皇家联合医院

AIMS:The ARREST trial demonstrated that in adult patients, transfer to a cardiac catheter laboratory in a cardiac arrest centre (CAC) following resuscitated out-of-hospital cardiac arrest (OHCA) without ST-elevation did not reduce deaths at 30 days compared with delivery to the geographically closest emergency department (standard care). More than half of the CACs had a co-located emergency department to which patients were delivered as part of the standard care arm, which may have influenced outcomes. AIMS:We performed a pre-specified as-treated analysis to determine if a CAC and the location patients were delivered to, either emergency department or cardiac catheter laboratory, reduced deaths. METHODS AND RESULTS:Patients (aged ≥18 years) with resuscitated OHCA without ST elevation who were enrolled in the ARREST trial were grouped according to the location they were to delivered to- either an emergency department with or without a co-located CAC or a cardiac catheter laboratory within a CAC-at one of 35 hospitals in London, UK-by London Ambulance Service irrespective of randomized allocation. The as-treated population was therefore analysed as one of three groups: 1) emergency department in a CAC, 2) direct to a cardiac catheter laboratory in a CAC, and 3) emergency department in a non-CAC. The primary outcome of the trial was all-cause mortality at 30 days. Secondary outcomes included all-cause mortality at 3 months and neurological outcome at discharge and 3 months. A pre-specified analysis adjusting for age, sex, initial shockable rhythm, witnessed cardiac arrest, bystander CPR, the time from cardiac arrest until ROSC, and location of cardiac arrest was performed in the as-treated groups. Between 15 January 2018 and 1 December 2022, a total of 862 participants were enrolled into the trial. Data for the primary outcome for this analysis were available in 818/862 (94.9%). Patients delivered to an ED in a CAC had fewer deaths at 30 days compared with the ED in a non-CAC group (83/182, 45.6% vs. 178/233, 76.4%; adjusted OR 0.43, 95% CI 0.24 to 0.76; P = 0.0039). Patients delivered to a cardiac catheter laboratory in a CAC also had fewer deaths compared with the ED in a non-CAC group, but there was no statistical difference (250/403, 62.0%: adjusted OR 0.72, 95% CI 0.44 to 1.18; P = 0.19). Survival with a favourable neurological outcome at hospital discharge occurred in 88/177 (49.7%) of the ED in a CAC group, 130/406 (32%) of the catheter laboratory in a CAC group, and 42/228 (18.4%) of the ED in a non-CAC group. CONCLUSION:In this as-treated analysis of the ARREST trial, in adult patients with resuscitated OHCA without ST-elevation, we observed a lower 30-day mortality and favourable neurological outcomes following delivery to an ED in a CAC and cardiac catheter laboratory in CAC, when compared with delivery to ED in a non-CAC.

Consultant Nurse (CN) roles were introduced in the United Kingdom (UK) in 1999 to enhance clinical leadership and patient care by keeping senior nurses focused on clinical practice. Defined by the Royal College of Emergency Medicine (RCEM) and Royal College of Nursing (RCN) [1], CNs are clinical experts in emergency nursing who lead on policy, research, education, and advancing practice. UK workforce standards mandate that every Emergency Department (ED) employs at least one CN at a senior pay, with additional roles in sub-specialties like paediatric emergency care. In practice these roles are undertaken by both nurses and allied health professionals. While the roles share the core functions of clinical practice, leadership, education, and research, their implementation varies. Policy initiatives such as workforce plans and a consultant-level practice capability framework have aimed to standardise and expand these roles. However, role configuration, pay, and qualifications continue to vary. Despite some evidence of positive impacts on clinical outcomes, the evidence base is limited, and inconsistent role definitions and integration into workforce planning have hindered implementation. Aim/Methods This study aimed to identify consultant nurse/practitioners in United Kingdom emergency care and describe their roles in EDs. A cross-sectional survey was developed, peer-reviewed, and distributed via professional networks, snowball sampling, and social media. Survey was administered via REDCap and was open June-August 2024. Results Thirty-seven survey responses were analysed, gathering data on demographics, confidence levels, and time spent in each domain. Consultant nurses/practitioners spent most time in expert clinical practice and least in research and innovation, reflecting lower confidence in research and fewer grant applications or publications. Respondents collectively had 299 years of experience, indicating a highly skilled workforce. Conclusion This study offers the first updated demographic review of consultant nurse and practitioner roles in UK emergency care since 2005, revealing workforce shortfalls and role variation. Despite a skilled workforce, reasons for under-recruitment remain unclear. The findings highlight the need for further research to guide workforce planning and optimise consultant-level practice in emergency care.

Increased right ventricle to left ventricle (RV:LV) ratio in acute pulmonary embolism (PE) indicates right heart strain (RHS), a marker of poor prognosis.1,2 RV:LV ratio is unreliably reported in CT pulmonary angiography (CTPA) despite its importance in risk stratification.3 Automated measurement could improve reporting consistency and influence patient care. To retrospectively compare the performance of an artificial intelligence (AI) automated RV:LV quantification software with routine and expert thoracic radiologist assessment. To assess its potential clinical impact on acute PE risk stratification and patient management in line with European Society of Cardiology guidelines.2 Retrospective, single-centre analysis of 114 consecutive CTPAs (Dec 2022-Nov 2023) confirmed PE-positive by an expert thoracic radiologist. RV:LV ratios were measured retrospectively by the expert thoracic radiologist and AI using contrast-enhanced axial slices. RHS was defined as an expert RV:LV ratio >1.0 and an AI derived RV:LV ratio >1.18, in keeping with previous research.4 Original CT reports were interrogated for mention of RHS by two senior clinicians. Cohen’s kappa (κ) evaluated their agreement. Clinical outcome data was extracted from electronic health records. Sensitivity, intraclass correlation coefficient (ICC), and Kaplan-Meier analyses evaluated performance and one year survival. RV:LV ratios were measurable for 108/114 (95%) CTPAs. Mean RV:LV ratios for expert and AI were 1.09 (range 0.58-2.12) and 1.17 (0.56-2.97) respectively. ICC was 0.78 (p<0.01) indicating good agreement between methods although systematic bias in AI measurements was present (mean difference = 0.09 [-0.28, 0.46]). RHS was mentioned in 92/114 (81%) initial reports (RHS-positive 27/92 [29%], RHS-negative 65/92 [71%]; κ = 0.99). AI would have reclassified RHS in 18 patients: upgrading 16 to RHS-positive and downgrading 2 to RHS-negative (Figure 1). The expert review reclassified 17 additional scans as RHS-positive deemed RHS-negative by AI. The sensitivity and specificity of AI RV:LV ratio >1.18 for detecting RHS compared to expert radiologist were 0.70 (95% CIs 0.56-0.81) and 0.92 (95% CIs 0.81-0.98). Risk stratification using an AI RV:LV ratio >1.18 upgraded 3 patients from low to high risk and downgraded 1 patient from high to low risk compared to the initial CT reports. Complete risk stratification was limited by missing troponin data. This was only available in 73/114 (64%) cases. AI derived RV:LV ratio >1.18 significantly improved prediction of one year survival (p = 0.04) compared to initial radiologist assessment of RHS (p = 0.31) (Figure 2). AI derived RV:LV ratio calculation is reliable, offering better evaluation of RHS compared to initial radiologist report. AI derived RV:LV ratio >1.18 is a poor prognostic marker of all-cause mortality and should be used with other means of risk stratification to inform patient care.

Background Novel non-invasive or minimally invasive diagnostic tests for endometriosis are a research priority. Superficial peritoneal endometriosis, the most prevalent subtype of endometriosis (80% of all laparoscopically diagnosed disease), currently eludes reliable detection by standard imaging techniques (eg, transvaginal ultrasound and MRI). We aimed to evaluate the diagnostic potential and accuracy of 99mTc-maraciclatide, a gamma-emitting radiotracer that binds to αvβ3 integrins for imaging inflammatory diseases, in people with endometriosis. Methods The DETECT study was a prospective, single-centre, exploratory, open-label, non-randomised, phase 2 study in a tertiary hospital setting that generated single-photon-emission CT-CT (SPECT-CT) imaging data before surgery (the reference standard). The Women's Centre and Oxford Endometriosis CaRe Centre (University of Oxford, Oxford, UK) served as the recruiting site, with scans performed at the Royal United Hospital (Bath, UK). Female participants aged 18 years and older with confirmed or suspected endometriosis based on previous clinical investigation and who were due to have a diagnostic or therapeutic laparoscopy or thoracoscopic surgery were recruited to the study. Participants underwent preoperative imaging with 10-min or 20-min SPECT-CT, with intravenous 99mTc-maraciclatide administered as a bolus followed by saline flush. The primary outcome was agreement of radiological and surgical findings in participants completing both imaging and surgery and was assessed per protocol. The surgical report and World Endometriosis Research Foundation surgical form on lesion type and location were compared with images for alignment. Safety was assessed in all participants who underwent the SPECT-CT scan from the time of administering 99mTc-maraciclatide and for the duration of the imaging day. The study is registered with ClinicalTrials.Gov, NCT05623332, and is active. Findings Between March 6, 2023, and Sept 16, 2024, 20 participants were recruited and imaged. Of the 20 participants recruited, 17 (85%) underwent laparoscopy and two (10%) had thoracoscopy after SPECT-CT imaging. Imaging results were concordant with the surgical presence or absence of endometriosis in 16 (84%, 95% CI 60–97) of the 19 participants who completed the study, with endometriosis imaged in 14 (82%) of 17 surgically positive participants, including two participants with thoracic endometriosis. Although the study was not powered for definitive diagnostic accuracy, participant-level sensitivity was calculated to be 82% (95% CI 57–96) and specificity to be 100% (16–100). There were no serious adverse events during the study or adverse events that resulted in participant withdrawal from the study. Interpretation The DETECT study highlights the potential of imaging with 99mTc-maraciclatide to identify endometriosis, especially superficial peritoneal endometriosis. If the effectiveness of this technique is supported in a larger study, there might be a role for 99mTc-maraciclatide as a novel diagnostic tool for endometriosis. Funding National Institute for Health and Care Research Oxford Biomedical Research Centre and Serac Healthcare