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In elite football, the emphasis is placed on monitoring the output from the Global Positioning Systems (GPS) component of a Micro-Electro-Mechanical Systems (MEMS) device; however, this does not comprehensively overview the total demands due to the intermittent multidirectional nature. The aim of the study was to investigate the application of accelerometer data provided by MEMS, to evaluate movement requirements in elite football. A two-staged research approach, involving an effectiveness and efficacy stage, was deployed. The effectiveness stage examined two MEMS-accelerometer variables (PlayerLoadTM (PL) and PlayerLoadTM per meter (PL.m-1)) for four years and four months. Ninety-nine English Premier League outfield football players' participated. In the efficacy stage, 26 elite outfield football players completed three different training modalities (running, possession and dribbling) and a range of MEMS-accelerometer variables were analysed. In the effectiveness stage, the mean difference in PL for all training activities other than Set Pieces were similar to Matches (-283 to -246au). Model coefficients for PL.m-1 were smallest in Team Shape (-0.00114au), Attacking (0.00025au) and Games (0.00196au), and largest for Possession (0.03356AU), Defending (0.03182au) and Skills Games (0.03106au) compared to Matches. The findings suggest that PL.m-1 but not PL may be effective at describing differences in movement requirements. In the efficacy stage, PL.m-1 and inertial movement analysis (IMA) efforts were the only variables that had greater mean differences in the smaller conditions, confirming PL.m-1's suitability in evaluating movement requirements of different training activities and pitch dimensions. The findings suggest such a variable offers value in a monitoring strategy in football.

The Prevent Alcohol and Risk-related Trauma in Youth (P.A.R.T.Y.) program is an immersive hospital-based education program designed to reduce trauma in adolescents. The efficacy of the program in reducing risk-taking attitudes and preventing traumatic injuries has been proven through various methodologies. However, there is currently no study that has investigated the efficacy of the program using a validated, multi-domain questionnaire. This study outlines the design of the P.A.R.T.Y. Program Questionnaire (PPQ) and validates it through examining its construct and criterion validity as well as its internal consistency. Its capacity to risk-stratify participants was compared against the RT-18, a robust, 18-item risk-profiling instrument. The PPQ and the RT-18 were completed by New South Wales school students (N = 458) aged 15 to 18. The PPQ was designed in consultation with relevant field experts to optimise engagement and sensitivity. Examination of the construct validity of the PPQ was performed through exploratory factor analysis which demonstrated the presence of two underlying factors which aligned with the constructed two-scenario questionnaire format. The PPQ was shown to be internally consistent with a Cronbach's alpha of 0.77. Individual scenarios were shown to be internally consistent as well (α = 0.69, α = 0.66). The PPQ also identified high risk and low risk participants effectively as demonstrated by comparison against the risk stratification performed with the RT-18 (p-value0.001). This suggests the PPQ demonstrates criterion validity. Hence, the PPQ is an effective and valid tool for assessing risk-taking attitudes in adolescent populations.

OBJECTIVE Patients intubated in the ED are at an increased risk of post-intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. METHODS This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre- and post-intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre- and post-intubation was the primary measure of haemodynamic stability. RESULTS From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre-intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose-dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. CONCLUSION Propofol was associated with post-intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post-intubation hypotension.

We aimed to determine, in those who present to the ED with low back pain (LBP): (i) the prevalence of four key diagnostic categories, (ii) trends in lumbar imaging from 2015 to 2019 and (iii) the effect of a new model of care on lumbar imaging in the ED.We conducted a retrospective analysis of routinely collected medical data of four tertiary hospitals in Sydney, Australia. We analysed ED presentations for LBP between January 2012 and October 2019. Outcomes were the prevalence of four key diagnostic categories of LBP and use of lumbar imaging. We examined trends in lumbar imaging over time and used interrupted time series analysis to determine the impact of model of care implementation on imaging use.There were 31 168 presentations for LBP of which 64.5% were non-specific LBP, 27.2% were problems beyond the spine, 5.3% were LBP with neurological signs and 2.3% were serious spinal conditions. 28.9% received lumbar imaging; use did not change substantially between 2012 and 2019. Patients diagnosed with serious spinal conditions were more likely to receive imaging (59%) than those diagnosed with non-specific LBP (29%). Implementation of a state-wide model of care in November 2016 did not appear to influence imaging use.Most presentations to the ED for LBP are for non-specific LBP. Around 2% will have specific spinal pathology. Use of imaging in those diagnosed with non-specific LBP remains high and was unaffected by implementation of a state-wide model of care.

IntroductionVasopressor use is an important facet of septic shock management, in order to maintain hemodynamic targets and end organ perfusion. Traditionally, Noradrenaline has been the ‘gold standard’ drug of choice for septic shock. Metaraminol is an alternative vasopressor that has been used for septic shock. However, there has been minimal research in comparing the two drugs in septic patients, particularly with regards to total time spent on infusion. ObjectivesTo compare total time spent on either Metaraminol or Noradrenaline infusion by septic shock patients, whilst adjusting for baseline severity of illness. Secondary outcomes included incidence of mechanical ventilation and new requirement of renal replacement therapy, and mortality. MethodsA retrospective medical records review was undertaken, looking at all septic shock patients admitted to ICU in 2019, who received either Metaraminol or Noradrenaline. Data extracted from eRIC (the ICU database) included total time spent on infusion, APACHE III scores, incidence of mechanical ventilation, incidence of renal replacement therapy, and mortality. ResultsOur review yielded 174 patients who were eligible for further statistical analysis (63 in Metaraminol group, and 111 in the Noradrenaline group). The mean duration of infusion in the Metaraminol group was 1655 minutes, and 2663 minutes in the Noradrenaline group. The mean APACHE III Scores were 62 in the Metaraminol group and 77 in the Noradrenaline group. A one-way ANCOVA test found that there was a statistically significant [F(1, 171)=4.511, p=0.035] reduction in time spent on Metaraminol infusion, compared with Noradrenaline, after adjusting for baseline severity of illness by way of APACHE III Score. ConclusionOur study found a statistically significant reduction in time spent on a Metaraminol infusion compared with Noradrenaline by septic shock patients, after controlling for severity of illness. However, due to its retrospective study design, we were unable to account for bias and confounders, such as antibiotic and fluid administration, or clinician preference for one drug over the other. Nevertheless, our study adds to the paucity of literature comparing Metaraminol to Noradrenaline, and paves the way for future randomized trials comparing the two drugs in septic shock.

Background The potential for the co-existence of genetically disparate cells (microchimerism) and associated cytokine profiles following red blood cell (RBC) transfusion in trauma patients has not been well characterized to date. This study investigated the incidence of surviving donor white blood cells (known as transfused-associated microchimerism (TAM)) and cytokine changes following blood transfusion in trauma patients. Study design and methods Trauma patients with an injury severity score (ISS) >12 who had been transfused between 2012–2016 with at least 5 units of RBC units over a 4 h period were recruited. Trauma patients with ISS > 12 who did not require blood transfusion were recruited as controls. The incidence of TAM was determined using a panel of insertion/deletion (InDel) bi-allelic polymorphisms. Selected pro- and anti-inflammatory cytokine profiles were analyzed using cytometric bead array. Results The transfused cohort (n = 40) had median ISS of 28 [12–66], received a median of 11 RBC units [4–114] and had median hospital length of stay of 35 days [1–152]. Only 11 (27.5%) patients returned for follow-up blood sampling after discharge. Of these, one patient showed an InDel pattern indicating the presence of TAM. No patients in the control cohort (n = 49) showed TAM. Cytokines IL-10 and IL-6 were found to be elevated in the transfused trauma patients. Conclusion In this cohort, TAM was found to occur in one patient of the 11 who received a blood transfusion. Elevated IL-6 and IL-10 cytokines were detected in those patients who were transfused. However, the incidence of TAM could not be correlated with the elevated cytokine profiles for this cohort.

BackgroundDetermining the severity of COVID-19 remains an unmet medical need. Our objective was to develop a blood-based host-gene-expression classifier for the severity of viral infections and validate it in independent data, including COVID-19.MethodsWe developed the classifier for the severity of viral infections and validated it in multiple viral infection settings including COVID-19. We used training data (N=705) from 21 retrospective transcriptomic clinical studies of influenza and other viral illnesses looking at a preselected panel of host immune response messenger RNAs.ResultsWe selected 6 host RNAs and trained logistic regression classifier with a cross-validation area under curve of 0.90 for predicting 30-day mortality in viral illnesses. Next, in 1,417 samples across 21 independent retrospective cohorts the locked 6-RNA classifier had an area under curve of 0.91 for discriminating patients with severe vs. non-severe infection. Next, in independent cohorts of prospectively (N=97) and retrospectively (N=100) enrolled patients with confirmed COVID-19, the classifier had an area under curve of 0.89 and 0.87, respectively, for identifying patients with severe respiratory failure or 30-day mortality. Finally, we developed a loop-mediated isothermal gene expression assay for the 6-messenger-RNA panel to facilitate implementation as a rapid assay.ConclusionsWith further study, the classifier could assist in the risk assessment of COVID-19 and other acute viral infections patients to determine severity and level of care, thereby improving patient management and reducing healthcare burden.

Purpose: Determine the repeatability of and optimum stimulus parameters for testing polarization pattern perception in a real-world clinical population, and assess the ability of polarization perception to distinguish normal from abnormal eyes. Methods: Polarization perception was evaluated in staff and patients attending ophthalmology clinics at Warwick Hospital, UK. A series of visual stimuli were presented in pseudorandom order using a liquid-crystal-display–based polarization pattern generator. Stimuli included geometric patterns, gratings, checkerboards, and optotypes. Participants had one or both eyes diagnosed as normal or abnormal following ophthalmic examination, optical coherence tomography, and measures of visual acuity. Measurement scores were assigned to the eye(s) of each participant depending on the total number of stimuli perceived or identified. Results: Stimuli covered the range of spatial scales resolvable within polarization perception by normal and abnormal eyes. Different stimuli had different saliencies. For each stimulus type, polarization perception in the abnormal group was significantly reduced compared with normal eyes (P < 0.001). Relative stimulus salience was broadly similar for normal-eye and abnormal-eye viewing groups, being greatest for radially symmetric patterns and least for optotypes. Checkerboard pattern salience had an inverse logarithmic relationship with check fundamental spatial frequency. A devised metric covering the dynamic range of polarization perception was repeatable, and the score derived from the metric was reduced in the abnormal group compared with the normal group (P < 0.001). Conclusions: Clinically useful metrics of polarization perception distinguish between normal and abnormal eyes. Translational Relevance: Perception of spatial patterns formed of non-uniform polarization fields has potential as a quantitative clinical diagnostic measurement

Objective To assess the differences in the types of injuries sustained by surfboard and bodyboard riders and to identify common mechanisms of injury. Methods Subjects were prospectively recruited to the study on presentation to one of the six hospital emergency departments. Consented subjects completed a questionnaire while in the emergency departments. Data regarding radiological investigations undertaken and their findings were collected retrospectively. Results A total of 224 males and 28 females in the surfing group and 14 males in the bodyboard group were recruited. In surfers, the most common injured body parts were the head/face (115; 45.6%) and lower limb (69; 27.4%). Surfers were most commonly injured by a surfboard, either their own (178; 70.6%) or someone else’s (18; 7.1%). Unfortunately, the small number of subjects recruited to the bodyboard group precluded meaningful comparison with the surfing group. Conclusions The most common body part injured in surfers is the head/face compared with the lower limbs in bodyboard riders. Contact with a surfer’s board (most commonly their own) is the most common cause of injury. Significant spinal fractures/injuries are sustained when the surfer (usually their head) strikes the seafloor. Head and facial fractures occur when the surfer is struck by their own board. Future research into surfboard design which incorporates softer compounds into the deck, rail, and fins is recommended. The need for local authorities and surf lifesavers to disseminate information relating to specific beaches to the general public regarding surf conditions, water depth, and the nature of the seafloor is also essential for injury prevention.

Background While major progress has been made to establish diagnostic tools for the diagnosis of SARS-CoV-2 infection, determining the severity of COVID-19 remains an unmet medical need. With limited hospital resources, gauging severity would allow for some patients to safely recover in home quarantine while ensuring sicker patients get needed care. We discovered a 5 host mRNA-based classifier for the severity of influenza and other acute viral infections and validated the classifier in COVID-19 patients from Greece. Methods We used training data (N=705) from 21 retrospective clinical studies of influenza and other viral illnesses. Five host mRNAs from a preselected panel were applied to train a logistic regression classifier for predicting 30-day mortality in influenza and other viral illnesses. We then applied this classifier, with fixed weights, to an independent cohort of subjects with confirmed COVID-19 from Athens, Greece (N=71) using NanoString nCounter. Finally, we developed a proof-of-concept rapid, isothermal qRT-LAMP assay for the 5-mRNA host signature using the QuantStudio 6 qPCR platform. Results In 71 patients with COVID-19, the 5 mRNA classifier had an AUROC of 0.88 (95% CI 0.80-0.97) for identifying patients with severe respiratory failure and/or 30-day mortality (Figure 1). Applying a preset cutoff based on training data, the 5-mRNA classifier had 100% sensitivity and 46% specificity for identifying mortality, and 88% sensitivity and 68% specificity for identifying severe respiratory failure. Finally, our proof-of-concept qRT-LAMP assay showed high correlation with the reference NanoString 5-mRNA classifier (r=0.95). Figure 1. Validation of the 5-mRNA classifier in the COVID-19 cohort. (A) Expression of the 5 genes used in the logistic regression model in patients with (red) and without (blue) mortality. (B) The 5-mRNA classifier accurately distinguishes non-severe and severe patients with COVID-19 as well as those at risk of death. Conclusion Our 5-mRNA classifier demonstrated very high accuracy for the prediction of COVID-19 severity and could assist in the rapid, point-of-impact assessment of patients with confirmed COVID-19 to determine level of care thereby improving patient management and healthcare burden. Disclosures ljubomir Buturovic, PhD, Inflammatix Inc. (Employee, Shareholder) Purvesh Khatri, PhD, Inflammatix Inc. (Shareholder) Oliver Liesenfeld, MD, Inflammatix Inc. (Employee, Shareholder) James Wacker, n/a, Inflammatix Inc. (Employee, Shareholder) Uros Midic, PhD, Inflammatix Inc. (Employee, Shareholder) Roland Luethy, PhD, Inflammatix Inc. (Employee, Shareholder) David C. Rawling, PhD, Inflammatix Inc. (Employee, Shareholder) Timothy Sweeney, MD, Inflammatix, Inc. (Employee)

The WHO declared COVID-19 a global pandemic on 11 March 2020.1 On 20 and 23 March 2020, faced with a rising number of both COVID-19 cases and deaths, the UK government imposed a range of measures in an attempt to control the pandemic in the UK. Although individuals were allowed to run and cycle outdoors, these instructions effectively put sport on hold, resulting in widespread training disruption to the elite athlete population. The chief medical officers of many of the major Olympic, Paralympic and Professional Sports in the UK formed a group to share thinking around how elite sport might best plan for a return at the appropriate time. While it was acknowledged that there were fundamental differences between the sports, including but not limited to current and future competition schedules, financial and personnel resources, potential risks of COVID-19 transmission between participants and their ability to align with any relaxation of population social distancing (SD), a collaborative approach to planning ‘how’ elite sport might restart was agreed to be the most effective manner to inform a single dialogue with government and Public Health England. Central to this approach was the development of a five-stage model (figure 1) that set out the discrete stages that sport would need to progress through, to ultimately return to unrestricted competition, starting with stages with a lower risk of COVID-19 transmission. It was hoped that this model would help create a consistent taxonomy when …

The commercial activity of any elite football organisation is related to the successful performance of the team in their competitive fixtures. The desire to win has created support systems in elite football organisations that specialise in sports medicine and science. The role of these individuals is to plan and implement strategies that both maximise performance and reduce the burden of injury on the team. These performance teams are frequently managed by a performance director. This position broadly focuses on the management of the high-performance support group, bringing both leadership and co-ordinated direction to the different components of a multi-disciplinary team and facilitating communication of significant performance issues to the organisations hierarchy (executives, coaches, and players). This chapter aims to provide a critical insight into both the role of the performance director in elite football as well as a discussion of the role that sports science and medicine can play in supporting performance.

ObjectivesTo establish the proportion of mild traumatic brain injury (mTBI) diagnosis among people presenting to an emergency department (ED), to determine the accuracy of recorded ED diagnoses. We also aimed to describe challenges in mTBI case identification and its acute hospital management.Design and settingA retrospective chart review of all ED attendances to a major trauma hospital, over a 9-month period (June 2015–February 2016).ParticipantsAdults aged 18–65 years consecutively presenting to an ED.Primary outcome measuresProportion of mTBI diagnosis among ED attendances (ie, confirmed mTBI based on the WHO criteria or indeterminate mTBI based on secondary criteria), and proportion of accurately recorded mTBI diagnosis by ED clinicians (ie, ‘mTBI’, ‘concussion’).ResultsOf 30 479 ED attendances, 351 (1.15%) confirmed mTBI diagnosis and 180 (0.6%) indeterminate diagnosis were identified. Only 81 (23.1%) individuals with a confirmed mTBI had a ‘mTBI diagnosis’ clearly recorded in the medical notes. Of the allocated discharge diagnosis codes to the two identified cohorts, 89.8% were not indicative of mTBI. Intracranial injuries were found in 31 (8.5%) confirmed cases. Glasgow Coma Scale scores were consistently assessed in the ED but identified only 117 (33.3%) confirmed mTBI cases. Post-traumatic amnesia (PTA) testing was able to confirm acute cognitive impairment in 113 (62.1%) of those who were tested (182, 51.3%).ConclusionsmTBI is a common, but an under-recognised cause for ED attendance. Despite challenges, the use of an operational definition such as the WHO diagnostic criteria can improve accuracy in mTBI identification. Acute management may be enhanced by rapid assessment of PTA.

Injuries to the lower limb muscles are a common cause of absence from training and competition in athletes. The different muscular groups of the thigh and leg are involved in various activities with kicking and sprinting being responsible for the largest number of injuries. The muscle acts on bone through the tendon and the fascia. The failure of one or more of these structures results in various degrees of loss of function of the muscle(s) involved. Usually, the point of weakness is the interface between different structures with different elastic properties (myofascial, myotendinous, avulsion). Diagnostic imaging is best performed by MRI that provides valuable information about the severity of the injury and its anatomical extent. In this article, we will review the MRI features of muscle injuries which can be used to guide return to play. We will emphasize the clinical implications of the MRI findings by dividing the muscle injuries into three categories "The Good, The Bad and The Ugly" to help the clinician in the planning of the most appropriate rehabilitation strategy.

Background In critical care medicine, US views of the inferior vena cava (IVC) and its change with respiration are used to estimate the intravascular volume status of unwell patients and, in particular, to answer the question: ‘Is this patient likely to be fluid responsive?’ Most commonly in the literature, the subxiphisternal (SX) window in the longitudinal plane is utilised. To date, no study has specifically assessed interrater agreement in estimating IVC diameter between emergency medicine specialists (experts) and trainees (learners). Objectives To determine the interrater agreement between an expert (senior emergency specialist with US qualifications) and learner (emergency medicine trainee) when measuring IVC diameter (IVCD) and IVC collapsibility index (IVCCI) in the SX longitudinal US window in healthy volunteers. Methods Healthy volunteers (ED staff) were scanned in the supine position using a sector (cardiac) probe of a portable US machine, in the SX longitudinal position. The maximum and minimum diameters of the IVC were measured in each of these positions and the IVCCI calculated. Results were analysed using Bland–Altman plots. Results In the longitudinal SX window, the operators' measurements of maximum IVCD differed by an average of 1.9 mm (95% limits of agreement −9.4 mm to +5.5 mm) and their measurement of IVCCI differed by an average of 4% (95% limits of agreement −30% to 38%). Conclusions The wide 95% limits of agreement demonstrate a poor interrater agreement between the IVC US measurements obtained by expert and learner users in the assessment of fluid status. These ranges are greater than clinically acceptable.

Background Pneumatic tube transport of pathology specimens from the emergency department to the laboratory for analysis is a widely used practice. When compared to manual specimen transport, it results in savings in both time and labour. Sampling of cerebrospinal fluid still forms part of the workup of patients with suspected subarachnoid haemorrhage. There are claims in the literature that transport of cerebrospinal fluid samples by pneumatic tube results in excess haemolysis, which interferes with cerebrospinal fluid analysis for the presence of bilirubin. The aim of our study was to ascertain whether pneumatic tube transport of blood-stained cerebrospinal fluid to the laboratory, results in clinically significantly higher levels of haemolysis compared with manual transport of the same specimens. Methods Stored cerebrospinal fluid was spiked with varying amounts of red blood cells creating 72 specimens of varying red cell concentration. Half of these specimens were transported to the laboratory manually while the other half were sent by pneumatic tube transport. The rates of haemolysis were compared between the pneumatic tube and manual transport samples. Results There was no clinically significant difference in the rates of haemolysis between the samples transported to the laboratory by pneumatic tube compared with those moved manually. Conclusions Pneumatic tube transport of cerebrospinal fluid to the laboratory is not associated with clinically significantly higher rates of haemolysis when compared to manual transport.

Objective Standard ampoules and prefilled syringes of adrenaline are widely available in Australasian EDs for use in cardiac arrest. We hypothesise that prefilled syringes can be administered more rapidly and accurately when compared with the two available standard ampoules. Methods This is a triple arm superiority study comparing the time to i.v. administration and accuracy of dosing of three currently available preparations of adrenaline. Results In their standard packaging, prefilled syringes were on average more than 12 s faster to administer than the 1 mL 1:1000 ampoules and more than 16 s faster than the 10 mL 1:10 000 ampoules (P < 0.01 in both comparisons). With packaging removed, the time to administration was equal for the 1 mL (1:1000) ampoule and the prefilled syringe. Accuracy of dosing was excellent with both the 10 mL (1:10 000) ampoules and prefilled syringes. The 1 mL (1:1000) ampoules delivered a small number of markedly inaccurate doses, but these did not reach statistical significance. Conclusions The speed of administration of adrenaline utilising a Minijet (CSL Limited, Parkville, Victoria, Australia) is faster than using adrenaline in glass ampoules presented in their plastic packaging. Removing the plastic packaging from the 1 mL (1 mg) ampoule might result in more rapid administration similar to the Minijet. Resuscitation personnel requiring rapid access to adrenaline should consider storing it as either Minijets or ampoules devoid of packaging. These results might be extrapolatable to other clinical scenarios, including pre-hospital and anaesthesia, where other drugs are required for rapid use.

BACKGROUND: There is a wide variety of techniques to secure intravenous cannulas but little objective evidence to support their relative efficacy. This study compares the security of the two most common methods used within a major Australian Emergency Department. METHODS: The plastic sheaths of four needle-less intravenous cannulas were secured to the skin surface (not intravenously) of 40 volunteers using two different taping styles, an “under and over” method with one of the tapes applied to the posterior surface of the hub then crossed anteriorly to adhere to the opposite skin surface or “horizontal” taping with the tapes applied horizontally across the anterior surface of the hub. The peak force required to dislodge the taped cannulas using each of these different methods was then measured in both an anterograde and retrograde direction of force using a force transducer. RESULTS: The force required to dislodge a cannula taped in an ‘under and over’ taping style was significantly higher than that required for the horizontal taping in both anterograde and retrograde directions of force (p < 0.001). CONCLUSIONS: The results of this study suggest that the “under and over” taping technique offers significantly more security than “horizontal” taping and should be considered as a more effective method for securing intravenous cannulas.

The aim of the study was to identify the mechanisms and spectrum of injuries sustained to the head and face in surfboard riders, requiring presentation to an emergency department. A retrospective case series was undertaken from January 2008 to April 2012 at a tertiary hospital on the North Shore of Sydney. Twenty-nine patients were included, 26 with acute injuries and 3 with chronic pathologies. Fifteen patients (58%) had been struck in the head by their own board – 9 (60%) suffered facial bone fractures. Contact with the surfboard was the cause of facial bone fracture in 100% of cases. One patient struck by their own board ruptured their globe. Chronic/progressive deafness was the indication for undertaking imaging in three patients. Hundred percent had bilateral exostoses of the external auditory canal (surfers ear). Head and facial injuries are a significant and potential risk of surfboard riding. It is envisaged that greater knowledge of the spectrum and mechanisms of injuries sustained by surfers will drive surfboard and surfing accessory design and increase public awareness to minimise the risk of injury in the future.

IntroductionPsychological distress is a prevalent condition often overlooked following a motor vehicle crash (MVC), particularly when injuries are not severe. The aim of this study is to examine whether biomarkers of autonomic regulation alone or in combination with other factors assessed shortly after MVC could predict risk of elevated psychological distress and poor functional recovery in the long term, and clarify links between mental and physical health consequences of traffic injury.Methods and analysisThis is a controlled longitudinal cohort study, with follow-up occurring at 3, 6 and 12 months. Participants include up to 120 mild to moderately injured MVC survivors who consecutively present to the emergency departments of two hospitals in Sydney and who agree to participate, and a group of up to 120 non-MVC controls, recruited with matched demographic characteristics, for comparison. WHO International Classification of Functioning is used as the framework for study assessment. The primary outcomes are the development of psychological distress (depressive mood and anxiety, post-traumatic stress symptoms, driving phobia, adjustment disorder) and biomarkers of autonomic regulation. Secondary outcomes include indicators of physical health (presence of pain/fatigue, physical functioning) and functional recovery (quality of life, return to function, participation) as well as measures of emotional and cognitive functioning. For each outcome, risk will be described by the frequency of occurrence over the 12 months, and pathways determined via latent class mixture growth modelling. Regression models will be used to identify best predictors/biomarkers and to study associations between mental and physical health.Ethics and disseminationEthical approvals were obtained from the Sydney Local Health District and the research sites Ethics Committees. Study findings will be disseminated to health professionals, related policy makers and the community through peer-reviewed journals, conference presentations and health forums.Trial registration numberACTRN12616001445460.

OBJECTIVE We investigated and compared the importance of the considerations and discussions when withdrawing and withholding life-sustaining healthcare between emergency physicians (EP) and emergency registrars (ER). METHODS This was a sub-study of a prospective cross-sectional questionnaire-based case series conducted in six EDs. Primary outcomes were, which of the discussion and considerations, were rated most important by EP and ER in the decision-making process. RESULTS We studied responses relating to the care of 320 patients, of which 49.4% were women and the median age was 83 (interquartile range [IQR] 72-88). EP and ER were sole decision-makers in 185 (39.7%) and 135 (30.0%) of cases, respectively. Treatment was withdrawn or withheld in 72.0 and 90.6% of all deaths by EP and ER, respectively (P

Colchicine overdose is uncommon but frequently fatal. In this article we present two cases which exhibit the wide spectrum of colchicine toxicity and review the drug's pharmacology and organ system effects. Finally we provide a treatment algorithm and propose new directions for management. Colchicine binds to intracellular tubulin and prevents its polymerisation to form microtubules. As microtubules subserve a wide variety of roles in basic cellular function including protein assembly, mitosis, endocytosis, exocytosis, cell shape and motility, colchicine is profoundly toxic to all cell lines of the body. Previous studies have offered little to aid the clinician in the management of such patients. We present a series of treatment guidelines based on the current literature. Specifically, we propose that patients who do not develop gastrointestinal symptoms within eight hours of a small, isolated colchicine ingestion can be medically cleared. Additionally, the onset of gastrointestinal symptoms should be seen as an indicator of possible significant systemic toxicity requiring early resuscitation and intensive monitoring. The newer modalities of treatment including the use of colchicine-specific Fab fragments and Granulocyte-Colony Stimulating Factor are also addressed.

Host response biomarkers can accurately distinguish between influenza and bacterial infection. However, published biomarkers require the measurement of many genes, thereby making it difficult to implement them in clinical practice. This study aims to identify a single-gene biomarker with a high diagnostic accuracy equivalent to multi-gene biomarkers.In this study, we combined an integrated genomic analysis of 1071 individuals with

In critical care medicine, US views of the inferior vena cava (IVC) and its change with respiration are used to estimate the intravascular volume status of unwell patients and, in particular, to answer the question: 'Is this patient likely to be fluid responsive?' Most commonly in the literature, the subxiphisternal (SX) window in the longitudinal plane is utilised. To date, no study has specifically assessed interrater agreement in estimating IVC diameter between emergency medicine specialists (experts) and trainees (learners).To determine the interrater agreement between an expert (senior emergency specialist with US qualifications) and learner (emergency medicine trainee) when measuring IVC diameter (IVCD) and IVC collapsibility index (IVCCI) in the SX longitudinal US window in healthy volunteers.Healthy volunteers (ED staff) were scanned in the supine position using a sector (cardiac) probe of a portable US machine, in the SX longitudinal position. The maximum and minimum diameters of the IVC were measured in each of these positions and the IVCCI calculated. Results were analysed using Bland-Altman plots.In the longitudinal SX window, the operators' measurements of maximum IVCD differed by an average of 1.9 mm (95% limits of agreement -9.4 mm to +5.5 mm) and their measurement of IVCCI differed by an average of 4% (95% limits of agreement -30% to 38%).The wide 95% limits of agreement demonstrate a poor interrater agreement between the IVC US measurements obtained by expert and learner users in the assessment of fluid status. These ranges are greater than clinically acceptable.

Standard ampoules and prefilled syringes of adrenaline are widely available in Australasian EDs for use in cardiac arrest. We hypothesise that prefilled syringes can be administered more rapidly and accurately when compared with the two available standard ampoules.This is a triple arm superiority study comparing the time to i.v. administration and accuracy of dosing of three currently available preparations of adrenaline.In their standard packaging, prefilled syringes were on average more than 12 s faster to administer than the 1 mL 1:1000 ampoules and more than 16 s faster than the 10 mL 1:10,000 ampoules (P0.01 in both comparisons). With packaging removed, the time to administration was equal for the 1 mL (1:1000) ampoule and the prefilled syringe. Accuracy of dosing was excellent with both the 10 mL (1:10 000) ampoules and prefilled syringes. The 1 mL (1:1000) ampoules delivered a small number of markedly inaccurate doses, but these did not reach statistical significance.The speed of administration of adrenaline utilising a Minijet (CSL Limited, Parkville, Victoria, Australia) is faster than using adrenaline in glass ampoules presented in their plastic packaging. Removing the plastic packaging from the 1 mL (1 mg) ampoule might result in more rapid administration similar to the Minijet. Resuscitation personnel requiring rapid access to adrenaline should consider storing it as either Minijets or ampoules devoid of packaging. These results might be extrapolatable to other clinical scenarios, including pre-hospital and anaesthesia, where other drugs are required for rapid use.

IntroductionPrevious literature confirms that a mild traumatic brain injury (mTBI) may result in long-term emotional impacts and, in vulnerable subgroups, cognitive deficits. The accurate diagnosis of mTBI and its written documentation is an important first step towards providing appropriate and timely clinical care. Surveillance studies involving emergency department (ED) and hospital-based data need to be prioritised as these provide incident mTBI estimates. This project will advance existing research findings by estimating the occurrence of mTBI among those attending an ED and quantifying the accuracy of mTBI diagnoses recorded by ED staff through a comprehensive audit of ED records.Methods and analysisRetrospective chart reviews (between June 2015 and June 2016) of electronic clinical records from an ED in Sydney (New South Wales, Australia) will be conducted. The study population will include persons aged 18–65 years who attended the ED with any clinical features potentially indicative of mTBI. The WHO operational criteria for the clinical identification of mTBI cases is the presence of: (1) a Glasgow Coma Scale (GCS) of 13–15 after 30 min postinjury or on presentation to hospital; (2) one or more of the following: post-traumatic amnesia (PTA) of less than 24 hours’ duration, confusion or disorientation, a witnessed loss of consciousness for ≤30 min and/or a positive CT brain scan. We estimate that 30 000 ED attendances will be screened and that a sample size of 500 cases with mTBI will be identified during this 1-year period, which will provide reliable estimates of mTBI occurrence in the ED setting.Ethics and disseminationThe study was approved by the Northern Sydney Local Health District Ethics Committee. The committee deemed this study as low risk in terms of ethical issues. The written papers from this study will be submitted for publication in quality peer-reviewed medical and health journals. Study findings will be disseminated via presentations at national/international conferences and peer-reviewed journals.

Host response biomarkers can accurately distinguish between influenza and bacterial infection. However, published biomarkers require the measurement of many genes, thereby making it difficult to implement them in clinical practice. This study aims to identify a single-gene biomarker with a high diagnostic accuracy equivalent to multi-gene biomarkers.In this study, we combined an integrated genomic analysis of 1071 individuals with in vitro experiments using well-established infection models.We identified a single-gene biomarker, IFI27, which had a high prediction accuracy (91%) equivalent to that obtained by multi-gene biomarkers. In vitro studies showed that IFI27 was upregulated by TLR7 in plasmacytoid dendritic cells, antigen-presenting cells that responded to influenza virus rather than bacteria. In vivo studies confirmed that IFI27 was expressed in influenza patients but not in bacterial infection, as demonstrated in multiple patient cohorts (n=521). In a large prospective study (n=439) of patients presented with undifferentiated respiratory illness (aetiologies included viral, bacterial and non-infectious conditions), IFI27 displayed 88% diagnostic accuracy (AUC) and 90% specificity in discriminating between influenza and bacterial infections.IFI27 represents a significant step forward in overcoming a translational barrier in applying genomic assay in clinical setting; its implementation may improve the diagnosis and management of respiratory infection.

Determines the incidence, nature and severity of SREIs in NSW over one year, between 30 December 2010 and 30 December 2011. Summary Surfing carries a well documented risk of head and facial injuries and these injuries may have become more frequent in recent times with overcrowding at beaches and the streamlining of surfboard design. Ocular trauma caused by surfboards can be severe, with long-term effects on the work prospects and lifestyles of otherwise fit, young people.There is an increasing number of case reports of severe surfboard related eye injuries (SREIs) and active discussion in the medical literature about the need for protective eyewear while surfing. Studies have found that protective headgear is seldom worn by surfers. No studies have examined the incidence of SREIs among surfers of all levels of experience in New South Wales or Australia. We need data on these injuries to establish the extent of the problem so that recommendation for the use of protective eyewear and headgear while surfing and guidelines for surfboard design can be developed for the Australian context, if required. In this prospective study, we aimed to determine the incidence, nature and severity of SREIs in NSW over 1 year, between 30 December 2010 and 30 December 2011.

There is growing evidence that health and social outcomes following motor vehicle crash injury are related to cognitive and emotional responses of the injured individual, as well as relationships between the injured individual and the compensation systems with which they interact. As most of this evidence comes from other states in Australia or overseas, investigation is therefore warranted to identify the key determinants of health and social outcomes following injury in the context of the New South Wales motor accident insurance scheme. In this inception cohort study, 2400 participants, aged 17 years or more, injured in a motor vehicle crash in New South Wales will be identified though hospital emergency departments, general and physiotherapy practitioners, police records and a government insurance regulator database. Participants will be initially contacted through mail. Baseline interviews will be conducted by telephone within 28 days of the injury and participants will be followed up with interviews at 6, 12 and 24 months post-injury. Health insurance and pharmaceutical prescription data will also be collected. The study results will report short and long term health and social outcomes in the study sample. Identification of factors associated with health and social outcomes following injury, including related compensation factors will provide evidence for improved service delivery, post-injury management, and inform policy development and reforms. Australia New Zealand Clinical trial registry identification number - ACTRN12613000889752 . Available at: ANZCTR Registered FISH Study.

Basketball and netball are both physically demanding sports involving movements that are often performed at high speeds in a multitude of directions. Any reduction in a participant’s ability to control the forces generated while running, cutting, jumping, or stopping could lead to excessive stress upon the musculoskeletal system. This stress could be traumatic or repetitive in nature, with the potential outcome resulting in injury....

The treatment of life- or limb-threatening injuries in the sporting arena constitutes one of the most intimidating challenges for any healthcare professional employed in sport. The skills required to cope with these scenarios decay very rapidly so that regular drills and scenario training are essential to maintain the competencies acquired from emergency training courses....

Muscle injuries of the lower extremity are extremely common among athletes leading to significant morbidity and time out from competition. Furthermore, increasing athletic activity in the general population has resulted in lower limb muscle injuries becoming commonplace. It is therefore vital for the musculoskeletal radiologist to be familiar with the imaging findings of lower limb muscle injuries and to be aware of the role of imaging in the prognostication and management of these injuries. The most commonly injured lower limb muscles are the quadriceps, the hamstring complex, and the gastrocnemius muscles. This article reviews the biomechanical and imaging features of common acute muscle injuries of the lower extremity and evaluates the role of imaging in the prognosis of these sport injuries.

Blind nasal intubation remains an important technique in the management of the difficult airway. Many aids to this technique have been described, but unfortunately, these often require additional expense, training, and equipment. Methods that involve listening at the end of the endotracheal tube and observing moisture condensation in the tube are relatively insensitive and may expose the operator to the patient's bodily fluids. Our aim was to devise an aid to blind nasal intubation that was effective, inexpensive, simple to learn, and easy to assemble. It is essential that breath sounds can be monitored through the endotracheal tube, as it is felt that this helps to minimize retropharyngeal perforation caused by the tube abutting the posterior pharyngeal wall. We describe the use of an endotracheal tube stethoscope in conjunction with either 'inline' or 'sidestream' capnometry and present a case of successful nasotracheal intubation using this device. The total cost of this aid is less than $10 Australian.

Aim: To describe a case of anaphylactic shock following the intravenous administration of vitamin K1. Clinical features: A 64- year-old male was admitted to intensive care following repair of an aortic abdominal aneurysm. Intravenous amiodarone, ceftriaxone, vancomycin and metronidazole were commenced without incident. During the administration of intravenous vitamin K1 (phytomenadione, Konakion) the patient developed a rash, hypotension and severe bronchospasm. Outcome: The patient recovered following paralysis, manual ventilation, and standard medication for anaphylaxis. Conclusion: Intravenous administration of vitamin K1 and other drugs solubilised with polyoxyl 35 castor oil occasionally causes severe anaphylactic shock. A new colloidal formulation may reduce the hazards of intravenous vitamin K1 administration. (author abstract)