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Introduction: Pre-hospital clinicians can expect to encounter patients with agitation, including acute behavioural disturbance (ABD). These situations carry significant risk for patients and emergency medical services. Advanced paramedics within the London Ambulance Service (LAS) are frequently tasked to these incidents. At present, little evidence exists regarding clinical decision-making and management of this patient group. We sought to explore the demographics of patients presenting with potential ABD and quantify the degree of agitation, physical restraint, effectiveness of chemical sedation and any associated complications.Methods: A retrospective analysis of pre-hospital clinical records for patients coded with ABD and attended by LAS advanced paramedics between 1 October 2019 and 30 September 2020. Sedation assessment tool (SAT) scores were used as the primary outcome measure.Results: A total of 237 patient records were identified. Of the patients, 147 (62%) were physically restrained and 104 (44%) were chemically sedated. Sedation was more commonly administered where patients were exposed to physical restraint. High SAT scores were associated with the administration of sedative agents and at higher doses. Of patients undergoing sedation, 89 (85%) had a SAT score reduction of 2 points or a final score ≤ 0. The mean SAT score reduction was 2.72. Three cases of minor injury were reported following physical restraint.Conclusion: Advanced paramedics undertook sedation in less than half the cohort, suggesting that other strategies such as communication and positioning were utilised. Most patients were managed into a state between being restless and rousable, largely negating the need for ongoing physical restraint during hospital transfer. Appropriately trained advanced paramedics can utilise sedation safely and effectively in selected cases.

Background: This study describes and evaluates advanced paramedic practitioner (APP) use of focused cardiac ultrasound (FoCUS) in out-of-hospital cardiac arrest (OHCA), and relates ultrasound findings with decisions to terminate resuscitation. The authors report characteristics of patients who do/do not undergo a FoCUS examination by APPs, ultrasound probe positions used and whether FoCUS findings were associated with decisions to terminate resuscitation or to convey patients to an emergency department (ED) with ongoing resuscitation. Method: A retrospective, observational cohort study of all adult medical OHCA patients attended by APPs in Greater London during 2018 was carried out using data from emergency medical services (EMS) and APP databases. Results: Twenty-eight APPs attended 1444 OHCA patients in 2018, of whom 744 underwent FoCUS. The subcostal probe position was used most frequently (74%), followed by the parasternal long axis (19%), with significantly smaller use of the parasternal short axis and apical windows. Absence of spontaneous cardiac motion (SCM) was associated with resuscitation being terminated (333 out of 391; 85%) and the presence of SCM was associated with conveyance to the emergency department (213 out of 264 patients; 80%). All decisions to terminate resuscitation were within the APP scope of practice. Conclusion: The authors believe this is the largest prehospital study involving FoCUS in OHCA. An association between FoCUS findings and decisions made to either convey patients to hospital or terminate resuscitation was found. The SC window was most used and ROLE decisions were deemed to be in accordance with local guidance and practice.

A New Literary History of the Long Twelfth Century offers a new narrative of what happened to English language writing in the long twelfth century, the period that saw the end of the Old English tradition and the beginning of Middle English writing. It discusses numerous neglected or unknown texts, focusing particularly on documents, chronicles and sermons. To tell the story of this pivotal period, it adopts approaches from both literary criticism and historical linguistics, finding a synthesis for them in a twenty-first century philology. It develops new methodologies for addressing major questions about twelfth-century texts, including when they were written, how they were read and their relationship to earlier works. Essential reading for anyone interested in what happened to English after the Norman Conquest, this study lays the groundwork for the coming decade's work on transitional English.

This paper demonstrates the potential of new methodologies for using existing corpora of medieval English to better contextualise linguistic variants, a major task of philology and a key underpinning of our ability to answer major literary-historical questions, such as when, where and to what purpose medieval texts and manuscripts were produced. The primary focus of the article is the assistance these methods can offer in dating the composition of texts, which it illustrates with a case study of the “Old” English Life of St Neot, uniquely preserved in the mid-twelfth-century South-Eastern homiliary, London, British Library, Cotton Vespasian D.xiv, fols. 4–169. While the Life has recently been dated around 1100, examining its orthography, lexis, syntax and style alongside that of all other English-language texts surviving from before 1150 using new techniques for searching theDictionary of Old English Corpussuggests it is very unlikely to be this late. The article closes with some reflections on what book-historical research should prioritise as it further evolves into the digital age.

Background Out-of-hospital cardiac arrest carries a poor prognosis with survival less than 10% in many patient cohorts. Survival is inversely associated with duration of resuscitation as external chest compressions do not provide sufficient blood flow to prevent irreversible organ damage during a prolonged resuscitation. Extracorporeal membrane oxygenation (ECMO) instituted during cardiac arrest can provide normal physiological blood flows and is termed Extracorporeal Cardio-Pulmonary Resuscitation (ECPR). ECPR may improve survival when used with in-hospital cardiac arrests. This possible survival benefit has not been replicated in trials of out-of-hospital cardiac arrests, possibly because of the additional time it takes to transport the patient to hospital and initiate ECPR. Pre-hospital ECPR may shorten the time between cardiac arrest and physiological blood flows, potentially improving survival. It may also mitigate some of the neurological injury that many survivors suffer. Methods Sub30 is a prospective six patient feasibility study. The primary aim is to test whether it is possible to institute ECPR within 30 ​min of collapse in adult patients with refractory out of hospital cardiac arrest (OHCA). The secondary aims are to gather preliminary data on clinical outcomes, resource utilisation, and health economics associated with rapid ECPR delivery in order to plan any subsequent clinical investigation or clinical service. On study days a dedicated fast-response vehicle with ECPR capability will be tasked to out-of-hospital cardiac arrests in an area of London served by Barts Heart Centre. If patients suffer a cardiac arrest refractory to standard advanced resuscitation and meet eligibility criteria, ECPR will be started in the pre-hospital environment. Discussion Delivering pre-hospital ECPR within 30 ​min of an out-of-hospital cardiac arrest presents significant ethical, clinical, governance and logistical challenges. Prior to conducting an efficacy study of ECPR the feasibility of timely and safe application must be demonstrated first. Extensive planning, multiple high-fidelity multiagency simulations and a unique collaboration between pre-hospital and in-hospital institutions will allow us to test the feasibility of this intervention in London. The study has been reviewed, refined and endorsed by the International ECMO Network (ECMONet). Trial registration Clinicaltrials. gov NCT03700125 , prospectively registered October 9, 2018.

Britain is not and never has been monolingual. The 2011 census counted inhabitants of Britain speaking nearly ninety languages, including Slovenian, Farsi, Tagalog, and Swahili; a visitor to mid-twelfth-century London might have heard as many as fourteen languages: English, French, German, Flemish, Danish, Genoese, Spanish, Breton, Welsh, Irish, Scottish Gaelic, Hebrew, Arabic, and Greek. Britain has therefore of necessity always been a site of language contact. This chapter focuses on what influence this language contact has had on British English, a topic of increasing interest to historical linguists. Following a brief account of some of the methodological challenges attendant on studying historical language contact, the chapter sketches the influence of the four main contact influences on English: Celtic, Latin, Norse, and French.

This article draws attention to a series of seven English annotations in a mid-twelfth-century copy of Bede’sHistoria ecclesiasticafrom Bury St Edmunds. It demonstrates that the annotations reflect the comparison of Bede’s Latin with a now-lost manuscript of the Old English Bede shortly after the twelfth-century codex’s production. The annotations are shown to hold a respect for the authority of the Old English Bede that contrasts with the prevailing twelfth-century attitude of gentle suspicion towards earlier vernacular translations.

Scholars studying medieval manuscripts work in a variety of disciplines, from literary atudies to history to linguistics to art history to classics. Publications in all these areas use manuscripts and offer important findings about medieval manuscripts. In addition to its practice within different fields, much of the study of medieval manuscripts is strongly interdisciplinary, using techniques native to the study of the medieval book like codicology and paleography, alongside text critical-methods originally developed in classics and refined there, in literary studies and in history, visual analysis pioneered in art history, and philological methods now found in literary studies and linguistics. Insofar as the study of medieval manuscripts has a unified goal, it is to describe and explain the production and use of manuscripts and the textual culture associated with them, generating primary data that assists in the writing of literary, cultural, and linguistic history. Given the breadth of the field, this Oxford Bibliographies entry must necessarily be selective. It focuses primarily on manuscripts of British and Irish literature in English (manuscripts of texts in Irish, Welsh, and other Celtic languages being specialist fields of study in their own right). As a consequence, the vast majority of the material listed is in English, though scholarship on medieval manuscripts is also published in French, Italian, and German, as well as other languages. After sections devoted to General Overviews, Reference Works, Textbooks, Anthologies, Bibliographies and Journals, the bibliography presents lists of Catalogues of Manuscripts and Facsimiles, which are two of the most important tools for medieval book historians. It finishes with lists of works relevant to the major subdisciplines of medieval book history, Codicology (the study of the physical structure of manuscripts); paleography, the study of Scripts used in those manuscripts; as well as studies of Scribal Practice and Manuscript Culture; and works concerned with Ownership and Provenance.

Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients.

INTRODUCTION OR BACKGROUND Ambulance services have historically found their targets particularly challenging. This article explores some areas of this multifaceted problem. SOURCES OF DATA Research articles, government publications and published audit data. AREAS OF AGREEMENT Demand is increasing in many areas of healthcare, but whilst hospitals saw a 7% increase in demand in recent times, ambulance services saw nearly double that. The services ambulance trusts provide have evolved from that of a transport service to that of a mobile health provider, and they have become victims of their own success. AREAS OF CONTROVERSY Ambulance targets have never evolved to match evolving care. Ambulance personnel strive to avoid hospital attendance where appropriate, but this can be difficult for a 24-hour service, when not all referral pathways have 24-hour referral systems. GROWING POINTS We discuss why demand might be growing disproportionately for ambulance services, and challenge the appropriateness of the targets themselves. AREAS TIMELY FOR DEVELOPING RESEARCH Possible formats for revised ambulance targets are discussed.

Automated external defibrillators (AEDs) in public spaces have saved countless cardiac arrest victims.1 They rely on rhythm detection algorithms with high specificity for recognizing ventricular arrhythmia when used appropriately. AED diagnostics can be difficult to retrieve once the patient has arrived in hospital, with patient management decisions often made in their absence. We present a case where retrieval of an AED download was critical to manage. An 18-year-old Afro-Caribbean semiprofessional basketball player collapsed for the first time while slowing down after a sprint in the middle of a match at a local gymnasium. This was his first collapse episode. He had no past medical history or family history of sudden death. First responders were unable to detect a peripheral pulse, and bystander cardiopulmonary resuscitation (CPR) was commenced by one of his teammates. A Zoll AED Plus was available and applied in under 2 minutes, promptly advising shock delivery. Having received a 120 J …

The prolific English poet John Lydgate (c.1371–1449) has been known as the “monk of Bury” since the early fifteenth century. Both his popularity and perceptions of his literary merit have fluctuated wildly since his zenith as the famous laureate of Henry V, Henry VI and Duke Humphrey, but readers have been constant in their association of Lydgate with the Benedictine abbey from which the epithet derives. However, there has been remarkably little examination of the details of Lydgate's existence at Bury: the critical emphasis has been on Lydgate's contact with Lancastrian society rather than on his quotidian life as a monk. “To trace in detail the connection between the Bury library and the characteristic configuration of Lydgate's thought and work, to see how his mind was formed and influenced by the books with which he was in such familiar contact” remains an unfulfilled desire. In particular, given the range of Lydgate's literary and intellectual allusions, it is surprising that there has been no full a...

The last 10 years have seen a swathe of revisionary scholarship on the afterlife of Old English texts in the 12th century. This article places this research beside work on the earliest Middle English texts and contemporary writing in Latin and French to suggest that the time is now ripe for a new, synthetic literary history of the period. In particular, the article identifies three key aspects of post-Conquest literary culture which have been neglected because they chafe against the conventional paradigms of literary history, with its expectation of a literature national, monolingual and constantly original. The 12th-century norms, by contrast, were regionalism, multilingualism, and the habitual recycling of older texts. Medievalists must insist these differences should inform wider discussions about the form and purpose of literary history in the 21st century.

ObjectivesTo describe the epidemiology of assaults resulting in stab injuries among young people. We hypothesised that there are specific patterns and risk factors for injury in different age groups.DesignEleven-year retrospective cohort study.SettingUrban major trauma centre in the UK.Participants1824 patients under the age of 25 years presenting to hospital after a stab injury resulting from assault.OutcomesIncident timings and locations were obtained from ambulance service records and triangulated with prospectively collected demographic and injury characteristics recorded in our hospital trauma registry. We used geospatial mapping of individual incidents to investigate the relationships between demographic characteristics and incident timing and location.ResultsThe majority of stabbings occurred in males from deprived communities, with a sharp increase in incidence between the ages of 14 and 18 years. With increasing age, injuries occurred progressively later in the day (r2=0.66, p2=0.59, pConclusionsAge, gender and deprivation status are potent influences on the risk of violent injury in young people. Stab injuries occur in characteristic temporal and geographical patterns according to age group, with the immediate after-school period associated with a spike in incident frequency in children. This represents an opportunity for targeted prevention strategies in this population.

This article discusses the assessment, management and treatment of patients with stab wounds on arrival in the emergency department. It describes the immediate approach to assessment. The assessment of stab wounds to the chest, abdomen and limbs is also examined.

This paper briefly describes the rationale for and the development of the CARE (Combined Assessment of Residential Environments) profiles. The CARE profiles represent a new approach to quality improvement in care homes for older people that seeks to gain the views of residents, relatives and staff, and to use these as a basis for celebrating what works well in a home and identifying areas that need attention. The paper begins with a consideration of the limitations of existing quality initiatives and argues for a model that is more inclusive. Subsequently, the theoretical underpinnings of the CARE profiles, positive events, the Senses Framework, and a relationship‐centred approach to care are outlined. The process by which the CARE profiles were developed is then described and a case study highlighting how they might be used is presented.

Aim: This paper reports the development and initial testing of the combined assessment of residential environments (CARE) profiles, which identify the frequency of positive events over a specified time based on the perceptions of residents, relatives and staff in care home settings. Background: Despite the well-known benefits of positive events for subjective well-being, little is known about the nature of positive events experienced by residents, relatives and staff in care homes. There is also a dearth of tools capable of systematically evaluating how frequently these events occur in this context. Methods: The CARE profiles were developed and tested between February 2004 and June 2005 with a combined sample of 372 residents, relatives and staff drawn from 11 care homes. An Event Frequency Approach was adopted to create three questionnaires (residents, relatives and staff), each containing 30 consensually valid positive events. The thematic content of these events was balanced for each questionnaire using the Senses Framework as a theoretical model. Once completed, the CARE profiles were tested in four care homes. Results: Test data from the CARE profiles were used to produce a bar chart showing median frequencies of positive events experienced by residents, relatives and staff during the timeframe in question (e.g. 1 month). These profiles were shown to be internally consistent, with alpha scores ranging from 0·70 to 0·89 for residents, 0·91 to 0·94 for relatives and 0·78 to 0·92 for staff. Conclusion: We envisage that feedback from the CARE profiles will both reinforce good care home practice and identify areas for change based on the experiences of all major stakeholders. However, further development of the profiles is needed if the experiences of cognitively impaired residents are to be included in the assessment process.

The participation of volunteers in the National Health Service (NHS) has been actively promoted during recent years, particularly within community and primary healthcare services (National Health Service 1996, 1998). As a consequence, volunteers currently make a significant contribution to health and social care within the UK. Concerning this contribution, the literature often portrays the volunteers' role as one of providing social support. In the present paper, the authors attempt to explore this role in more detail, drawing on interview data from studies of two separate volunteer programmes. One of these considered the role of volunteers supporting older hospitalised patients (Davies et al. 2001), and the other was based within general practice (Faulkner 2003, 2004). The social support provided by these programmes is considered from the perspective of four broad support mechanisms described by Langford et al. (1997), namely: emotional support; informational support; appraisal support; and instrumental support. Secondary analysis examines the potential contribution of volunteers to patient well-being.

This study aimed to develop valid models of empowerment and disempowerment relevant to staff/patient interaction as a means of generating a greater understanding of how these concepts are expressed in healthcare. This involved submitting the concepts of empowerment and disempowerment to an act frequency approach (Buss and Craik, 1983). Using this approach, registered nurses (n=38) were asked to nominate empowering and disempowering acts relevant to staff/patient interactions, yielding a list of 98 acts. Following this, older hospitalised people (n=20) were asked hypothetically to judge these acts as to the extent they would be 'control giving' if personally experienced. The 20 highest scoring acts for each concept were then incorporated into an act frequency observation scale. Using this composite scale, older hospitalised people (n=102) were asked to judge how often they had encountered each act over a pre-determined period of time. Act frequencies for each concept were then submitted to a principal components factor analysis. The principal components of empowerment were identified as 'promoting patient independence,' 'promoting information exchange' and 'being aware of patient needs'; and for disempowerment, 'impeding patient collaboration in care planning,' 'domination' and 'indifference to patient needs'. Models of these concepts illustrate the therapeutic and non-therapeutic aspects of interpersonal care.

The objective of this study was to investigate the relevance of learned helplessness (LH) and learned mastery (LM) theories in the respective development of dependence and independence in older hospitalized people. A two-staged experiment was performed. In stage I, meal-related responses of patient participants (n = 84) were automatically completed by a researcher during two consecutive mealtime events (LH induction). LH effects were then assessed by evaluating participant performance during a controllable meal-task and a non-meal-related psychomotor task. In stage II, "helpless" participants (n = 35) were then given an expectation of future control over the mealtime event followed by two further meals during which the researcher provided no active assistance (LM induction). LM effects were assessed as in stage I. Participants exposed to the LH inducing strategy demonstrated LH effects within both the meal and psychomotor tasks. These effects were alleviated through exposing participants to the LM inducing intervention. Exposing older hospitalized people to uncontrollable or disempowering circumstances may potentially lead them to develop a LH induced dependence. This may be alleviated by increasing patient's expectation of control leading to the development of LM.

Background The use of ketamine and midazolam in physician-led prehospital care teams within the UK is well established. Although both agents are in use by paramedics within emergency medical systems in North America and Australasia, there is a paucity of data relating to administration by UK paramedics. Methods A panel of clinicians utilised a standardised data extraction form to review patient report forms for all cases where an Advanced Paramedic Practitioner (APP) administered ketamine or midazolam from 1st May to 30th September 2015. Reviewers assessed indications for and appropriateness of administration, and identification and management of adverse events. Results A total of 21 patients received ketamine for analgesia (n=20, 95%) or to facilitate rapid extrication (n=1, 5%). Pain scores were recorded in 18 patients (90%), the majority of whom experienced a reduction in pain post administration (n=17, 94%). No adverse events occurred following ketamine use. Midazolam was administered to a total of 80 cases. The most common indications for administration were maintenance of an advanced airway in patients with return of spontaneous circulation post cardiac arrest (n=37, 46%), management of acute behavioural disturbance (n=28, 35%) and prolonged seizures (n=15, 18%). Transient airway compromise occurred in 10% (n=8) of cases, all of which were managed appropriately. No other adverse events occurred. The administration of ketamine and midazolam was judged to be appropriate in all cases. Conclusions The use of ketamine and midazolam in the context of an urban APP service with high levels of additional education, procedural experience and selective targeting to emergency calls appears safe and effective. Further prospective studies are warranted to confirm these findings.

Objective To develop and validate a prognostic model for early death in patients with traumatic bleeding.\ud \ud Design Multivariable logistic regression of a large international cohort of trauma patients.\ud \ud Setting 274 hospitals in 40 high, medium, and low income countries\ud \ud Participants Prognostic model development: 20 127 trauma patients with, or at risk of, significant bleeding, within 8 hours of injury in the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial. External validation: 14 220 selected trauma patients from the Trauma Audit and Research Network (TARN), which included mainly patients from the UK.\ud \ud Outcomes In-hospital death within 4 weeks of injury.\ud \ud Results 3076 (15%) patients died in the CRASH-2 trial and 1765 (12%) in the TARN dataset. Glasgow coma score, age, and systolic blood pressure were the strongest predictors of mortality. Other predictors included in the final model were geographical region (low, middle, or high income country), heart rate, time since injury, and type of injury. Discrimination and calibration were satisfactory, with C statistics above 0.80 in both CRASH-2 and TARN. A simple chart was constructed to readily provide the probability of death at the point of care, and a web based calculator is available for a more detailed risk assessment (http://crash2.lshtm.ac.uk).\ud \ud Conclusions This prognostic model can be used to obtain valid predictions of mortality in patients with traumatic bleeding, assisting in triage and potentially shortening the time to diagnostic and lifesaving procedures (such as imaging, surgery, and tranexamic acid). Age is an important prognostic factor, and this is of particular relevance in high income countries with an aging trauma population.

This article will explore the impact of empowering and disempowering care on older people. In particular, it will consider the relational links between empowering care and patient independence, and disempowering care and patient dependence. To unravel these links, reference will be made to the psychological theories of learned mastery (Peterson, Maier and Seligman 1993) and learned helplessness (Seligman 1975). These theories are crucial to our understanding of the therapeutic and non-therapeutic dynamics of interpersonal care. I will conclude by evaluating whether empowering strategies of care are suitable for all older patients.

The purpose of this paper is to present the findings of a review of the literature into pain and older people. The funded study was part of the development of an annotated bibliography published in August 2005. The review included all major databases and involved the collection of 214 papers between the dates of 1995 and 2005. The papers were divided into several major themes, which include experiences, management (pharmacological and non-pharmacological), assessment, and attitudes. Within this paper, the results of the review into pain assessment will be discussed, which includes 42 of the collected papers. The other sections will be published later. The paper will discuss issues pertaining to the development of specific tools for older people, a discussion of tools already available, comparisons of staff versus older people's perceptions of pain scales, and articles with cognitive impairment as a focus. Recommendations for further study are made.

The aim of this paper is to discuss the results of a review into the literature related to chronic pain and the older adult. Several themes within the review have been identified and reported elsewhere and the final report has been published by the University of Sheffield in the form of an annotated bibliography. This report focuses upon the findings of the in relation to the assessment of pain in the adult with cognitive impairment. Issues surrounding assessment in the non-cognitively impaired older adult have also been reported elsewhere. For this paper nine studies will be discussed which report the development and testing of pain assessment scales the focus of which is upon behavioural indicators of pain. Some scales have been omitted from the review and the rationale for this decision will be discussed. Each of the selected scales will be discussed and the authors will make recommendations for both clinical practice and for future research based upon the validity, reliability and user friendliness of the scales. From the paper it can be concluded that the Abbey, DOLOPLUS-2 and PACSLAC appear to be the most reliable and valid and in terms of the “user friendliness” would be appropriate to explore further. Recommendations are made for further multi-centre evaluation of these scales.