ImportanceBoarding in the emergency department (ED) is a critical indicator of quality of care for hospitals. It is defined as the time between the admission decision and departure from the ED. As a result of boarding, patients stay in the ED until inpatient beds are available; moreover, boarding is associated with various adverse events.

Objectives & BackgroundThe National Institute of Clinical Excellence (NICE) and the Royal College of Emergency Medicine recommend that adults should be tested for HIV in endemic areas with a prevalence >0.2%. It is estimated that approximately 25% of those living with HIV are unaware of their diagnosis. Late diagnosis is associated with a ten-fold increased risk of death in the following year,1 and increased risk of onwards HIV transmission. In July 2015 our Emergency Department commenced a pilot project to assess the feasibility of routine HIV testing within a busy inner city ED.MethodsPatients over the age of 16 had an HIV test performed if they required venepuncture during their emergency department attendance. Tests were ordered using a pre-configured blood order set including a pre-selected HIV test. Patients were informed of the intention to test all attendances and were able to opt out if desired. Positive or equivocal results were followed up by our HIV team.ResultsOver 36 weeks, 64% of ED attendances (19,569/30,461) were tested for HIV. Our prevalence was 0.9% (n=172) and of those 0.3% were not aware of their positive HIV status (n=68). Thirteen patients were not currently engaged in services, although aware of their diagnosis. Median age was 36(18–61). Patients who tested positive were predominantly male (84%) and Caucasian (59%) (37% BME, 4% Asian).50% of patients who tested positive self- identified as heterosexual, and 50% as MSM(men who have sex with men). A significant number (54%) of newly diagnosed patients had previously attended our emergency department prior to routine HIV testing. 23% of new diagnoses required an acute admission.ConclusionThe Emergency Department provides a suitable environment for opportunistic HIV testing in areas of high prevalence. We have maintained testing rates of >65% of our ED attendances, achieved early diagnosis and treatment engagement in patients who were unaware of their HIV status. In addition, we have identified a number of patients who had been lost to follow-up and have now re-engaged in care. Use of pre-configured blood order sets, regular staff education and feedback on results improves testing rates.

Pain management is a key issue in prehospital trauma. In Switzerland, paramedics have a large panel of analgesic options. Methoxyflurane was recently introduced into Switzerland, and the goal of this study was to describe both the effect of this medication and the satisfaction of its use. This was a retrospective cohort study, performed in one emergency ambulance service. It included adult patients with traumatic pain and a self-assessment of 3 or more on the visual analogue scale or verbal numerical rating scale. The primary outcome was the reduction in pain between the start of the care and the arrival at the hospital. Secondary outcomes included successful analgesia and staff satisfaction. From December 2018 to 4 June to October 2020, 263 patients were included in the study. Most patients had a low prehospital severity score. The median pain at arrival on site was 8 and the overall decrease in pain observed was 4.2 (95% CI 3.9–4.5). Regarding secondary outcomes, almost 60% had a successful analgesia, and over 70% of paramedics felt satisfied. This study shows a reduction in pain, following methoxyflurane, similar to outcomes in other countries, as well as the attainment of a satisfactory level of pain reduction, according to paramedics, with the advantage of including patients in their own care.

No abstract

Bladder cancer is the second most common urological malignancy with a one in 28 lifetime risk. Three-quarters of tumors are non-muscle-invasive (formerly termed superficial) at the time of presentation. Approximately half of all non-muscle-invasive bladder cancer (NMIBC) will recur and, depending on certain prognostic factors including grade, stage and presence of carcinoma in situ, a number will progress to muscle invasion. The standard of care for NMIBC is transurethral resection of bladder tumor (TURBT) to remove the mass lesion(s). Intravesical therapy of NMIBC post-TURBT therefore aims to delay/prevent recurrence and/or progression to muscle-invasive bladder cancer. While intravesical chemotherapy, such as mitomycin C, and immunotherapy, such as bacillus Calmette-Guérin are well established, there is current interest in novel therapies based on improved molecular understanding of bladder cancer. These novel therapies include gene therapy, using viral and non-viral vectors for transfer, monoclonal antibodies and direct tumoricidal viruses. While there is a sound theoretical basis for these therapies based on molecular targeting, there is little evidence in human studies that these therapies have clinical impact on NMIBC. However, it is certain that their use will be investigated further and they provide great hope for the future of NMIBC adjuvant therapy.