BackgroundThe aims of the study were to identify the characteristics of elderly frequent attenders to the emergency department (ED) presenting with chest pain and to assess the 1-year prognosis for developing adverse cardiac events.FindingsPatients over 75 years old, with four or more attendances to the ED between 1 January 2010 and 31 December 2010 with at least one attendance due to chest pain, were selected from a database. Data was collected on demographic details, visit history, disposition and admission outcomes. Each patient was followed up for 12 months after the index episode via the hospital electronic registry for adverse cardiac outcome. Adverse cardiac outcomes included death from cardiac event, acute myocardial infarction (ST elevation myocardial infarction (STEMI)/non-ST elevation myocardial infarction (NSTEMI)) or unstable angina. A total of 158 patients with 4 or more visits to the ED accounted for 290 visits with chest pain during 2010. There is a high prevalence of coronary risk factors in this cohort (hypertension 92.4%, hyperlipidaemia 65.2%, diabetes 49.4% and smoking 26.6%). The hospital admission rate was also high at 83.5%. Over the ensuing 12 months, 8 patients died of a primary cardiac event and a further 29 patients developed 36 non-fatal cardiac events. We could not establish any significant relationship between increase in adverse cardiac outcome and individual risk factors or even two or more risk factors (P = 0.0572). Patients with two or more attendances with chest pain were more likely to develop adverse cardiac outcome (P = 0.0068).ConclusionsElderly frequent attenders to the ED, who present with chest pain, have more cardiac risk factors and are more likely to develop adverse coronary outcomes if they re-attend with chest pain.

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AimAccurate and timely prognostication of patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC) is crucial in clinical decision-making, resource allocation, and communication with family. A clinical decision tool, Survival After ROSC in Cardiac Arrest (SARICA), was recently developed, showing excellent performance on internal validation. We aimed to externally validate SARICA in multinational cohorts within the Pan-Asian Resuscitation Outcomes Study.Materials and methodsThis was an international, retrospective cohort study of patients who attained ROSC after OHCA in the Asia Pacific between January 2009 and August 2018. Pediatric (age <18 years) and traumatic arrests were excluded. The SARICA score was calculated for each patient. The primary outcome was survival. We used receiver operating characteristics (ROC) analysis to calculate the model performance of the SARICA score in predicting survival. A calibration belt plot was used to assess calibration.ResultsOut of 207,450 cases of OHCA, 24,897 cases from Taiwan, Japan and South Korea were eligible for inclusion. Of this validation cohort, 30.4% survived. The median SARICA score was 4. Area under the ROC curve (AUC) was 0.759 (95% confidence interval, CI 0.753–0.766) for the total population. A higher AUC was observed in subgroups that received bystander CPR (AUC 0.791, 95% CI 0.782–0.801) and of presumed cardiac etiology (AUC 0.790, 95% CI 0.782–0.797). The model was well-calibrated.ConclusionThis external validation study of SARICA demonstrated high model performance in a multinational Pan-Asian cohort. Further modification and validation in other populations can be performed to assess its readiness for clinical translation.

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Passive leg raise (PLR), an experimental cardiopulmonary resuscitation (CPR) technique which involves the elevation of the lower limbs from the horizontal plane during CPR, is thought to improve clinical outcomes in cardiac arrest. By comparing the use of PLR to conventional CPR, we aimed to evaluate survival outcomes and the secondary outcomes of neurologically intact survival and return of spontaneous circulation (ROSC). Methods: In this systematic review, 3 bibliographic databases (PubMed, Embase, and Cochrane Library) were searched for relevant studies from inception to May 1st, 2021. Studies were included if they reported the use of PLR during CPR. Random-effects meta-analysis was performed for the outcome of survival to 30 days. Results:The search yielded 554 articles, of which 6 met criteria for inclusion (3 animal and 3 human studies). The most common implementation of PLR was elevation of the heels corresponding to a 20-to 45-degree elevation at the hips. Two human studies reported higher survival at hospital admission for patients that underwent PLR, though not to the point of statistical significance. Two human studies reported lower ROSC and neurologically intact survival while 2 animal studies reported higher ROSC and neurologically intact survival. The pooled effect on survival to 30 days/survival to hospital discharge was not statistically significantly different (P=0.68), although our analysis showed a trend favouring PLR-CPR. Conclusion: Despite several animal studies showing benefit from PLR-CPR, there is no human data supporting its use in human cardiac arrest. Future research needs to ascertain the best positioning during CPR to optimize clinical outcomes.

Background Older adults aged 65 years and above have a disproportionately higher utilization of emergency healthcare, of which Emergency Department (ED) visits are a key component. They experience higher degree of multimorbidity and mobility issues compared to younger patients, and are consequently more likely to experience a health event which requires an ED visit. During their visit, older adults tend to require more extensive workup, therefore spending a greater amount of time in the ED. Compared to the younger population, older adults are more susceptible to adverse events following discharge. Considering these factors, investigating the determinants of ED utilisation would be valuable. In this paper, we present a protocol for a systematic review of the determinants of ED utilisation among communitydwelling older adults aged 65 years and above, applying Andersen and Newman’s model of healthcare utilisation. Furthermore, we aim to present other conceptual frameworks for healthcare utilisation and propose a holistic approach for understanding the determinants of ED utilisation by older persons. Methods The protocol is developed in accordance with the standards of Campbell Collaboration guidelines for systematic reviews, with reference to the Cochrane Handbook for Systematic Review of Interventions. Medline, Embase and Scopus will be searched for studies published from 2000 to 2020. Studies evaluating more than one determinant for ED utilisation among older adults aged 65 years and above will be included. Search process and selection of studies will be presented in a PRISMA flow chart. Statistically significant (p < 0.05) determinants of ED utilisation will be grouped according to individual and societal determinants. Quality of the studies will be assessed using Newcastle Ottawa Scale (NOS). Discussion In Andersen and Newman’s model, individual determinants include predisposing factors, enabling and illness factors, and societal determinants include technology and social norms. Additional conceptual frameworks for healthcare utilisation include Health Belief Model, Social Determinants of Health and Big Five personality traits. By incorporating the concepts of these models, we hope to develop a holistic approach of conceptualizing the factors that influence ED utilisation among older people. Systematic review registration This protocol is registered on 8 May 2021 with PROSPERO’s International Prospective Register of Systematic Reviews (CRD42021253770).

Introduction: This paper compares the usage of inhaled methoxyflurane versus traditional procedural sedation and analgesia for manipulation and reduction of acute shoulder dislocation and acute elbow dislocation in the emergency department. Methods: This was a retrospective observational study of patients who presented with either acute shoulder dislocation or acute elbow dislocation to an adult tertiary emergency department between 1 April 2018 and 30 September 2019 and underwent manipulation and reduction with either methoxyflurane or procedural sedation and analgesia. Primary outcomes of patients’ length of stay in the emergency department and secondary outcomes of duration of procedure and success of reduction on first attempt for inhaled methoxyflurane were compared against those of procedural sedation and analgesia. Results: A total of 192 patients were included in this study; 74 patients underwent reduction with methoxyflurane while 118 patients (85 acute shoulder dislocation and 33 acute elbow dislocation) underwent reduction with procedural sedation and analgesia. The median length of stay in the emergency department was significantly shorter ( P<0.001) for the methoxyflurane group (99 minutes, interquartile range (IQR) 136.8 minutes) versus the procedural sedation and analgesia group (246.5 minutes, IQR 163 minutes). The median duration of procedure in the emergency department was also significantly shorter ( P<0.001) for the methoxyflurane group (16 minutes, IQR 17 minutes) versus the procedural sedation and analgesia group (32 minutes, IQR 40.3 minutes). There was no significant difference in reduction on first attempt between the two groups. Conclusion: The use of inhaled methoxyflurane in the manipulation and reduction of acute shoulder dislocation and acute elbow dislocation was associated with a shorter patient length of stay and a shorter duration of procedure, while no significant difference was observed in the success of reduction on first attempt when compared to procedural sedation and analgesia.