Preconceptual administration of doxycycline in women with recurrent miscarriage and chronic endometritis: protocol for the Chronic Endometritis and Recurrent Miscarriage (CERM) trial, a multicentre, double-blind, placebo-controlled, adaptive randomised trial with an embedded translational substudy.

INTRODUCTION: Recurrent miscarriage is a common condition with a substantial associated morbidity. A hypothesised cause of recurrent miscarriage is chronic endometritis (CE). The aetiology of CE remains uncertain. An association between CE and recurrent miscarriage has been shown. This study will aim to determine if preconceptual administration of doxycycline, in women with recurrent miscarriages, and CE, reduces first trimester miscarriages, increasing live births. METHODS AND ANALYSIS: Chronic Endometritis and Recurrent Miscarriage is a multicentre, double-blind adaptive trial with an embedded translational substudy. Women with a history of two or more consecutive first trimester losses with evidence of CE on endometrial biopsy (defined as ≥5 CD138 positive cells per 10 mm2) will be randomised to oral doxycycline or placebo for 14 days. A subset will be recruited to a mechanistic substudy in which microbial swabs and preintervention/postintervention endometrial samples will be collected. Up to 3062 women recruited from 29 National Health Service (NHS) hospital sites across the UK are expected to be screened with up to 1500 women randomised in a 1:1 ratio. Women with a negative endometrial biopsy (defined as <5 CD138 positive cells per 10 mm2) will also be followed up to test validity of the tool. The primary outcome is live births plus pregnancies ≥24 + 0 weeks gestation at the end of the trial, in the first or subsequent pregnancy. Secondary clinical outcomes will also be assessed. Exploratory outcomes will assess the effect of doxycycline treatment on the endometrial microbiota, the differentiation capacity of the endometrium and the senescent profile of the endometrium with CE. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the NHS Research Ethics Committee Northwest-Haydock (19/NW/0462). Written informed consent will be gained from all participants. The results will be published in an open-access peer-reviewed journal and reported in the National Institute for Health and Care Research journals library. TRIAL REGISTRATION NUMBER: ISRCTN23947730.

Hip fracture surgery performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary multicentre randomized controlled trial.

Aims: To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods: This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results: Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion: Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required.

Ankle fracture internal fixation performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary, multicentre randomized controlled trial.

Aims: Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance. Methods: We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs. Results: Overall, 139 ankle fractures were fixed by 28 postgraduate year three to five trainee surgeons (mean age 29.4 years; 71% males) during ten months' follow-up. Under the intention-to-treat principle, a technically superior fixation was performed by the cadaveric-trained group compared to the standard-trained group, as measured on the first postoperative radiograph against predefined acceptability thresholds. The cadaveric-trained group used a lower intraoperative dose of radiation than the standard-trained group (mean difference 0.011 Gym2, 95% confidence interval 0.003 to 0.019; p = 0.009). There was no difference in procedure time. Conclusion: Trainees randomized to cadaveric training performed better ankle fracture fixations and irradiated patients less during surgery compared to standard-trained trainees. This effect, which was previously unknown, is likely to be a consequence of the intervention. Further study is required.

Induction of labour for predicted macrosomia: study protocol for the 'Big Baby' randomised controlled trial.

INTRODUCTION: Large-for-gestational age (LGA) fetuses have an increased risk of shoulder dystocia. This can lead to adverse neonatal outcomes and death. Early induction of labour in women with a fetus suspected to be macrosomic may mitigate the risk of shoulder dystocia. The Big Baby Trial aims to find if induction of labour at 38+0-38+4 weeks' gestation, in pregnancies with suspected LGA fetuses, reduces the incidence of shoulder dystocia. METHODS AND ANALYSIS: The Big Baby Trial is a multicentre, prospective, individually randomised controlled trial of induction of labour at 38+0 to 38+4 weeks' gestation vs standard care as per each hospital trust (median gestation of delivery 39+4) among women whose fetuses have an estimated fetal weight >90th customised centile according to ultrasound scan at 35+0 to 38+0 weeks' gestation. There is a parallel cohort study for women who decline randomisation because they opt for induction, expectant management or caesarean section. Up to 4000 women will be recruited and randomised to induction of labour or to standard care. The primary outcome is the incidence of shoulder dystocia; assessed by an independent expert group, blind to treatment allocation, from delivery records. Secondary outcomes include birth trauma, fractures, haemorrhage, caesarean section rate and length of inpatient stay. The main trial is ongoing, following an internal pilot study. A qualitative reporting, health economic evaluation and parallel process evaluation are included. ETHICS AND DISSEMINATION: The study received a favourable opinion from the South West-Cornwall and Plymouth Health Research Authority on 23/03/2018 (IRAS project ID 229163). Study results will be reported in the National Institute for Health Research journal library and published in an open access peer-reviewed journal. We will plan dissemination events for key stakeholders. TRIAL REGISTRATION NUMBER: ISRCTN18229892.

Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss.

Miscarriage is generally defined as the loss of a pregnancy before viability. An estimated 23 million miscarriages occur every year worldwide, translating to 44 pregnancy losses each minute. The pooled risk of miscarriage is 15·3% (95% CI 12·5-18·7%) of all recognised pregnancies. The population prevalence of women who have had one miscarriage is 10·8% (10·3-11·4%), two miscarriages is 1·9% (1·8-2·1%), and three or more miscarriages is 0·7% (0·5-0·8%). Risk factors for miscarriage include very young or older female age (younger than 20 years and older than 35 years), older male age (older than 40 years), very low or very high body-mass index, Black ethnicity, previous miscarriages, smoking, alcohol, stress, working night shifts, air pollution, and exposure to pesticides. The consequences of miscarriage are both physical, such as bleeding or infection, and psychological. Psychological consequences include increases in the risk of anxiety, depression, post-traumatic stress disorder, and suicide. Miscarriage, and especially recurrent miscarriage, is also a sentinel risk marker for obstetric complications, including preterm birth, fetal growth restriction, placental abruption, and stillbirth in future pregnancies, and a predictor of longer-term health problems, such as cardiovascular disease and venous thromboembolism. The costs of miscarriage affect individuals, health-care systems, and society. The short-term national economic cost of miscarriage is estimated to be £471 million per year in the UK. As recurrent miscarriage is a sentinel marker for various obstetric risks in future pregnancies, women should receive care in preconception and obstetric clinics specialising in patients at high risk. As psychological morbidity is common after pregnancy loss, effective screening instruments and treatment options for mental health consequences of miscarriage need to be available. We recommend that miscarriage data are gathered and reported to facilitate comparison of rates among countries, to accelerate research, and to improve patient care and policy development.

Current provision of simulation in the UK and Republic of Ireland trauma and orthopaedic specialist training: a national survey.

AIMS: The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation. METHODS: The development of the survey was a collaborative effort between the authors and the British Orthopaedic Association Simulation Group. The survey items were embedded in the Performance and Opportunity Dashboard, which annually audits quality in training across several domains on behalf of the Speciality Advisory Committee (SAC). The survey was sent via email to the 30 training programme directors in March 2019. Data were retrieved and analyzed at the Warwick Clinical Trials Unit, UK. RESULTS: Overall, 28 of 30 programme directors completed the survey (93%). 82% of programmes had access to high-fidelity simulation facilities such as cadaveric laboratories. More than half (54%) had access to a non-technical skills simulation training. Less than half (43%) received centralized funding for simulation, a third relied on local funding such as the departmental budget, and there was a heavy reliance on industry sponsorship to partly or wholly fund simulation training (64%). Provision was higher in the mid-stages (ST3-5) compared to late-stages (ST6-8) of training, and was formally timetabled in 68% of prostgrammes. There was no assessment of the impact of simulation training using objective behavioural measures or real-world clinical outcomes. CONCLUSION: There is currently widespread, but variable, provision of simulation in T&O training in the UK and RoI, which is likely to expand further with the new curriculum. It is important that research activity into the impact of simulation training continues, to develop an evidence base to support investment in facilities and provision.

Assessment of technical skill in hip fracture surgery using the postoperative radiograph: pilot development and validation of a final product analysis core outcome set.

AIMS: To develop a core outcome set of measurements from postoperative radiographs that can be used to assess technical skill in performing dynamic hip screw (DHS) and hemiarthroplasty, and to validate these against Van der Vleuten's criteria for effective assessment. METHODS: A Delphi exercise was undertaken at a regional major trauma centre to identify candidate measurement items. The feasibility of taking these measurements was tested by two of the authors (HKJ, GTRP). Validity and reliability were examined using the radiographs of operations performed by orthopaedic resident participants (n = 28) of a multicentre randomized controlled educational trial (ISRCTN20431944). Trainees were divided into novice and intermediate groups, defined as having performed < ten or ≥ ten cases each for DHS and hemiarthroplasty at baseline. The procedure-based assessment (PBA) global rating score was assumed as the gold standard assessment for the purposes of concurrent validity. Intra- and inter-rater reliability testing were performed on a random subset of 25 cases. RESULTS: In total, 327 DHS and 248 hemiarthroplasty procedures were performed by 28 postgraduate year (PGY) 3 to 5 orthopaedic trainees during the 2014 to 2015 surgical training year at nine NHS hospitals in the West Midlands, UK. Overall, 109 PBAs were completed for DHS and 80 for hemiarthroplasty. Expert consensus identified four 'final product analysis' (FPA) radiological parameters of technical success for DHS: tip-apex distance (TAD); lag screw position in the femoral head; flushness of the plate against the lateral femoral cortex; and eight-cortex hold of the plate screws. Three parameters were identified for hemiarthroplasty: leg length discrepancy; femoral stem alignment; and femoral offset. Face validity, content validity, and feasibility were excellent. For all measurements, performance was better in the intermediate compared with the novice group, and this was statistically significant for TAD (p < 0.001) and femoral stem alignment (p = 0.023). Concurrent validity was poor when measured against global PBA score. This may be explained by the fact that they are measuring difference facets of competence. Intra-and inter-rater reliability were excellent for TAD, moderate for lag screw position (DHS), and moderate for leg length discrepancy (hemiarthroplasty). Use of a large multicentre dataset suggests good generalizability of the results to other settings. Assessment using FPA was time- and cost-effective compared with PBA. CONCLUSION: Final product analysis using post-implantation radiographs to measure technical skill in hip fracture surgery is feasible, valid, reliable, and cost-effective. It can complement traditional workplace-based assessment for measuring performance in the real-world operating room . It may have particular utility in competency-based training frameworks and for assessing skill transfer from the simulated to live operating theatre.Cite this article: Bone Joint Open 2020;1-9:594-604.

Analysis of Tools Used in Assessing Technical Skills and Operative Competence in Trauma and Orthopaedic Surgical Training: A Systematic Review.

BACKGROUND: Robust assessment of skills acquisition and surgical performance during training is vital to ensuring operative competence among orthopaedic surgeons. A move to competency-based surgical training requires the use of tools that can assess surgical skills objectively and systematically. The aim of this systematic review was to describe the evidence for the utility of assessment tools used in evaluating operative performance in trauma and orthopaedic surgical training. METHODS: We performed a comprehensive literature search of MEDLINE, Embase, and Google Scholar databases to June 2019. From eligible studies we abstracted data on study aim, assessment format (live theater or simulated setting), skills assessed, and tools or metrics used to assess surgical performance. The strengths, limitations, and psychometric properties of the assessment tools are reported on the basis of previously defined utility criteria. RESULTS: One hundred and five studies published between 1990 and 2019 were included. Forty-two studies involved open orthopaedic surgical procedures, and 63 involved arthroscopy. The majority (85%) were used in the simulated environment. There was wide variation in the type of assessment tools in used, the strengths and weaknesses of which are assessor and setting-dependent. CONCLUSIONS: Current technical skills-assessment tools in trauma and orthopaedic surgery are largely procedure-specific and limited to research use in the simulated environment. An objective technical skills-assessment tool that is suitable for use in the live operative theater requires development and validation, to ensure proper competency-based assessment of surgical performance and readiness for unsupervised clinical practice. CLINICAL RELEVANCE: Trainers and trainees can gain further insight into the technical skills assessment tools that they use in practice through the utility evidence provided.

Cadaveric simulation versus standard training for postgraduate trauma and orthopaedic surgical trainees: protocol for the CAD:TRAUMA study multicentre randomised controlled educational trial.

INTRODUCTION: The quantity and quality of surgical training in the UK has been negatively affected by reduced working hours and National Health Service (NHS) financial pressures. Traditionally surgical training has occurred by the master-apprentice model involving a process of graduated responsibility, but a modern alternative is to use simulation for the early stages of training. It is not known if simulation training for junior trainees can safeguard patients and improve clinical outcomes. This paper details the protocol for a multicentre randomised controlled educational trial of a cadaveric simulation training intervention versus standard training for junior postgraduate orthopaedic surgeons-in-training. This is the first study to assess the effect of cadaveric simulation training for open surgery on patient outcome. The feasibility of delivering cadaveric training, use of radiographic and clinical outcome measures to assess impact and the challenges of upscaling provision will be explored. METHODS AND ANALYSIS: We will recruit postgraduate orthopaedic surgeons-in-training in the first 3 years (of 8) of the specialist training programme. Participants will be block randomised and allocated to either cadaveric simulation or standard 'on-the-job' training, learning three common orthopaedic procedures, each of which is a substudy within the trial. The procedures are (1) dynamic hip screw, (2) hemiarthroplasty and (3) ankle fracture fixation. These procedures have been selected as they are very common procedures which are routinely performed by junior surgeons-in-training. A pragmatic approach to sample size is taken in lieu of a formal power calculation as this is novel exploratory work with no a priori estimate of effect size to reference. The primary outcome measure is the technical success of the surgery performed on patients by the participating surgeons-in-training during the follow-up period for the three substudy procedures, as measured by the implant position on the postoperative radiograph. The secondary outcome measures are procedure time, postoperative complication rate and patient health state at 4 months postoperation (EQ-5D-substudies 1 and 2 only). ETHICS, REGISTRATION AND DISSEMINATION: National research ethics approval was granted for this study by the NHS Research Authority South Birmingham Research Ethics Committee (15/WM/0464). Confidentiality Advisory Group approval was granted for accessing radiographic and outcome data without patient consent on 27 February 2017 (16/CAG/0125). The results of this trial will be submitted to a peer-reviewed journal and will inform educational and clinical practice. TRIAL REGISTRATION NUMBER: ISRCTN20431944.

How Does Cadaveric Simulation Influence Learning in Orthopedic Residents?

OBJECTIVE: The objectives of this study were to understand how cadaveric simulation impacts learning in orthopedic residents, why it is a useful training tool, and how skills learnt in the simulated environment translate into the workplace. DESIGN: This is a qualitative research study using in-depth, semistructured interviews with orthopedic residents who underwent an intensive cadaveric simulation training course. SETTING: The study was conducted at the University Hospital Coventry & Warwickshire, a tertiary care center with integrated cadaveric training laboratory in England, United Kingdom. PARTICIPANTS: Orthopedic surgery residents in the intervention group of a randomized controlled trial comparing intensive cadaveric simulation training with standard "on the job" training were invited to participate. Eleven of 14 eligible residents were interviewed (PGY 3-6, 8 male and 3 female). RESULTS: Learning from cadaveric simulation can be broadly categorized into intrinsic, surgeon-driven factors, and extrinsic environmental factors. Intrinsic factors include participant ability to "buy-in" to the simulation exercise, willingness to push one's own learning boundaries in a "safe space" and take out on resident experience and self-reported confidence, with the greatest learning gains seen at around the PGY4 stage in individuals who reported low preintervention operative confidence. Extrinsic factors included; the opportunity to perform operations in their entirety without external pressures or attending "take-over," leading to subjective improvement in participant operative fluency and confidence. The intensive supervision of subspecialist attending surgeons giving real-time performance feedback, tips and tricks, and the opportunity to practice unusual approaches was highly valued by participants, as was paired learning with alternating roles as primary surgeon/assistant and multidisciplinary involvement of scrub-staff and radiographers. Cadaveric simulation added educational value beyond that obtained in low-fidelity simulation training by "stirring into practice" and "becoming through doing." In providing ultrarealistic representation of the space, ritualism, and costuming of the operating theater, cadaveric simulation training also enabled the development of a range of nontechnical skills and sociocultural "nontechnical" lessons of surgery. CONCLUSIONS: Cadaveric simulation enhances learning in both technical and nontechnical skills in junior orthopedic residents within a single training package. Direct transfer of skills learnt in the simulation training to the real-world operating theater, with consequent patient benefit, was reported. Cadaveric simulation in the UK training system of orthopedics may be of greatest utility at around the PGY 4 stage, at which point operative fluency, independence, and confidence can be rapidly improved in the cadaveric laboratory, to enable the attainment of competence in index trauma operations.

A systematic review of the diagnostic accuracy of automated tests for cognitive impairment.

OBJECTIVE: The aim of this review is to determine whether automated computerised tests accurately identify patients with progressive cognitive impairment and, if so, to investigate their role in monitoring disease progression and/or response to treatment. METHODS: Six electronic databases (Medline, Embase, Cochrane, Institute for Scientific Information, PsycINFO, and ProQuest) were searched from January 2005 to August 2015 to identify papers for inclusion. Studies assessing the diagnostic accuracy of automated computerised tests for mild cognitive impairment (MCI) and early dementia against a reference standard were included. Where possible, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios were calculated. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess risk of bias. RESULTS: Sixteen studies assessing 11 diagnostic tools for MCI and early dementia were included. No studies were eligible for inclusion in the review of tools for monitoring progressive disease and response to treatment. The overall quality of the studies was good. However, the wide range of tests assessed and the non-standardised reporting of diagnostic accuracy outcomes meant that statistical analysis was not possible. CONCLUSION: Some tests have shown promising results for identifying MCI and early dementia. However, concerns over small sample sizes, lack of replicability of studies, and lack of evidence available make it difficult to make recommendations on the clinical use of the computerised tests for diagnosing, monitoring progression, and treatment response for MCI and early dementia. Research is required to establish stable cut-off points for automated computerised tests used to diagnose patients with MCI or early dementia.

A Systematic Review of the Prevalence and Types of Adverse Events in Interfacility Critical Care Transfers by Paramedics.

OBJECTIVE: The aim of this study was to investigate if paramedics can safely transfer interfacility critically ill adult patients and to determine the prevalence and types of adverse events when paramedics lead interfacility critical care transfers. METHODS: MEDLINE, Web of Science, Embase, and CINAHL databases were searched from 1990 up to February 2016. Eligibility criteria were adult patients (16 years and over), interfacility transfer (between two health care facilities), quantitative or qualitative description of adverse events, and a paramedic as the primary care provider or the sole health care provider. RESULTS: Seven publications had paramedics as the sole health care provider conducting interfacility critical care transfers. All seven studies were observational studies published in the English language. The study duration ranged from 14 months to 10 years. The frequency of adverse events seen by paramedics in interfacility transfers ranges from 5.1% to 18%. CONCLUSION: There is a gap in literature on the safety and adverse events in interfacility transfers by paramedics. The prevalence of in-transit adverse events is well established; however, because the published literature is lacking longitudinal monitoring of patients and only reporting in-transit events, we believe that further research in this area might provide the basis of paramedics safety in interfacility transfers.

Automated tests for diagnosing and monitoring cognitive impairment: a diagnostic accuracy review.

BACKGROUND: Cognitive impairment is a growing public health concern, and is one of the most distinctive characteristics of all dementias. The timely recognition of dementia syndromes can be beneficial, as some causes of dementia are treatable and are fully or partially reversible. Several automated cognitive assessment tools for assessing mild cognitive impairment (MCI) and early dementia are now available. Proponents of these tests cite as benefits the tests' repeatability and robustness and the saving of clinicians' time. However, the use of these tools to diagnose and/or monitor progressive cognitive impairment or response to treatment has not yet been evaluated. OBJECTIVES: The aim of this review was to determine whether or not automated computerised tests could accurately identify patients with progressive cognitive impairment in MCI and dementia and, if so, to investigate their role in monitoring disease progression and/or response to treatment. DATA SOURCES: Five electronic databases (MEDLINE, EMBASE, The Cochrane Library, ISI Web of Science and PsycINFO), plus ProQuest, were searched from 2005 to August 2015. The bibliographies of retrieved citations were also examined. Trial and research registers were searched for ongoing studies and reviews. A second search was run to identify individual test costs and acquisition costs for the various tools identified in the review. REVIEW METHODS: Two reviewers independently screened all titles and abstracts to identify potentially relevant studies for inclusion in the review. Full-text copies were assessed independently by two reviewers. Data were extracted and assessed for risk of bias by one reviewer and independently checked for accuracy by a second. The results of the data extraction and quality assessment for each study are presented in structured tables and as a narrative summary. RESULTS: The electronic searching of databases, including ProQuest, resulted in 13,542 unique citations. The titles and abstracts of these were screened and 399 articles were shortlisted for full-text assessment. Sixteen studies were included in the diagnostic accuracy review. No studies were eligible for inclusion in the review of tools for monitoring progressive disease. Eleven automated computerised tests were assessed in the 16 included studies. The overall quality of the studies was good; however, the wide range of tests assessed and the non-standardised reporting of diagnostic accuracy outcomes meant that meaningful synthesis or statistical analysis was not possible. LIMITATIONS: The main limitation of this review is the substantial heterogeneity of the tests assessed in the included studies. As a result, no meta-analyses could be undertaken. CONCLUSION: The quantity of information available is insufficient to be able to make recommendations on the clinical use of the computerised tests for diagnosing and monitoring MCI and early dementia progression. The value of these tests also depends on the costs of acquisition, training, administration and scoring. FUTURE WORK: Research is required to establish stable cut-off points for automated computerised tests that are used to diagnose patients with MCI or early dementia. Additionally, the costs associated with acquiring and using these tests in clinical practice should be estimated. STUDY REGISTRATION: The study is registered as PROSPERO CRD42015025410. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Does the use of dedicated dispatch criteria by Emergency Medical Services optimise appropriate allocation of advanced care resources in cases of high severity trauma? A systematic review.

BACKGROUND AND OBJECTIVES: The deployment of Enhanced Care Teams (ECTs) capable of delivering advanced clinical interventions for patients at the scene of incidents is commonplace by Emergency Medical Services in most developed countries. It is unclear whether primary dispatch models for ECT resources are more efficient at targeting deployment to patients with severe trauma than secondary dispatch, following requests from EMS personnel at scene. The objective of this study was to review the evidence for primary and secondary models in the targeted dispatch of ECT resources to patients with severe traumatic injury. METHODS: This review was completed in accordance with a protocol developed using the PRISMA guidelines. We conducted a search of the MEDLINE, EmBase, Web of Knowledge/Science databases and the Cochrane library, focussed on subject headings and keywords involving the dispatch of ECT resources by Emergency Medical Services. Design and results of each study were described. Heterogeneity in the design of the included studies precluded the completion of a meta-analysis. A narrative synthesis of the results therefore was performed. RESULTS: Five hundred and forty-eight articles were screened, and 16 were included. Only one study compared the performance of the different models of dispatch. A non-statistically significant reduction in the length of time for HEMS resources to reach incident scenes of 4min was found when primary dispatch protocols were utilised compared to requests from EMS personnel at scene. No effect on mortality; severity of injury or proportion of patients admitted to intensive care was observed. The remaining studies examined the processes utilised within current primary dispatch models but did not perform any comparative analysis with existing secondary dispatch models. CONCLUSIONS: This review identifies a lack of evidence supporting the role of primary dispatch models in targeting the deployment of Enhanced Care Teams to patients with severe injuries. It is therefore not possible to identify a model for ECT dispatch within pre-hospital systems that optimises resource utilisation. Further studies are required to assess the efficiency of systems utilised at each stage of the process used to dispatch Enhanced Care Team resources to incidents within regionalised pre-hospital trauma systems.

An autonomous role in emergency departments.

Heart of England NHS Foundation Trust, which manages 250,000 patients in three emergency units each year, has created an advanced clinical practitioner (ACP) role to ensure that patients can be seen in a timely manner as demand for emergency services continues to rise. Advanced clinical practitioners are non-medical clinicians who eventually work autonomously at the level of middle-grade doctors and manage patients with all types of clinical presentations in the emergency department (ED). This article provides an overview of the development and benefits of the ACP role and outlines the phases of a programme for staff who wish to achieve senior clinician status in the ED.

Immigrant women's perceptions of their maternity care: a review of the literature. Part 2.

In the first of this two part article, the methods of the literature review looking at immigrant women's perceptions of their maternity were outlined along with the first two themes identified, including communication and impediments to access of maternity care. In this concluding part, the remaining three themes of the literature review will be discussed and conclusions will be drawn, with recommendations for practice.

Immigrant women's perceptions of their maternity care: a review of the literature part 1.

Every year since 2004, the Office for National Statistics (ONS) has recorded increasing levels of immigration with nearly 600,000 immigrants entering the UK in 2011 (ONS 2012). More than 50 per cent of these immigrants were women. With this increasing immigration to the UK, a review of the literature was conducted to understand the experiences that immigrant women have when encountering the maternity services in the UK. Twelve quantitative and qualitative studies were included in the review, each approach contributing uniquely to our understanding of the subject area. Five themes were identified when the articles in the review were analysed. They were: communication, impediments to accessing healthcare, relationships with healthcare providers, cultural standpoint and social circumstances. The first two of those themes will be considered in this article.

Good intentions, increased inequities: developing social care services in Emergency Departments in the UK.

Addressing the quality of services provided in Emergency Departments (EDs) has been a central area of development for UK government policy since 1997. Amongst other aspects of this concern has been the recognition that EDs constitute a critical boundary between the community and the hospital and a key point for the identification of social care needs. Consequently, EDs have become the focus for a variety of service developments which combine the provision of acute medical and nursing assessment and care with a range of activities in which social care is a prominent feature. One approach to this has been the establishment of multidisciplinary teams aiming to prevent re-attendance or admission, re-direct patients to other services, or speed patients through EDs with the aim of providing improved quality of care. This study, carried out between September 2007 and April 2008, was the first UK national survey of social care initiatives based in EDs and aimed to determine the objectives, organisation, extent, functions, funding and evidence on outcomes of such interventions. Eighty-three per cent of UK Type I and II EDs responded to the survey. Approximately, one-third of EDs had embedded social care teams, with two-thirds relying on referrals to external social care services. These teams varied in their focus, size and composition, leadership, availability, funding and permanence. As a result, the unintended effect has been to increase inequities in access to social care services through EDs. Three further conclusions are drawn about policy led, locally-based service development. This survey adds to international evidence pointing to the potential benefits of a variety of social care interventions being based in EDs and justifies the establishment of a research programme which can provide answers to key outstanding questions.

Hospital consultants breaking bad news with simulated patients: an analysis of communication using the Roter Interaction Analysis System.

OBJECTIVE: To explore how experienced clinicians from wide ranging specialities deliver bad news, and to investigate the relationship between physician characteristics and patient centredness. METHODS: Consultations involving 46 hospital consultants from 22 different specialties were coded using the Roter Interaction Analysis System. RESULTS: Consultants mainly focussed upon providing biomedical information and did not discuss lifestyle and psychosocial issues frequently. Doctor gender, age, place of qualification, and speciality were not significantly related to patient centredness. CONCLUSION: Hospital consultants from wide ranging specialities tend to adopt a disease-centred approach when delivering bad news. Consultant characteristics had little impact upon patient centredness. Further large-scale studies are needed to examine the effect of doctor characteristics on behaviour during breaking bad news consultations. PRACTICE IMPLICATIONS: It is possible to observe breaking bad news encounters by video-recording interactions between clinicians and simulated patients. Future training programmes should focus on increasing patient-centred behaviours which include actively involving patients in the consultation, initiating psychosocial discussion, and providing patients with opportunities to ask questions.