical Guide for Review, Medicines and Falls in Hospital: British Society Guidelines, STOPP & START criteria and NICE Guidelines: Falls in Older People 2013. Results We identified 33 charts for review (n = 33)—54.55% (18) female and 45.45% (15) male. Average age was 81 ± 11.2 years. The immediate post-fall review was mainly completed by interns (48.49% (16)) and SHO’s (39.39% (13)). A medication review was carried out 9.09% (3) of the time. A total of n = 28 (84.85%) had poly pharmacy. When analysed for medications known to increase risk of falling, 51.52% (n = 17) were on anti-hypertensives, 45.45% (n = 15) on laxatives, 24.24% (n = 8) on sedative medications, 18.18% (n = 6) on hypnotics/anxiolytics, 15.15% (n = 5) on opioids and 15.15% (n = 5) on diuretics at the time of fall. The majority of these medications (77.42% (n = 24)) were commenced prior to admission. None of these medications were discontinued or the dose changed on review post fall. Conclusion Our audit demonstrates that in a cohort of patients who had an inpatient fall medication discontinuation and dose reductions were not performed. Yet, a high burden of polypharmacy and high-risk falls medication were found. This may result in missing a pertinent opportunity to prevent future falls. We advise a structured medication review is carried out for each patient who suffers an in-patient fall to efficiently modify such an easily identifiable risk factor.

Background Patients with dementia and delirium are often waiting long times in the emergency department (ED) prior to being transferred to a ward bed during an acute hospital admission. This may be associated with increased morbidity and mortality. Best practice is for rapid triage to an appropriate bed via a delirium/dementia pathway. Our aim was to document the patient experience time (PET) for older patients with a diagnosis of dementia or delirium in ED in an urban tertiary-referral hospital. Methods Over a two-week period 07/12/20–21/12/20, we identified all patients admitted under a general medical specialty through ED, aged ≥65 years, with a diagnosis of dementia or delirium on the admission sheet. Patients admitted with a stroke or hip fracture were excluded. ED PET was recorded, as well as final ward destination. Results We included 29 patients in the study—median age was 82 years (range 71–92); 19 (66%) were female. Delirium was the presenting complaint in 79.31% (n = 23) of cases. Sixteen (55%) patients presented between 8 am-5 pm. The average time spent from triage to ED doctor review was 1 hour 48 minutes; from ED doctor review to medical referral −1 hour 27 minutes; from medical referral to decision for medical admission—2 hours 28 minutes; from decision for medical admission to ward admission- 5 hours. Overall, the average ED PET for these patients was 10 hours 42 minutes. Five patients (17%) were admitted directly to a Specialist Geriatric Ward (SGW). Twenty patients (69%) did not reach a SGW during the study period. Conclusion Patients with dementia and delirium may spend prolonged periods of time in the ED putting them at risk for multiple complications. We hope that by introduction of a dementia/delirium combined pathway and care bundle that we can reduce PET for these vulnerable patients.

OBJECTIVES Arthrocentesis is commonly performed in the emergency department, but success rates vary based on location. Presently, there is a paucity of data assessing the utility of ultrasound-guided (USG) medium-sized joint arthrocentesis. The objective of this study was to compare the success of USG and landmark-guided (LMG) medium-sized joint arthrocentesis. METHODS This was a single-center, prospective, randomized clinical trial (NCT03327584) of a convenience sample of adult patients who presented to an urban, university hospital with > 105,000 visits annually. Patients with a suspected medium-sized joint effusion (defined as elbow, wrist, or ankle) undergoing arthrocentesis were randomized into LMG or USG using the GE Logiq e linear transducer (4-10 MHz). The following patients were excluded: on anticoagulation, with soft tissue infection overlying the joint, or involving an artificial joint. Statistical analysis included the Fisher exact, Mann-Whitney U-test, and t-test. RESULTS Overall, 44 patients were enrolled with 23 patients randomized into the LMG group and 21 patients into the USG arm. USG was significantly better than LMG with an overall success of 94.1% versus 60% for LMG (difference = 34.1%, 95% confidence interval [CI] = 4.90 to 58.83). USG first-pass success was 82.4% versus 46.7% for LMG (difference = 35.7%, 95% CI = 2.76 to 60.37) and a mean of 1.35 attempts versus 2.00 for LMG (difference = 0.65, 95% CI = 0.005 to 1.296). Of the 14 LMG failures, eight had no effusion present on USG crossover. Four patients in the USG group had no effusion present. CONCLUSIONS Ultrasound guidance improved first-pass and overall successful arthrocentesis of medium-sized joint effusions.

IntroductionThere is limited real-world evidence surrounding the effectiveness of early, mild-to-moderate COVID-19 treatments following the emergence and dominance of Omicron SARS-CoV-2 subvariants. Here, characteristics and acute clinical outcomes are described for patients with COVID-19 treated with sotrovimab, nirmatrelvir/ritonavir or molnupiravir, or patients at highest risk per NHS criteria but who were untreated.MethodsRetrospective cohort study of non-hospitalised patients who received early treatment for, or were diagnosed with, COVID-19 between 1 December 2021 and 31 May 2022, using data from the Discover dataset in north-west London. Patients were included if aged ≥12 years and treated with sotrovimab, nirmatrelvir/ritonavir or molnupiravir, or were untreated but expected to be eligible for early treatment per NHS highest-risk criteria at time of diagnosis. Outcomes were reported for 28 days from COVID-19 diagnosis (index). Subgroup analyses were conducted in patients with advanced renal disease, those aged 18–64 and ≥65 years and by period of Omicron BA.1, BA.2 and BA.5(post-hocexploratory analysis) predominance.ResultsA total of 696 patients prescribed sotrovimab, 337 prescribed nirmatrelvir/ritonavir, 470 prescribed molnupiravir and 4,044 eligible high-risk untreated patients were included. A high proportion of patients on sotrovimab had advanced renal disease (29.3%), ≥3 high-risk comorbidities (47.6%) and were aged ≥65 years (36.9%). In total, 5/696 (0.7%) patients on sotrovimab, ConclusionPatients who received sotrovimab appeared to show evidence of multiple comorbidities that may increase risk of severe COVID-19. Low hospitalisation rates were observed for all treated cohorts across subgroups and periods of predominant variants of concern. These descriptive results require confirmation with comparative effectiveness analyses adjusting for differences in underlying patient characteristics.Key pointsWhy carry out this study?There is limited real-world evidence surrounding early, mild-to-moderate COVID-19 treatments, particularly during Omicron subvariant dominance periods, and the UK National Institute for Health and Care Excellence has recommended more is gathered.We described patient characteristics and clinical outcomes among patients treated with sotrovimab, nirmatrelvir/ritonavir, molnupiravir or who met the highest-risk eligibility criteria but were untreated.What was learned from the study?Sotrovimab was often utilised amongst more elderly and at-risk patients, such as those with advanced renal disease, than patients treated with nirmatrelvir/ritonavir or molnupiravir.We found that hospitalisation rates were low across all treated cohorts.For patients treated with sotrovimab, clinical outcomes appeared consistent when observed across the age subgroups and Omicron subvariant periods, as well as among patients with advanced renal disease.

Background Falls are the most common adverse incident of inpatients in Irish hospitals. 6% of inpatient falls cause serious injury. Older inpatients have the highest risk of falling and the highest risk of injury. The post-fall medical review is critical to assess why a patient fell, did the fall cause injury and for the introduction of measures to prevent future falls. We assessed the quality of the post fall reviews in a large hospital. We then introduced a standardised post-fall medical review pro forma and reassessed the quality of the reviews. Methods We reviewed 18 charts of patients that fell in hospital and assessed the documentation of the post fall review in terms of the inclusion of key elements such as patient identifiers, history, examination, injury management and future falls prevention. We then introduced a post-fall standardised pro-forma on five wards in the hospital and following this assessed 19 charts of patients who had fallen looking at the same key elements of the post fall review. We compared the quality of the post-fall review before and after the introduction of the pro forma. Results The post-falls medical review pro forma improved the quality of the post fall medical review. Hip Trauma: 11.1% of doctors asked about hip strike prior to proforma versus 100% who asked with the proforma. Joint examination: 50% assessed this prior to the proforma versus 100% with the pro-forma. Other aspects of the review that improved included head-strike assessment (89% versus 100%), loss of consciousness history (61% versus 95%), medication reviewed (22% versus 68%) and vital signs assessed (67% versus 95%). Conclusion The introduction of a standardised post fall review pro forma improves the quality of this important medical review. It is a useful aid for doctors and provides a framework to follow when reviewing the patient.

Background One-third of older general medical patients have delirium; it is present in half of these patients on admission and develops during hospitalisation in the other half. Despite its high prevalence, delirium is frequently not recognised, evaluated or managed appropriately resulting in poor outcomes. Our aim was to assess whether or not delirium was being recognised and documented on the General Medical Wards (GMW). Methods We completed a prospective chart review using an audit tool on all patients aged ≥65 years on a GMW and a Specialist Geriatric Ward (SGW) over a 24-hour period. We screened all identified patients using the 4AT Test. The standard measured against was the HSE Guideline – Delirium on General Hospital Wards: Identifying Patients at Risk, Delirium Screening and Next Steps. Results We included 27 patients in the study (n=27) – median age was 80 years (range 65-90); 17 were male (62.96%); 10 were on a SGW (37.04%). There was a 4AT documented on 9 (n=10) of the patients on the SGW (90%) in comparison to 0 (n=17) on the GMW (0%). We identified n=7 patients with a 4AT ≥4 consistent with acute delirium – 4 were on the SGW (57.14%). All 4 of these patients (n=4) were documented as delirious on the SGW (100%). Of the 3 patients identified on the GMW (n=3), 1 was documented as delirious (33.33%). All patients with delirium (n=7) had non-pharmacological measures implemented (100%), most commonly catheter avoidance (100%), analgesia (100%) and regular mobilization (85.71%). Pharmacological management was administered in 2 cases (28.57%). Conclusion Our audit demonstrates that despite a high prevalence of delirium amongst older adults on GMWs, it remains under-recognized missing a pertinent opportunity to investigate and initiate management. This may result in adverse outcomes. The first step in improving care in older adults suffering from delirium is detection. Detection begins with screening.

BackgroundSotrovimab, a recombinant human monoclonal antibody (mAb) against SARS-CoV-2 had US FDA Emergency Use Authorization (EUA) for the treatment of high-risk outpatients with mild- to-moderate COVID-19 from May 26, 2021 to April 5, 2022. The study objective was to evaluate the real-world effectiveness of sotrovimab in reducing the risk of 30-day all-cause hospitalization and/or mortality during the time period when the prevalence of circulating SARS-CoV-2 variants was changing between Delta and Omicron sub-lineages in the US.MethodsA retrospective analysis was conducted on de-identified claims data for 1,530,501 patients diagnosed with COVID-19 (ICD-10: U07.1) from September 1, 2021, to April 30, 2022, in the FAIR Health National Private Insurance Claims (FH NPIC®) database. Patients meeting EUA high-risk criteria were identified via pre-specified ICD-10-CM diagnoses in records ≤24 months prior to their first COVID-19 diagnosis and divided into two cohorts based on claimed procedural codes: treated with sotrovimab (“sotrovimab”) and not treated with a mAb (“no mAb”). All-cause hospitalizations and facility-reported all-cause mortality within 30 days of diagnosis (“30-day hospitalization or mortality”) were identified. Multivariable and propensity score-matched Poisson and logistic regressions were conducted to estimate the adjusted relative risk (RR) and odds of 30-day hospitalization or mortality among those treated with sotrovimab compared with those not treated with a mAb.ResultsOf the high-risk COVID-19 patients identified, 15,633 were treated with sotrovimab and 1,514,868 were not treated with a mAb. Compared with the no mAb cohort, the sotrovimab cohort was older and had a higher proportion of patients across the majority of high-risk conditions. In the no mAb cohort, 84,307 (5.57%) patients were hospitalized and 8,167 (0.54%) deaths were identified, while in the sotrovimab cohort, 418 (2.67%) patients were hospitalized and 13 (0.08%) deaths were identified. After adjusting for potential confounders, high-risk COVID-19 patients treated with sotrovimab had a 55% relative risk reduction of 30-day hospitalization or mortality (RR: 0.45, 95% CI: 0.41,0.49) and an 85% relative risk reduction of 30-day mortality (RR: 0.15, 95% CI: 0.08, 0.29) compared with high-risk patients not treated with a mAb. From September 2021 to April 2022, sotrovimab maintained clinical effectiveness with relative risk reductions of 30-day hospitalization or mortality ranging from 46% to 71%. Stratifying by high-risk condition, sotrovimab-treated patients exhibited statistically significant relative risk reductions of 30-day hospitalization or mortality compared with the no mAb cohort across all high-risk conditions (PConclusionIn this large, US real-world, observational study of high-risk COVID-19 patients with reported diagnosis between September 2021 and April 2022 during the Delta and early Omicron variant waves, treatment with sotrovimab was associated with reduced risk of 30-day all-cause hospitalization and facility-reported mortality compared with no mAb treatment. Sotrovimab clinical effectiveness persisted throughout the months when Delta and early Omicron sub-lineages were the predominant circulating variants in the US, though there was an uncertain RR estimate in April 2022 with wide confidence intervals due to the small sample size. Sotrovimab clinical effectiveness also persisted among all high-risk subgroups assessed.

Background A cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy. Case Report We present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department. Why Should an Emergency Physician Be Aware of This? Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy.

Background Emergency physicians are frequently required to identify and triage patients with increased intracranial pressure (ICP). Idiopathic intracranial hypertension (IIH) is a possible cause that must be considered. Its prognosis depends on prompt recognition and treatment, and progression of the disease can lead to permanent vision loss and considerable morbidity. Point-of-care ultrasound can rapidly identify elevated ICP. Measurements of the optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) can act as surrogates for ICP. Case Series We describe five cases in which ultrasound was used to identify increased ICP and aid clinical decision-making. In several of the cases, ultrasound was used to confirm a suspicion for IIH and initiate therapy while awaiting the results of a more time-consuming and technically challenging test, such as lumbar puncture or optical coherence tomography. One of the patients was pregnant, and sonographic evidence of elevated ICP helped avoid exposing the patient to unnecessary radiation. Why Should an Emergency Physician Be Aware of This? Ultrasound is a quick and versatile tool for screening patients with neurologic symptoms, and when integrated into the proper clinical context, can reduce the use of more invasive tests. It can be particularly useful in patients with pathology that may not show abnormalities on computed tomography scan or in whom lumbar puncture is technically difficult, making patients at risk for IIH well-suited to examination by ultrasound. We use a cutoff of 5 mm for ONSD and 0.6 mm for ODE, though there are no universally agreed on cutoff values.

Physical examination for peritonsillar abscess (PTA) has limited sensitivity. Traditional management involves blind needle aspiration, which has a false negative rate of 10-24%. A randomized controlled trial by Costantino et al. demonstrated that point-of-care ultrasound (POCUS) improves PTA management.Compare the use and impact of POCUS between patient cohorts prior to and after the trial by Costantino et al.Retrospective cohort study of adult patients diagnosed with PTA. Cohort 1 presented to the emergency department (ED) January 2007-December 2008. Cohort 2 presented between January 2013 and December 2014. Data were separated into those with POCUS vs. without ultrasound (NUS). Primary endpoint was POCUS utilization. Secondary endpoints were successful aspiration, otolaryngology (ear, nose, and throat [ENT]) consultation, computed tomography (CT) imaging, unscheduled return visits, and length of stay (LOS). The Fisher's exact and t-tests analyzed data.Cohort 1 enrolled 48 patients, vs. 114 patients for cohort 2. Twelve patients in cohort 1 had a POCUS (25%) vs 89 in cohort 2 (78%) (p 0.0001; odds ratio [OR] 0.09 (95% confidence interval [CI] 0.04-0.20). Emergency physician (EP) successful aspiration: 89.1% POCUS vs. 24.5% NUS (p 0.0001; OR 25 [95% CI 10-59]). Combined EP/ENT successful aspiration: 99.0% POCUS vs. 80.3% NUS (p 0.0001; OR 24 [95% CI 3-193]). ENT consultation:12.9% POCUS vs. 65.6% NUS (p 0.0001; OR 0.07 [95% CI 0.03-0.17]). CT usage: 23.8% POCUS vs. 37.7% NUS (p = 0.07; OR 0.51 [95% CI 0.25-1.02]). Return visits: 3.96% POCUS vs. 18.0% NUS (p = 0.004; OR 0.18 [95% CI 0.05-0.61]).POCUS use has increased for PTA treatment, improves aspiration, and decreases consultations, CTs, return visits, and LOS.

To compare the quality of life (QoL) in children with spina bifida with a control group of their peers using a validated questionnaire, the Neurogenic Bowel Dysfunction Score (NBDS). The NBDS questionnaire was prospectively distributed to children attending a multi-disciplinary Spina Bifida clinic and healthy controls attending pediatric urology clinics. A score (out of 41) was assigned to each child based on their responses to the validated questionnaire. A lower score indicates better bowel function-related quality of life. SPSS software (v.25) was used for all statistical analysis. There were 98 respondents to the questionnaire, 48 children with spina bifida and 50 controls. The average age of respondents was 7.88 years (3–16 years). Of those with Spina Bifida, 33 (69%) were on retrograde rectal irrigations, [19 (58%) Peristeen® system, 11 (33%) tube rectal irrigations, and 3 (9%) Willis system], 6 (12%) were on laxatives, and 9 (19%) were on no treatment. The median NBDS for Spina Bifida patients was significantly higher 13.5 (2–32) compared to the control group 2 (0–26, p

Aim One of the most commonly performed procedures in orthopaedics is anterior cruciate ligament reconstruction. Autograft hamstring tendons are mostly used. The preparation of a hamstring autograft varies on patient factors and clinician choices. The use of a bulky, and expensive metal platform is usually involved, or an assistant is tasked to hold the other end of the graft. We aim to produce a 3D-printed sterilisable preparation system (G-Master) that improves autonomy and speed of the surgeon preparing the ACL graft. Method A stereolithography file (.stl) of the device was designed on Blender program and then manufactured on a commercial Fusion Deposition Modelling Ender 5 3-dimensional (3D) printer using a polylactic acid variant. The 3D printed parts include an attachable platform, two pillars whereby the attached pillar is where the endobutton (SN) holding the autograft sits in tension. These were autoclaved at 121°C under 15 psi of steam pressure for 30 minutes before the operation. Approval for device use was subjected to a rigorous process as class I devices as per the UK government Medicines and Healthcare Products Regulatory Agency guidelines and was then successfully used in vivo. Results We found the bespoke device to be beneficial in reducing graft preparation time and overall cost while increasing the autonomy of the surgeon and efficiency of the knee operating theatre list. Conclusions This is, to our knowledge, the first ACL graft preparation system that was produced using rapid prototyping and 3D printing. Other applications of 3D printing in manufacturing orthopaedic surgical instruments should be explored.

Aim Enhanced recovery pathway(ERP) in elective joint replacements has been shown to reduce length of stay, reduce re-admission rates, and can improve early functional recovery. Local analgesia and VTE prophylaxis protocol in current use has been produced by members of the multidisciplinary team but awareness of it needs to be optimised. Method We performed a retrospective review of discharge summaries and prescriptions from April 1 to April 30, 2021, of all primary joint replacements at Chelsea and Westminster Hospital. These were assessed against the local ERP Protocols for elective arthroplasties. ‘E-Lective App’ - a peer to peer shared mobile application containing an offline repository of existing Enhanced Recovery medication protocols, ward directory and follow-up booking feature was presented to clinical staff at the clinical governance meeting. Prior to these, protocols were only accessed or shared through WhatsApp. Re-assessment was done a three months later for a period of one month’s July 1 to July 31, 2021. Results Prior to launching ‘E-Lective App,’ compliance with the ERP Discharge Medications protocol was 70.1%. At last review in July 2021 this had significantly improved to 96% on average (p Conclusions This quality improvement project highlights the need to innovate to improve compliance to current standards of prescribing medications as part of the Enhanced Recovery Protocol. ’E-lective app’ is a novel and effective guide on maximising ERP pathway for joint replacements.

ObjectiveIn order to identify areas of unmet need in patients with primary biliary cholangitis (PBC), this study sought to use real-world observational healthcare data to characterise the burden in patients with PBC and in PBC patients with a recorded diagnosis of pruritus.DesignThis retrospective, cross-sectional database study compared prevalence of prespecified comorbidities and medications in the PBC population and PBC-pruritus subpopulation with non-cases using an indirect standardisation approach. The PBC population was identified from the US IBM MarketScan Commercial Claims and Medicare Supplemental Database during 2016 using International Classification of Diseases 10th Revision, Clinical Modification codes (≥2 claims for PBC); the PBC-pruritus subpopulation additionally had ≥1 claim for pruritus during this period. Non-cases had no claims for PBC. Indirect age-sex standardised prevalence ratios (iSPR) and 95% confidence intervals (CIs) were calculated for prespecified comorbidities and medications recorded during 2017.ResultsThe PBC population (N=1963) and PBC-pruritus subpopulation (N=139) had significantly higher prevalence of fatigue (19.9%, iSPR (95% CI): 1.51 (1.36 to 1.66); 26.6%, 2.10 (1.48 to 2.90)), depression/anxiety (21.3%, 1.09 (0.99 to 1.20); 28.1%, 1.46 (1.04 to 2.00)) and sleep-related issues (6.9%, 1.18 (0.99 to 1.40); 14.4%, 2.58 (1.58 to 3.99)) compared with non-cases. Bile acid sequestrants were prescribed in 5.8% and 18.0% of the PBC and PBC-pruritus populations, respectively. In general, a higher prevalence of comorbidities and medication use was observed in the PBC-pruritus subpopulation compared with the PBC population and non-cases.ConclusionDespite availability of treatments for PBC, the PBC population had a higher burden of comorbidities than non-cases. This burden was even greater among the PBC-pruritus subpopulation, with a particularly high prevalence of sleep disorders and depression/anxiety. Despite this, pruritus remains undertreated highlighting a need for treatments specifically indicated for cholestatic pruritus.

Functional overlap between species (redundancy) shapes competitive and mutualistic interactions, determining community responses to perturbations. Most studies view functional redundancy as static, even though individuals within species vary in traits over seasonal or spatial gradients. Consequently, we lack knowledge on trait turnover within species, how functional redundancy spatiotemporally varies, and when and where interaction networks are vulnerable to functional loss. Studying an Arctic bumblebee community, we investigated how body-size turnover over elevation and season shapes their host-plant interactions, and test how sensitive networks are to sequentially losing body-size groups. With trait turnover being larger than species, we found: i) late-season networks were less specialised when nodes comprised functionally similar bumblebees; ii) removal of bumblebee-body-size groups over species accelerated coextinction of host plants, with the magnitude varying in space and time. We demonstrate functional redundancy can vary spatiotemporally, and functional loss impacts interaction partners more than expected from species loss alone.

Introduction: COVID-19 is a pulmonary disease associated with fever and dyspnea, affecting all age groups. Older patients, however, have a higher likelihood of adverse outcomes including death. Severe disease is associated with hyperinflammation and differential expression of inflammatory mediators has been demonstrated for patients aged ≥70 years. Aim: To evaluate the impact of level of care on length of hospital stay (LOS) and costs for COVID-19 patients stratified by age. Methods: We conducted a cohort study of patient data from the Premier Health Database comprising healthcare and billing information for a geographically diverse selection of hospitals in the United States from April 2020 through March 2021. Results: We identified over 162,000 hospitalized COVID-19 patients requiring respiratory support; approximately 68,000 (42%) were aged ≥70 years, 66,000 (41%) were aged 50–69 years, and 28,000 (17%) were aged Conclusion: Higher levels of care for patients with COVID-19 are associated with LOS and costs. Funded by GSK: medical writing support provided by Fishawack Indicia Ltd, funded by GSK.

Objective: To describe patient characteristics, treatment patterns and healthcare utilization (HCU) of non-active users of maintenance asthma medications in the United Kingdom.Methods: Retrospectiv...

The ability to improve the data quality of ion mobility-mass spectrometry (IM-MS) measurements is of great importance for enabling modular and efficient computational workflows and gaining better qualitative and quantitative insights from complex biological and environmental samples. We developed the PNNL PreProcessor, a standalone and user-friendly software housing various algorithmic implementations to generate new MS-files with enhanced signal quality and in the same instrument format. Different experimental approaches are supported for IM-MS based on Drift-Tube (DT) and Structures for Lossless Ion Manipulations (SLIM), including liquid chromatography (LC) and infusion analyses. The algorithms extend the dynamic range of the detection system, while reducing file sizes for faster and memory-efficient downstream processing. Specifically, multidimensional smoothing improves peak shapes of poorly defined low-abundance signals, and saturation repair reconstructs the intensity profile of high-abundance peaks from various analyte types. Other functionalities are data compression and interpolation, IM demultiplexing, noise filtering by low intensity threshold and spike removal, and exporting of acquisition metadata. Several advantages of the tool are illustrated, including an increase of 19.4% in lipid annotations and a two-times faster processing of LC-DT IM-MS data-independent acquisition spectra from a complex lipid extract of a standard human plasma sample. The software is freely available at https://omics.pnl.gov/software/pnnl-preprocessor.

Aim Our aim was to present an overview of patterns of paediatric organ donation in the Republic of Ireland from January 2007 to January 2018. Methods We performed a retrospective audit of organ donation practice in paediatric intensive care units (PICU) in Ireland. Results Thirty-six children donated organs or tissue heart valves over the 11-year period. There were 13 paediatric organ donors between 2007 and 2012, this increased to 23 paediatric organ donors between 2013 and 2017. 2017 had the highest number of organ donors at 9 Conclusion Organ donation in Irish PICUs has increased over the last 11 years due to a combination of factors: improved resourcing and organization of Organ Donation Transplantation Ireland (ODTI), the establishment of clinical leads (both medical and nursing) in organ donation, a heightened awareness of organ donation and improved specialist Intensive Care dedicated consultant staffing. Finally organ donation is possible only through the generosity and altruism of bereaved families. Outcomes from donated organs have been excellent throughout the 11 year period audited.