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This board is owned by Matt Holland, NWAS LKS, Librarian. Contact Matt.Holland@nwas.nhs.uk


Hosts recent articles from research based journals. Pinboard started in September 2016.


Filling the Gap: Simulation-based Crisis Resource Management Training for Emergency Medicine Residents.

Abstract: In today's team-oriented healthcare environment, high-quality patient care requires physicians to possess not only medical knowledge and technical skills but also crisis resource management (CRM) skills. In emergency medicine (EM), the high acuity and dynamic environment makes CRM skills of physicians particularly critical to healthcare team success. The Accreditation Council of Graduate Medicine Education Core Competencies that guide residency program curriculums include CRM skills; however, EM residency programs are not given specific instructions as to how to teach these skills to their trainees. This article describes a simulation-based CRM course designed specifically for novice EM residents.The CRM course includes an introductory didactic presentation followed by a series of simulation scenarios and structured debriefs. The course is designed to use observational learning within simulation education to decrease the time and resources required for implementation. To assess the effectiveness in improving team CRM skills, two independent raters use a validated CRM global rating scale to measure the CRM skills displayed by teams of EM interns in a pretest and posttest during the course.The CRM course improved leadership, problem solving, communication, situational awareness, teamwork, resource utilization and overall CRM skills displayed by teams of EM interns. While the improvement from pretest to posttest did not reach statistical significance for this pilot study, the large effect sizes suggest that statistical significance may be achieved with a larger sample size.This course can feasibly be incorporated into existing EM residency curriculums to provide EM trainees with basic CRM skills required of successful emergency physicians. We believe integrating CRM training early into existing EM education encourages continued deliberate practice, discussion, and improvement of essential CRM skills.

Pub.: 01 Feb '18, Pinned: 02 Feb '18

A comparison of care delivered in hospital-based and freestanding emergency departments.

Abstract: We compare case-mix, hospitalization rates, length of stay (LOS), and resource use in independent freestanding emergency departments (FSEDs) and hospital-based emergency departments (H-EDs).Data from 74 FSEDs (2013-5) in Texas and Colorado, were compared to H-ED data from the 2013-14 National Hospital Ambulatory Medical Care Survey. In the unrestricted sample, large differences in visit characteristics (e.g. payer and case mix) were found between patients that use FSEDs compared to H-EDs. Therefore, we restricted our analysis to patients commonly treated in both settings (<65 years, privately insured, non-ambulance) and used inverse propensity score weighting (IPW) to balance the two settings on observable patient characteristics. We then compared ED length of stay and as well as hospital admission rates and resource utilization rates in the IPW-weighted samples.Before balancing, FSEDs saw more young adults (age 25-44), and fewer older adults (age 45-64) than H-EDs. FSED patients had fewer comorbidities, more injuries and respiratory infections, and fewer diagnoses of chest or abdominal pain. In balanced samples, LOS for FSED visits was 46% shorter (60 minutes) than H-ED patients. Hospital admission rates were 37% lower overall (95% CI -51%, -23%) in FSEDs and varied considerably by primary discharge diagnosis. X-ray and EKG use was significantly lower at FSEDs while others measures of resource utilization were similar (ultrasound, CT scans and laboratory tests).In this sample of FSEDs, a greater proportion of younger patients with fewer comorbidities and more injuries and respiratory system diseases were evaluated, and almost all patients had private health insurance. When restricted to <65, privately insured, and non-ambulance patients in both samples, LOS was considerably shorter and hospital admission rates lower at FSEDs, as well as the use of some diagnostic testing. This study is limited as diagnoses codes may not fully capture severity and patients who perceived greater need of hospital admission may have chosen a H-ED over FSEDs. This article is protected by copyright. All rights reserved.

Pub.: 31 Jan '18, Pinned: 01 Feb '18

Abdominal prehospital ultrasound impacts treatment decisions in a Dutch Helicopter Emergency Medical Service.

Abstract: The aim of this study was to determine the impact of abdominal prehospital ultrasound (PHUS) on patient care in a Dutch physician-staffed Helicopter Emergency Medical Service (HEMS) and to determine its diagnostic performance.We carried out a retrospective analysis of abdominal ultrasound (US) examinations performed by the HEMS of Nijmegen, the Netherlands, from January 2007 until December 2016. Data including patient demographics, type of incident, abdominal US findings, impact on treatment decisions, and the physicians' narrative report were retrieved from the HEMS database and analyzed. PHUS diagnostic performance was compared with computed tomography scan or laparotomy.Of 17 077 recorded scrambles and 8699 patients treated, 1583 underwent 1631 abdominal US examinations. After eliminating missing data, 251 impacts on treatment in 194 out of 1539 PHUS examinations were identified (12.6%, 95% confidence interval: 10.9-14.3). This affected 188 out of 1495 (12.6%) patients. The four main categories of treatment decisions impacted by PHUS were information provided to the destination hospital (45.4%); mode of transportation (23.5%); choice of destination hospital (13.1%); and fluid management (11.6%). The sensitivity of prehospital abdominal US for hemoperitoneum was 31.3%, specificity was 96.7%, and accuracy was 82.1%.Abdominal PHUS in our setting impacts treatment decisions significantly. Therefore, it is a valuable tool in the Dutch HEMS setting and probably beyond.

Pub.: 31 Jan '18, Pinned: 01 Feb '18

Neighborhood Poverty and 9-1-1 Ambulance Response Time.

Abstract: Are 9-1-1 ambulances relatively late to poorer neighborhoods? Studies suggesting so often rely on weak measures of neighborhood (e.g., postal zip code), limit the analysis to particular ambulance encounters (e.g., cardiac arrest responses), and do little to account for variations in dispatch priority or intervention severity.We merged EMS ambulance contact records in a single California county (n = 87,554) with tract-level data from the American Community Survey (n = 300). After calculating tract-level median ambulance response time (MART), we used ordinary least squares (OLS) regression to estimate a conditional average relationship between neighborhood poverty and MART and quantile regression to condition this relationship on 25th, 50th, and 75th percentiles of MART. We also specified each of these outcomes by five dispatch priorities and by three intervention severities. For each model, we estimated the associated changes in MART per 10 percentage point increase in tract-level poverty while adjusting for emergency department proximity, population density, and population size.Our study produced three major findings. First, most of our tests suggested tract-level poverty was negatively associated with MART. Our baseline OLS model estimates that a 10 percentage point increase in tract-level poverty is associated with almost a 24 s decrease in MART (-23.55 s, 95% confidence interval [CI] -33.13 to -13.98). Results from our quantile regression models provided further evidence for this association. Second, we did not find evidence that ambulances are relatively late to poorer neighborhoods when specifying MART by dispatch priority. Third, we were also unable to identify a positive association between tract-level poverty and MART when we specified our outcomes by three intervention severities. Across each of our 36 models, tract-level poverty was either not significantly associated with MART or was negatively associated with MART by a magnitude smaller than a full minute per estimated 10 percentage point increase in poverty concentration.Our study challenges the commonly held assumption that ambulances are later to poor neighborhoods. We scrutinize our findings before cautiously considering their relevance for ambulance response time research and for ongoing conversations on the relationship between neighborhood poverty and prehospital care.

Pub.: 31 Jan '18, Pinned: 01 Feb '18

Interactive Effect between On-Scene Hypoxia and Hypotension on Hospital Mortality and Disability in Severe Trauma.

Abstract: It is unclear whether effect size of the hypoxia is different on in-hospital mortality and disability according to hypotension status in the field.Adult severe trauma (ST) patients during 2012-13 who were treated by emergency medical services (EMS) and had abnormal revised trauma scores in the field or who had positive trauma triage criteria were analyzed. Exposure was hypoxia (<94%) measured by EMS. End points were hospital mortality and disability defined as a Glasgow Outcome Scale that decreased by 2 points or more. Multivariable logistic regression with interaction model between hypoxia and hypotension was used for outcomes to calculate the adjusted odds ratios (AOR) with 95% confidence intervals (95% CIs) after adjusting for potential confounders.A total of 17,406 EMS-ST patients were analyzed. Of those, 2,598 (14.9%) died, and 3,292 (21.5%) were considered disabled at discharge. The total hypoxia group showed higher mortality and disability indices (35.7 and 51.2%) than the non-hypoxia group (10.7 and 15.9%) (each p-value < 0.0001). The AOR of hypoxia was 2.15 (1.92-2.40) for mortality and was 1.97 (1.75-2.21) for disability. In the interaction model, AORs for mortality by hypoxia in the hypotensive and non-hypotensive groups were 2.66 (2.32-3.04) and 1.74 (1.61-1.87), respectively (P < 0.0001 for interaction). The AORs for disability in the hypotensive and non-hypotensive groups were 2.17 (1.87-2.53) and 1.55 (1.42-1.69), respectively (P < 0.0001 for interaction).The effect of hypoxia was much greater in the hypotensive group than in the non-hypotensive group both in terms of mortality and disability.

Pub.: 27 Jan '18, Pinned: 31 Jan '18

An Effective Treatment in the Austere Environment? A Critical Appraisal into the Use of Intra-Articular Local Anesthetic to Facilitate Reduction in Acute Shoulder Dislocation.

Abstract: Acute shoulder dislocation is a common injury in the outdoor environment. The objective of this systematic review of the literature was to determine if intra-articular local anesthetic (IAL) is an effective treatment that could have prehospital application. A methodical search of MEDLINE, PubMed, and EMBASE databases targeted publications from January 1, 1990 until January 1, 2017. Eligible articles compared IAL with other analgesic techniques in patients 16 years or older experiencing acute glenohumeral dislocation. Reduction success, complications, and patient-reported outcome measures underwent comparison. All identified publications originated from the hospital setting. Procedural success rates ranged widely among randomized control trials comparing IAL with intravenous analgesia and sedation (IAL 48-100%, intravenous analgesia and sedation 44-100%). A pooled risk ratio [RR] favored intravenous analgesia and sedation (RR 0.91, 95% confidence interval [CI] 0.84-0.98), but there was significant inconsistency within the analysis (I2 = 75%). IAL provided lower complication rates (4/170, 2%) than intravenous analgesia and sedation (20/150, 13%) (RR 1.11, 95% CI 1.04-1.19, I2 = 63%). One trial found a clinically relevant reduction in visual analogue pain scores when comparing IAL against no additional analgesia in the first minute (IAL 21±13 mm; control 49±15 mm; P<0.001) and fifth minute (IAL 10±10 mm; control 40±14 mm, P<0.001) after reduction. The results suggest that IAL is an effective intervention for acute anterior shoulder dislocation that would have a place in the repertoire of the remote physician. Further research might be beneficial in determining the outcomes of performing IAL in the prehospital setting.

Pub.: 27 Jan '18, Pinned: 31 Jan '18

Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis.

Abstract: Endotracheal intubation (ETI) is a critical procedure performed by both air medical and ground based emergency medical services (EMS). Previous work has suggested that ETI success rates are greater for air medical providers. However, air medical providers may have greater airway experience, enhanced airway education, and access to alternative ETI options such as rapid sequence intubation (RSI). We sought to analyze the impact of the type of EMS on RSI success.A systematic literature search of Medline, Embase, and the Cochrane Library was conducted and eligibility, data extraction, and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success.Forty-nine studies were included in the meta-analysis. There was no difference in the overall success between flight and ground based EMS; 97% (95% CI 96-98) vs. 98% (95% CI 91-100), and no difference in first-pass success for flight compared to ground based RSI; 82% (95% CI 73-89) vs. 82% (95% CI 70-93). Compared to flight non-physicians, flight physicians have higher overall success 99% (95% CI 98-100) vs. 96% (95% CI 94-97) and first-pass success 89% (95% CI 77-98) vs. 71% (95% CI 57-84). Ground-based physicians and non-physicians have a similar overall success 98% (95% CI 88-100) vs. 98% (95% CI 95-100), but no analysis for physician ground first pass was possible.Both overall and first-pass success of RSI did not differ between flight and road based EMS. Flight physicians have a higher overall and first-pass success compared to flight non-physicians and all ground based EMS, but no such differences are seen for ground EMS. Our results suggest that ground EMS can use RSI with similar outcomes compared to their flight counterparts.

Pub.: 30 Jan '18, Pinned: 31 Jan '18

Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke.

Abstract: Endovascular thrombectomy is a highly efficacious treatment for large vessel occlusion (LVO). LVO prediction instruments, based on stroke signs and symptoms, have been proposed to identify stroke patients with LVO for rapid transport to endovascular thrombectomy-capable hospitals. This evidence review committee was commissioned by the American Heart Association/American Stroke Association to systematically review evidence for the accuracy of LVO prediction instruments.Medline, Embase, and Cochrane databases were searched on October 27, 2016. Study quality was assessed with the Quality Assessment of Diagnostic Accuracy-2 tool.Thirty-six relevant studies were identified. Most studies (21 of 36) recruited patients with ischemic stroke, with few studies in the prehospital setting (4 of 36) and in populations that included hemorrhagic stroke or stroke mimics (12 of 36). The most frequently studied prediction instrument was the National Institutes of Health Stroke Scale. Most studies had either some risk of bias or unclear risk of bias. Reported discrimination of LVO mostly ranged from 0.70 to 0.85, as measured by the C statistic. In meta-analysis, sensitivity was as high as 87% and specificity was as high as 90%, but no threshold on any instruments predicted LVO with both high sensitivity and specificity. With a positive LVO prediction test, the probability of LVO could be 50% to 60% (depending on the LVO prevalence in the population), but the probability of LVO with a negative test could still be ≥10%.No scale predicted LVO with both high sensitivity and high specificity. Systems that use LVO prediction instruments for triage will miss some patients with LVO and milder stroke. More prospective studies are needed to assess the accuracy of LVO prediction instruments in the prehospital setting in all patients with suspected stroke, including patients with hemorrhagic stroke and stroke mimics.

Pub.: 26 Jan '18, Pinned: 27 Jan '18

2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Abstract: The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates.Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format.These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings.These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Pub.: 26 Jan '18, Pinned: 27 Jan '18

Video Versus Direct Laryngoscopy for Initial Trauma Airway Management: Is There a Winner?

Abstract: Intubation of patients suffering acute traumatic injuries is associated with higher airway-related morbidity and mortality than when the same procedure occurs under elective conditions. Indirect video-enabled laryngoscopes (VL) offer the potential advantage of improved glottic visualization as an integral step in the process of endotracheal intubation when compared to traditional direct laryngoscopy (DL). However, despite robust evidence that VL consistently achieves a superior view of the vocal cords in critically ill and injured adults, a consistent improvement in first-attempt intubation success has not yet been demonstrated.A review of recent literature suggests that the primary limitations of VL in urgent airway management include steps subsequent to sighting, such as tube delivery and cannulation of the trachea; these are distinct, non-intuitive motor skills that require extensive, device-specific training to master. This has been demonstrated across acute care settings, including the prehospital environment, the emergency department, and the intensive care unit.Given the spectrum of health care personnel who may be responsible for urgent airway management in trauma care, training programs should focus on high-volume opportunities to practice device-specific motor skills to improve the successful use of VL in acute care settings. Innovative stylet and/or tube technology may further optimize tube delivery and tracheal cannulation.

Pub.: 26 Jan '18, Pinned: 27 Jan '18

What fluids are given during air ambulance treatment of patients with trauma in the UK, and what might this mean for the future? Results from the RESCUER observational cohort study.

Abstract: We investigated how often intravenous fluids have been delivered during physician-led prehospital treatment of patients with hypotensive trauma in the UK and which fluids were given. These data were used to estimate the potential national requirement for prehospital blood products (PHBP) if evidence from ongoing trials were to report clinical superiority.The Regional Exploration of Standard Care during Evacuation Resuscitation (RESCUER) retrospective observational study was a collaboration between 11 UK air ambulance services. Each was invited to provide up to 5 years of data and total number of taskings during the same period.Patients with hypotensive trauma (systolic blood pressure <90 mm Hg or absent radial pulse) attended by a doctor.The primary outcome was the number of patients with hypotensive trauma given prehospital fluids. Secondary outcomes were types and volumes of fluids. These data were combined with published data to estimate potential national eligibility for PHBP.Of 29 037 taskings, 729 (2.5%) were for patients with hypotensive trauma attended by a physician. Half were aged 21-50 years; 73.4% were male. A total of 537 out of 729 (73.7%) were given fluids. Five hundred and ten patients were given a single type of fluid; 27 received >1 type. The most common fluid was 0.9% saline, given to 486/537 (90.5%) of patients who received fluids, at a median volume of 750 (IQR 300-1500) mL. Three per cent of patients received PHBP. Estimated projections for patients eligible for PHBP at these 11 services and in the whole UK were 313 and 794 patients per year, respectively.One in 40 air ambulance taskings were manned by physicians to retrievepatients with hypotensive trauma. The most common fluid delivered was 0.9% saline. If evidence justifies universal provision of PHBP, approximately 800 patients/year would be eligible in the UK, based on our data combined with others published. Prospective investigations are required to confirm or adjust these estimations.

Pub.: 25 Jan '18, Pinned: 26 Jan '18

The development of an in vitro Pig-a assay in L5178Y cells.

Abstract: A recent flow cytometry-based in vivo mutagenicity assay involves the hemizygous phosphatidylinositol class A (Pig-a) gene. Pig-a forms the catalytic subunit of N-acetylglucosaminyltransferase required for glycophosphatidylinositol (GPI) anchor biosynthesis. Mutations in Pig-a prevent GPI-anchor synthesis resulting in loss of cell-surface GPI-linked proteins. The aim of the current study was to develop and validate an in vitro Pig-a assay in L5178Y mouse lymphoma cells. Ethyl methanesulfonate (EMS)-treated cells (186.24-558.72 µg/ml; 24 h) were used for method development and antibodies against GPI-linked CD90.2 and stably expressed CD45 were used to determine GPI-status by flow cytometry. Antibody concentration and incubation times were optimised (0.18 µg/ml, 30 min, 4 °C) and Zombie Violet™ (viability marker; 0.5%, 30 min, RT) was included. The optimum phenotypic expression period was 8 days. The low background mutation frequency of GPI-deficiency [GPI(-)] in L5178Y cells (0.1%) constitutes a rare event, thus flow cytometry acquisition parameters were optimised; 104 cells were measured at medium flow rate to ensure a CV ≤ 30%. Spiking known numbers of GPI(-) cells into a wild-type population gave high correlation between measured and spiked numbers (R2 0.999). We applied the in vitro Pig-a assay to a selection of well-validated genotoxic and non-genotoxic compounds. EMS, N-ethyl-N-nitrosourea and 4-nitroquinoline-N-oxide dose dependently increased numbers of GPI(-) cells, while etoposide, mitomycin C, and a bacterial-specific mutagen did not. Cycloheximide and sodium chloride were negative. Sanger sequencing revealed Pig-a mutations in the GPI(-) clones. In conclusion, this in vitro Pig-a assay could complement the in vivo version, and follow up weak Ames positives and late-stage human metabolites or impurities.

Pub.: 25 Jan '18, Pinned: 26 Jan '18

Catheterization laboratory activations and time intervals for patients with pre-hospital ECGs.

Abstract: The use of pre-hospital ECGs (PH-ECG) reduces time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI). The feasibility of reperfusion therapy within 60 minutes for hospitals with 24/7 PCI capability has been questioned, and current guidelines have set time targets to 90 minutes. Our primary objective was to investigate the proportion of false-positive catheterization laboratory activations by PH-ECG. Our secondary objective was to describe the time intervals from first medical contact to reperfusion and to establish the proportion of patients receiving reperfusion within 60 minutes.A retrospective cohort study among 4298 patients for whom a PH-ECG was transmitted to the investigating hospital, mainly due to chest pain, during 2013 were included.Among patients with PH-ECGs, 139 (3.2%) patients had a STEMI. There were 115 pre-hospital catheterization laboratory activations among which 16% (95% confidence interval 10-23) were false-positive for STEMI. The median total time from emergency call to arterial puncture was 76 minutes. The target of PCI within 60 minutes was met in 83% of the cases. The time from EMS arrival to PH-ECG was 20 minutes for female patients and 13 minutes for male patients (p < .001), and only 16% had a PH-ECG within 10 minutes from Emergency Medical Service arrival.The rate of false-positive catheterization laboratory activations based on pre-hospital ECGs was low and the target of PCI within 60 minutes is achievable for a majority of patients. Efforts should be made to reduce the time from ambulance arrival to PH-ECG transmission, especially for female patients.

Pub.: 25 Jan '18, Pinned: 26 Jan '18

Descriptive Analysis Of Mental Health-Related Presentations To Emergency Medical Services.

Abstract: In many developed countries, a lack of community-based mental health services is driving increased utilization of emergency medical services (EMS). In this descriptive study, we sought to describe the demographic and clinical characteristics of mental health-related EMS presentations in Victoria, Australia.A retrospective observational study of EMS presentations occurring between January and December 2015. Computer Aided Dispatch and electronic patient care record data were extracted from an electronic data warehouse. Characteristics of EMS-attended mental health presentations were described and compared to other EMS-attended patients using descriptive statistics.Of the total 504,676 EMS attendances, 48,041 (9.5%) were mental health presentations. In addition, 4,708 (6.6%) cases managed by a paramedic or nurse via the EMS secondary telephone triage service also involved mental health complaints. EMS-attended mental health patients were younger and more often female compared to other patients attended by EMS. Most mental health patients were transported to hospital (74.4%); however, paramedics provided treatment to significantly fewer mental health patients compared to other EMS-attended patients (12.4% vs. 50.3%, p < 0.001%). The majority of mental health patients (76.8%) had a documented mental health history. Social or emotional issues were the most common presentation in mental health patients aged ≤15 years (19.1%); whereas, for patients aged ≥65 years, anxiety was the most common clinical presentation (41.2%). For patients undergoing secondary triage, 52.5% were frequent callers or anxiety presentations. A total of 27.7% of triaged patients were referred to an alternative service, while 24.6% were managed under an existing care plan.Mental health-related cases represent one in ten EMS attendances in Victoria. A large proportion of mental health presentations receive little intervention by EMS, and could benefit from community-based services provided by mental health clinicians.

Pub.: 25 Jan '18, Pinned: 26 Jan '18

Comparison Of The I-Gel Supraglottic And King Laryngotracheal Airways In A Simulated Tactical Environment.

Abstract: When working in a tactical environment there are several different airway management options that exist. One published manuscript suggests that when compared to endotracheal intubation, the King LT laryngotracheal airway (KA) device minimizes time to successful tube placement and minimizes exposure in a tactical environment. However, comparison of two different blind insertion supraglottic airway devices in a tactical environment has not been performed. This study compared the I-Gel airway (IGA) to the KA in a simulated tactical environment, to determine if one device is superior in minimizing exposure and minimizing time to successful tube placement.This prospective randomized cross over trial was performed using the same methods and tactical environment employed in a previously published study, which compared endotracheal intubation versus the KA in a tactical environment. The tactical environment was simulated with a one-foot vertical barrier. The participants were paramedic students who wore an Advanced Combat Helmet (ACH) and a ballistic vest (IIIA) during the study. Participants were then randomized to perform tactical airway management on an airway manikin with either the KA or the IGA, and then again using the alternate device. The participants performed a low military type crawl and remained in this low position during each tube placement. We evaluated the time to successful tube placement between the IGA and KA. During attempts, participants were videotaped to monitor their height exposure above the barrier. Following completion, participants were asked which airway device they preferred. Data was analyzed using Student's t-test across the groups for time to ventilation and height of exposure.In total 19 paramedic students who were already at the basic EMT level participated. Time to successful placement for the KA was 39.7 seconds (95%CI: 32.7-46.7) versus 14.4 seconds (95%CI: 12.0-16.9) for the IGA, p < 0.001. Maximum height exposure of the helmet above a one foot vertical barrier for the KA resulted in 1.42 inches of exposure (95%CI: 0.38-0.63) compared to the IGA with 1.42 inches, 95%CI:0.32-0.74, p = 0.99. On questioning 100% of the participants preferred the IGA device over the KA.In a simulated tactical environment placement of the IGA for airway management was faster than with the KA, but there was no difference in regard to exposure. Additionally, all the participants preferred using the IGA device over the KA.

Pub.: 25 Jan '18, Pinned: 26 Jan '18

Improving Prehospital Protocol Adherence Using Bundled Educational Interventions.

Abstract: Seizures and anaphylaxis are life-threatening conditions that require immediate treatment in the prehospital setting. There is variation in treatment of pediatric prehospital patients for both anaphylaxis and seizures. This educational study was done to improve compliance with pediatric prehospital protocols, educate prehospital providers and decrease variation in care.To improve the quality of care for children with seizures and anaphylaxis in the prehospital setting using a bundled, multifaceted educational intervention.Evidence-based pediatric prehospital guidelines for seizures and anaphylaxis were used to create a curriculum for the paramedics in the EMS system. The curriculum included in-person training, videos, distribution of decision support tools, and a targeted social media campaign to reinforce the evidence-based guidelines. Prehospital charts were reviewed for pediatric patients with a chief complaint of anaphylaxis or seizures who were transported by paramedics to one of ten hospitals, including three children's hospitals, for 8 months prior to the intervention and eight months following the intervention. The primary outcome for seizures was whether midazolam was given via the preferred intranasal (IN) or intramuscular (IM) routes. The primary outcome for anaphylaxis was whether IM epinephrine was given.A total of 1,402 pediatric patients were transported for seizures by paramedics to during the study period. A total of 88 patients were actively seizing pre-intervention and 93 post-intervention. Of the actively seizing patients, 52 were given midazolam pre-intervention and 62 were given midazolam post-intervention. Pre-intervention, 29% (15/52) of the seizing patients received midazolam via the preferred IM or IN routes, compared to 74% (46/62) of the seizing patients post-intervention. A total of 45 patients with anaphylaxis were transported by paramedics, 30 pre-intervention and 15 post-intervention. Paramedics administered epinephrine to 17% (5/30) patients pre-intervention and 67% (10/15) patients post-intervention.The use of a bundled, multifaceted educational intervention including in-person training, decision support tools, and social media improved adherence to updated evidence-based pediatric prehospital protocols.

Pub.: 25 Jan '18, Pinned: 26 Jan '18

Association of Time to Treatment With Short-term Outcomes for Pediatric Patients With Refractory Convulsive Status Epilepticus.

Abstract: Treatment delay for seizures can lead to longer seizure duration. Whether treatment delay is associated with major adverse outcomes, such as death, remains unknown.To evaluate whether untimely first-line benzodiazepine treatment is associated with unfavorable short-term outcomes.This multicenter, observational, prospective cohort study included 218 pediatric patients admitted between June 1, 2011, and July 7, 2016, into the 11 tertiary hospitals in the United States within the Pediatric Status Epilepticus Research Group. Patients, ranging in age from 1 month to 21 years, with refractory convulsive status epilepticus (RCSE) that did not stop after the administration of at least 2 antiseizure medications were included. Patients were divided into 2 cohorts: those who received the first-line benzodiazepine treatment in less than 10 minutes and those who received it 10 or more minutes after seizure onset (untimely). Data were collected and analyzed from June 1, 2011, to July 7, 2016.The primary outcome was death during the related hospital admission. The secondary outcome was the need for continuous infusion for seizure termination. Multivariate analysis of mortality controlled for structural cause, febrile RCSE, age, and previous neurological history (including previous RCSE events). Use of continuous infusions was additionally adjusted for generalized RCSE, continuous RCSE, and 5 or more administrations of antiseizure medication.A total of 218 patients were included, among whom 116 (53.2%) were male and the median (interquartile range) age was 4.0 (1.2-9.6) years. The RCSE started in the prehospital setting for 139 patients (63.8%). Seventy-four patients (33.9%) received their first-line benzodiazepine treatment in less than 10 minutes, and 144 (66.1%) received untimely first-line benzodiazepine treatment. Multivariate analysis showed that patients who received untimely first-line benzodiazepine treatment had higher odds of death (adjusted odds ratio [AOR], 11.0; 95% CI, 1.43 to ∞; P = .02), had greater odds of receiving continuous infusion (AOR, 1.8; 95% CI, 1.01-3.36; P = .047), had longer convulsive seizure duration (AOR, 2.6; 95% CI, 1.38-4.88; P = .003), and had more frequent hypotension (AOR 2.3; 95% CI, 1.16-4.63; P = .02). In addition, the timing of the first-line benzodiazepine treatment was correlated with the timing of the second-line (95% CI, 0.64-0.95; P < .001) and third-line antiseizure medications (95% CI, 0.25-0.78; P < .001).Among pediatric patients with RCSE, an untimely first-line benzodiazepine treatment is independently associated with a higher frequency of death, use of continuous infusions, longer convulsion duration, and more frequent hypotension. Results of this study raise the question as to whether poor outcomes could, in part, be prevented by earlier administration of treatment.

Pub.: 23 Jan '18, Pinned: 24 Jan '18

Association between Weather-Related Factors and Cardiac Arrest of Presumed Cardiac Etiology: A Prospective Observational Study Based on Out-of-Hospital Care Data.

Abstract: The objective of this study was to determine the association between weather-related factors and out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology.This was a prospective observational study performed in a prehospital setting. Data from the Emergency Medical Service in Hamburg (Germany) and data from the local weather station were evaluated over a 5-year period. Weather data (temperature, humidity, air pressure, wind speed) were obtained every minute and matched with the associated rescue mission data. Lowess-Regression analysis was performed to assess the relationship between the above-mentioned weather-related factors and OHCA of presumed cardiac etiology. Additionally, varying measuring-ranges were defined for each weather-related factor in order to compare them with each other with regard to the probability of occurrence of OHCA.During the observation period 1,558 OHCA with presumed cardiac etiology were registered (age: 67 ± 19 yrs; 62% male; hospital admission: 37%; survival to hospital discharge: 6.7%). Compared to moderate temperatures (5 - 25°C), probability of OHCA-occurrence increased significantly at temperatures above 25°C (p = 0.028) and below 5°C p = 0.011). Regarding air humidity, probability of OHCA-occurrence increased below a threshold-value of 75% compared to values above this cut-off (p = 0.006). Decreased probability was seen at moderate atmospheric pressure (1000 hPa - 1020 hPa), whereas increased probability was seen above 1020 hPa (p = 0.023) and below 1000 hPa (p = 0.035). Probability of OHCA-occurrence increased continuously with increasing wind speed (p < 0.001).There are associations between several weather-related factors such as temperature, humidity, air pressure, and wind speed, and occurrence of OHCA of presumed cardiac etiology. Particularly dangerous seem to be cold weather, dry air and strong wind.

Pub.: 19 Jan '18, Pinned: 21 Jan '18

No Benefit in Neurologic Outcomes of Survivors of Out-of-Hospital Cardiac Arrest with Mechanical Compression Device.

Abstract: Out-of-hospital cardiac arrest (OHCA) is a major cause of death and morbidity in the United States. Quality cardiopulmonary resuscitation (CPR) has proven to be a key factor in improving survival. The aim of our study was to investigate the outcomes of OHCA when mechanical CPR (LUCAS 2 Chest Compression System™) was utilized compared to conventional CPR. Although controlled trials have not demonstrated a survival benefit to the routine use of mechanical CPR devices, there continues to be an interest for their use in OHCA.We conducted a retrospective observational study of OHCA comparing the outcomes of mechanical and manual chest compressions in a fire department based EMS system serving a population of 1.4 million residents. Mechanical CPR devices were geographically distributed on 11 of 33 paramedic ambulances. Data were collected over a 36-month period and outcomes were dichotomized based on utilization of mechanical CPR. The primary outcome measure was survival to hospital discharge with a cerebral performance category (CPC) score of 1 or 2.This series had 3,469 OHCA reports, of which 2,999 had outcome data and met the inclusion criteria. Of these 2,236 received only manual CPR and 763 utilized a mechanical CPR device during the resuscitation. Return of spontaneous circulation (ROSC) was attained in 44% (334/763) of the mechanical CPR resuscitations and in 46% (1,020/2,236) of the standard manual CPR resuscitations (p = 0.32). Survival to hospital discharge was observed in 7% (52/763) of the mechanical CPR resuscitations and 9% (191/2,236) of the manual CPR group (p = 0.13). Discharge with a CPC score of 1 or 2 was observed in 4% (29/763) of the mechanical CPR resuscitation group and 6% (129/2,236) of the manual CPR group (p = 0.036).In our study, use of the mechanical CPR device was associated with a poor neurologic outcome at hospital discharge. However, this difference was no longer evident after logistic regression adjusting for confounding variables. Resuscitation management following institution of mechanical CPR, specifically medication and airway management, may account for the poor outcome reported. Further investigation of resuscitation management when a mechanical CPR device is utilized is necessary to optimize survival benefit.

Pub.: 19 Jan '18, Pinned: 21 Jan '18

Effects of night-time and weekend admissions on in-hospital mortality in acute myocardial infarction patients in Japan.

Abstract: Patients admitted to hospital during off-hours may experience poorer quality of care and clinical outcomes. However, few studies have examined the variations in clinical processes and outcomes across admission times and days of the week in acute myocardial infarction (AMI) patients. This study aimed to comparatively analyze the effect of weekend and weekday admissions stratified by admission time on in-hospital mortality in AMI patients.Using a large nationwide administrative database, we analyzed 103,908 AMI patients admitted to 639 Japanese acute care hospitals between April 2011 and March 2015. We divided patients into the following 4 groups: weekday daytime admissions, weekday night-time admissions, weekend daytime admissions, and weekend night-time admissions. A hierarchical logistic regression model was used to comparatively examine in-hospital mortality among the groups after adjusting for age, sex, ambulance use, Killip class, comorbidities, and the number of cardiologists in the admitting hospital. In addition, we also calculated and compared the adjusted odds ratios of various AMI therapies among the groups. The in-hospital mortality rate of weekend daytime admissions was higher than those admitted during other times (weekday daytime: 6.8%; weekday night-time; 6.5%, weekend daytime; 7.6%; weekend night-time: 6.6%; P < 0.001), even after adjusting for the covariates (adjusted odds ratio for weekend daytime admissions: 1.10; 95% confidence interval: 1.03-1.19). The prescription rates of guideline-based medications provided on the first day of admission were higher in night-time admissions than in daytime admissions.In-hospital mortality rates were higher in AMI patients admitted during weekend daytime hours when compared with patients admitted during other times. Furthermore, patients admitted during daytime hours had lower prescription rates of guideline-based medications. Our findings indicate that weekend daytime admissions may be a potential target for improvement in the Japanese healthcare system.

Pub.: 20 Jan '18, Pinned: 21 Jan '18

Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature Review.

Abstract: As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods.This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported.The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support).While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.

Pub.: 20 Jan '18, Pinned: 21 Jan '18

Pediatric Anaphylaxis in the Prehospital Setting: Incidence, Characteristics, and Management.

Abstract: Although hospital presentations for pediatric anaphylaxis have been described in the literature, a minimal amount is known regarding the incidence, characteristics, and management of pediatric anaphylaxis presenting to emergency medical services (EMS).We performed a retrospective observational study of pediatrics (≤16 years) presenting to EMS in Victoria, Australia. Patients with suspected anaphylaxis were included if they were treated with epinephrine before or after EMS arrival. We used descriptive statistics to compare baseline characteristics and linear regression to assess trends in incidence over time.Between July 2008 and June 2016, we identified 2,137 pediatric anaphylaxis presentations. Overall, 59% were male and 70% had pre-existing anaphylaxis. The age-adjusted incidence increased over the study period, from 11.8 presentations per 100,000 person-years in 2008-09 to 38.7 in 2015-16 (p for trend < 0.001). Common suspected allergens included nuts (52%) and dairy/milk formula (17%). In total, 1,333 (62%) patients received epinephrine via an autoinjector, and 51 (2%) from a doctor before EMS arrival. When compared to patients receiving epinephrine after EMS arrival, patients treated prior were more likely to present with vital signs within normal limits, including heart rate (66% vs. 84%, p < 0.001), systolic blood pressure (77% vs. 93%, p < 0.001) and respiratory rate (79% vs. 91%, p < 0.001). The most common EMS interventions were intramuscular epinephrine (45%) and inhaled salbutamol (14%). Three out-of-hospital cardiac arrests were observed, two of whom received endotracheal intubation.The incidence of prehospital pediatric anaphylaxis is increasing significantly. Despite this, most patients are hemodynamically stable on presentation and few require emergency treatments beyond the administration of intramuscular epinephrine.

Pub.: 20 Jan '18, Pinned: 21 Jan '18

Effects of Telestroke on Thrombolysis Times and Outcomes: A Meta-analysis.

Abstract: Telestroke systems are tools, used to provide an advanced stroke care in regions without sufficient neurologic services. We performed this meta-analysis to assess the effects of telemedicine on treatment times and clinical outcomes of acute stroke care.A literature search of PubMed, SCOPUS, and Cochrane CENTRAL was conducted for original studies investigating telemedicine applications in acute stroke care. Dichotomous data on treatment outcomes were pooled as odds ratios (ORs), while continuous data on thrombolysis times were pooled as mean differences (MDs) with 95% confidence interval (CI), using RevMan software (version 5.3).Pooling data from 26 studies (6605 thrombolysed patients) showed no significant differences between the telestroke and control groups in terms of in-hospital mortality (OR = 1.21, 95% CI [0.98, 1.49]), 90-day mortality (OR = 1.08, 95% CI [0.85, 1.37]), symptomatic intracranial hemorrhage (sICH) (OR = 1.10, 95% CI [0.79, 1.53]), and favorable clinical outcome at discharge (OR = 1.03, 95% CI [0.69, 1.53]) and 90 days later (OR = 0.99, 95% CI [0.82, 1.18]). The onset-to-door (OTD) duration (MD = -10.4 minutes, 95% CI [-14.79, -.01]) and length of hospital stay (MD = -0.55 days, 95% CI [-1.02, -0.07]) were significantly shorter in the telestroke group, compared to the control group. Although the overall effect estimate (under the fixed-effect model) showed a significant decrease in the onset-to-treatment (OTT) duration in the telestroke group (MD = -5.83 minutes, 95% CI [-8.57, -3.09]), employing the random-effects model for between-study heterogeneity abolished this significance (MD = -5.90 minutes, 95% CI [-13.23, 1.42]).Telestroke significantly reduced OTD and hospital stay durations in stroke patients without increasing the risk of mortality or sICH. Therefore, telemedicine can improve stroke care in regional areas with minor experience in thrombolysis. Further randomized controlled trials are needed to assess the benefits of telestroke systems, especially in terms of cost-effectiveness and quality of life outcomes.

Pub.: 19 Jan '18, Pinned: 19 Jan '18

Evaluation of the implementation of a 24-hour stroke thrombolysis emergency treatment for patients with acute ischemic stroke.

Abstract: To assess the trends of intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) among patients with acute ischemic stroke (AIS) admitted to our hospital between 2012 and 2014 and investigate the effects of a 24-hours (h) stroke thrombolysis emergency treatment on the intra-hospital clinical data and outcomes of these patients treated with IV rt-PA thrombolysis.Although pre-notification of stroke by emergency medical services have been endorsed by the national recommendations and implemented in some developed countries, the development in China is limited.A retrospective, single-center, observational study.Patients with AIS admitted to our hospital between January 2012 and December 2014 were included; those who received IV rt-PA thrombolysis within 4.5 h of onset were investigated. Demographic characteristics, including age and sex, and clinical data and outcomes, including onset-to-treatment time (OTT), door-to-needle time (DNT), premorbid Modified Rankin Scale score, and proportion of patients treated per year, were all recorded.The proportion of patients with AIS who received thrombolytic therapy within 4.5 h increased from 2012 to 2014. The baseline characteristics of all patients were similar. Since the implementation of 24-h stroke thrombolysis emergency treatment in 2013, the median DNT significantly decreased in 2014 after implementation (42 min) compared with that in 2012 before implementation (81 min) (p < 0.05). Moreover, the admission-to-imaging time (37 vs. 33 vs. 36 min) and OTT (176 vs. 147 vs. 124 min) significantly decreased during the three years (p < 0.05).The 24-h stroke thrombolysis emergency treatment reduced in-hospital delay before thrombolytic therapy but had no effect on the functional outcomes of the patients with AIS.This study provides opportunities to improve the experiences in using 24-h stroke thrombolysis emergency treatment in patients with AIS in clinical practice. This article is protected by copyright. All rights reserved.

Pub.: 19 Jan '18, Pinned: 19 Jan '18

The Effect of Prehospital Transport Time, Injury Severity, and Blood Transfusion on Survival of US Military Casualties in Iraq.

Abstract: Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival.A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003 to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared to Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival.For the total population, percent killed in action (16.6% vs 11.1%), percent died of wounds (5.9% vs 4.3%), and case fatality rate (10.0 vs 8.6) were higher for Iraq vs Afghanistan (P<0.001). Among 1,692 casualties (mean NISS, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (NISS 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (P<0.01) and more frequently within 60 minutes (P<0.01) than other casualties. Critical casualties had lower mortality when blood was received (P<0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (P<0.01).Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan.Performance Improvement and Epidemiological, level IV.

Pub.: 16 Jan '18, Pinned: 19 Jan '18

Ambulance Emergency Response Optimization in Developing Countries

Abstract: The lack of emergency medical transportation is viewed as the main barrier to the access of emergency medical care in low and middle-income countries (LMICs). In this paper, we present a robust optimization approach to optimize both the location and routing of emergency response vehicles, accounting for uncertainty in travel times and spatial demand characteristic of LMICs. We traveled to Dhaka, Bangladesh, the sixth largest and third most densely populated city in the world, to conduct field research resulting in the collection of two unique datasets that inform our approach. This data is leveraged to develop machine learning methodologies to estimate demand for emergency medical services in a LMIC setting and to predict the travel time between any two locations in the road network for different times of day and days of the week. We combine our robust optimization and machine learning frameworks with real data to provide an in-depth investigation into three policy-related questions. First, we demonstrate that outpost locations optimized for weekday rush hour lead to good performance for all times of day and days of the week. Second, we find that significant improvements in emergency response times can be achieved by re-locating a small number of outposts and that the performance of the current system could be replicated using only 30% of the resources. Lastly, we show that a fleet of small motorcycle-based ambulances has the potential to significantly outperform traditional ambulance vans. In particular, they are able to capture three times more demand while reducing the median response time by 42% due to increased routing flexibility offered by nimble vehicles on a larger road network. Our results provide practical insights for emergency response optimization that can be leveraged by hospital-based and private ambulance providers in Dhaka and other urban centers in LMICs.

Pub.: 16 Jan '18, Pinned: 19 Jan '18

Syringe Administration of Epinephrine by Emergency Medical Technicians for Anaphylaxis.

Abstract: In recent years, the costs of epinephrine autoinjectors (EAIs) in the United States have risen substantially. King County Emergency Medical Services implemented the "Check and Inject" program to replace EAIs by teaching emergency medical technicians (EMTs) to manually aspirate epinephrine from a single-use 1 mg/mL epinephrine vial using a needle and syringe followed by prehospital intramuscular administration of the correct adult or pediatric dose of epinephrine for anaphylaxis or serious allergic reaction. Treatment was guided by an EMT protocol that required a trigger and symptoms. We sought to determine if the "Check and Inject" program was safely implemented by EMTs treating presumed prehospital anaphylaxis or serious allergic reaction.We conducted a prospective investigation of all cases treated as part of the "Check and Inject" program from July 2014 through December 2016 in suburban King County, Washington, and January 2016 through December 2016 within the city of Seattle. All cases were prospectively collected using a custom quality improvement data form completed by the first responding EMTs. Two physicians completed a structured review of each EMS medical record to determine if the EMTs followed the Check and Inject protocol and determine if epinephrine was clinically-indicated based on physician review.Of the 411 cases eligible for analysis, EMTs followed the protocol appropriately in 367 (89.3%) cases. In the remaining 44 (10.7%) cases, the EMS incident report form failed to document either a clear inciting allergic trigger or an appropriate symptom from the protocol list. Physician review determined that epinephrine was clinically indicated in 36 of the 44 cases. Among the remaining 8 cases (1.9%) that did not meet protocol criteria and were not clinically-indicated based on physician review, none had a documented adverse reaction to the epinephrine.We observed that EMTs successfully implemented the manual "Check and Inject" program for severe allergic reactions and anaphylaxis in a manner that typically agreed with physician review and without any overt identified safety issues.

Pub.: 16 Jan '18, Pinned: 19 Jan '18