Publications

OBJECTIVES: To investigate post-operative opioid use, functionality, and overall survival following internal fixation for pathologic or impending fractures at 3 and 6 months.

BACKGROUND: Pathologic and impending fractures commonly occur in the proximal femur, and patients may be prescribed opioids prior to surgery and often require opioids for post-operative pain relief. This study compared post-operative opiate usage and ambulatory functional status in patients with impending versus pathologic fractures in the proximal femur.

DESIGN: This was a retrospective case-control study of patients using opioids post-operatively who underwent internal fixation for a pathologic or impending fracture between 2016 and 2022. Preoperative and post-operative opioid usage as well as ambulation status and risk factors at 3 and 6 months associated with post-operative opioid use were recorded.

RESULTS: Twenty-four pathologic fractures and 23 impending fractures were included. Preoperative opioid daily morphine milligram equivalent was significantly higher in the pathologic fracture group, but there were no significant differences at 3 or 6 months. There was statistically significant post-operative improvement in ambulation status in the combined cohort and impending fracture cohort at 3 months and 6 months.

CONCLUSIONS: Although patients did not experience a significant post-operative change in opioid use, patients with pathologic fractures notably required higher opioid dosages preoperatively, and there was overall improvement in function following fixation. Future studies should examine post-operative opioid use with careful consideration of concurrent pain management pain therapies and tumor characteristics.

OBJECTIVE: To examine associations between race, comorbidity, opioid and nonopioid treatment burden, and socioeconomic status (SES) in patients with chronic low back pain (CLBP).

DESIGN: A case-control study.

SETTING: Tertiary academic system.

PARTICIPANTS: A total of 4,193 subjects with CLBP and 4,193 age-, sex-, race-, and region-matched subjects with nonchronic low back pain participated in this study.

MAIN OUTCOME MEASURE(S): The primary outcome measures were prescription frequencies of opioid and nonopioid medications as well as nonpharmaceutical interventions. Secondary measures pertained to the prevalence of comorbidities, race, and SES traits.

RESULTS: The median age of the subjects was 55.50 years, with 61.75 percent female distribution, 48.84 percent Black or African American, 30.65 percent White non-Hispanic, and 15.93 percent non-White Hispanic or Latino among the subjects. Black or African American and non-White Hispanic or Latino identity was associated with higher hardship compared to patients identifying as White non-Hispanic (Tukey-Kramer adjusted p-value < 0.0001). Opioid use was significantly higher in the CLBP group (Cochran-Armitage trend test p-value < 0.0001), and there was a significant positive trend between the number of comorbidities and opioids used. As hardship index group (HIG) increased by 1, the expected number of comorbidities increased by a factor of 1.09 (95 percent confidence interval [CI]: 1.06-1.11), and the expected number of treatments increased by a factor of 1.07 (95 percent CI: 1.04-1.09). Physical therapy and spine procedures had a significant negative relationship with hardship.

CONCLUSIONS: Higher opioid prescribing behavior, particularly for morphine, hydrocodone, and tramadol, exists in patients with CLBP, especially in patients facing hardship and identifying as Black or African American and non-White Hispanic or Latino. Further prospective studies are needed to strengthen causality.

AIM: This study aims to assess the application of opioids for pain control in patients following a cesarean section (CS) at a tertiary referral obstetric hospital.

METHODS: A retrospective cohort audit of CSs in September 2022 was conducted. Medical records were reviewed to capture patient demographics, opioid used, and discharge medications.

RESULTS: Medical records of 46 patients were reviewed. Of those, 46 percent (n = 21) had a non-elective lower uterine CS (NELUSCS), 43 percent (n = 20) had an elective lower uterine CS (ELUSCS), and the remainder had a nonelective classical CS (NEClassicalCS). NEClassicalCS had higher total morphine equivalent opioid use with an average of 245.7 mg, compared with 92.4 mg and 60.1 mg for NELUSCS and ELUSCS, respectively. Tramadol was the most common opioid supplied on discharge (85 percent), followed by buprenorphine (17 percent) and oxycodone/naloxone (15 percent). An average discharge medication supply of 3 days was provided.

CONCLUSIONS: NEClassicalCS procedures had higher use of opioid pain medications. All patients were initiated on opioids post-CS, with 93 percent (n = 43) discharged with at least one opioid.

INTRODUCTION: 'Deaths of despair' (DoD) - encompassing fatalities from suicide, drug overdoses and alcohol-related causes - represent a growing public health crisis. Socioeconomic vulnerability and healthcare disparities are well-documented drivers of DoD. While healthcare contacts preceding despair-related deaths have been studied extensively, the role of ambulance services is underexplored. This study aimed to address this gap by utilising ambulance service data to provide insights into 'calls of despair' received by a UK ambulance service over a 12-month period.

METHODS: This exploratory, retrospective study analysed data collected during 2023 by Yorkshire Ambulance Service (YAS), which serves urban and rural areas with varying levels of deprivation. Calls were included if they involved suicidal ideation and/or drug or alcohol misuse. Data were sourced from computer-aided dispatch and electronic patient records and were analysed to describe call characteristics, demographic profiles, geographical distribution, temporal trends and repeat caller patterns.

RESULTS: In 2023 YAS received 40,870 calls of despair. Nearly half of those calls originated from the most deprived quintile. Urban areas had more than double the rate of calls compared to rural areas. More than half (54%) of the calls involved drug and alcohol misuse, while 43% were related to suicidal ideation. Females were more likely to call for substance misuse (58%) than suicide (46%), and young females (<25 years) represented a disproportionate share of calls. Only 43% of calls resulted in hospital conveyance, suggesting ambulance services capture crises that are not reflected in hospital datasets. Repeat callers were common, with 119 individuals making more than 10 calls each.

CONCLUSION: The findings highlight the utility of ambulance service data in understanding despair-related crises, particularly among socioeconomically disadvantaged and young populations. Ambulance data offers a valuable lens for public health monitoring, capturing acute needs often absent in traditional healthcare datasets. These insights emphasise the need for targeted interventions and cross-sectoral approaches to address the underlying drivers of despair.

AIMS: Professional practice in paramedicine is evolving rapidly, and with this evolution comes a growing ability - and responsibility - for paramedics to contribute to public health. Palliative and end-of-life care (PEOLC) public health is one such area where paramedicine has begun to contribute substantially and might still have significant untapped potential.This article explores developments in PEOLC paramedicine in the Scottish Highlands, an area classified as remote and rural, characterised by low population density, widely spaced communities and susceptibility to health inequalities created by access to healthcare, especially to specialist services. The role of paramedicine in PEOLC is examined in the context of public health priorities and policy, while considering the ability of paramedics to reduce health inequalities by widening access.

BACKGROUND: An informal literature search was conducted to identify interventions through which paramedicine can make improvements to the experience of death and dying on a population level, and lead to substantial healthcare cost savings. These interventions range from reducing PEOLC hospital admissions through effective use of advance care planning, just-in-case medications and independent prescribing and local referral pathways, to effectively managing palliative emergencies amenable to treatment in hospital.

CONCLUSION: Paramedicine could thus play a significant role in making policy ambitions in PEOLC a reality, and conversely, achieving PEOLC policy ambitions might be difficult without support from paramedicine. Paramedics play a growing role in community healthcare provision, especially in remote and rural settings, by providing a link between care provided in the community and specialist services. Better integration of paramedicine into primary and secondary healthcare systems could facilitate turning more PEOLC public health theory into practice. The information collated in this discussion reinforces the need to reflect this potential in research funding allocation, in social and government policy development and in clinical practice decisions made by each individual paramedic.

INTRODUCTION: Vitamin D deficiency can impact health and well-being and may affect workplace performance. Shift, indoor and night working, alongside variable awareness of vitamin D, likely puts ambulance staff at an increased risk of deficiency. Screening in one ambulance service detected that 46% of staff had insufficient or deficient vitamin D levels (i.e. 50.0 nmol/L or less, as defined by NICE). The aim of the EVOLVED study was to explore the behaviours and lifestyle factors of ambulance service staff with a range of vitamin D levels and understand the impacts on their work and personal lives.

METHODS: A purposive sample of 40 ambulance staff was recruited over four months and invited to a one-hour online semi-structured interview. Interviews explored behaviours and lifestyle factors of those above and below the recommended adequate vitamin D levels and included questions about the impacts of vitamin D level on personal and professional well-being, with the opportunity to suggest possible improvements. Interview transcription analysis was undertaken using an intuitive thematic analysis strategy.

RESULTS: Participants were aged between 21 and 69 years and worked in varying roles, including control room (n = 9), operational (n = 20) and support staff (n = 11) and included those from diverse ethnic backgrounds to represent Trust demographics. Five themes were identified: reaction to result; diet; deficiency symptoms and impacts; impact of work on maintaining adequate vitamin D levels; and activity levels.

CONCLUSION: A lack of awareness of vitamin D-related issues was identified, alongside a variety of improvement suggestions, including participants emphasising the importance of awareness, to allow staff to take responsibility to promote their own health and well-being. Strategies to promote awareness of vitamin D should be considered to improve staff well-being in this area. Participants positively perceived research exploring staff health and well-being, highlighting this as an area for future research.

INTRODUCTION: Simulation-based learning (SBL) is a recognised teaching and learning tool within higher education (HE) and one capable of facilitating skill retention and knowledge retrieval. Successfully achieving these outcomes relies on effective design, delivery and debriefing; yet a limited range of publications draw together these fundamental components. High-fidelity simulation (HFS) describes a sub-division of SBL that, in recent years, has generated traction within healthcare education.

AIMS: To support educators in orchestrating HFS with greater impact and influence, the author set out to compose an article outlining five constructs that collectively possess scope to optimise HE teaching and learning outcomes. These five constructs consist of: (1) creating a believable scenario; (2) integrating the five principles of 'fidelity harmony'; (3) selecting an appropriate modality; (4) adopting a clear pedagogical stance; and (5) amalgamating concepts of experiential learning theory into the briefing and debriefing. When dynamically incorporated, important gaps between theory and practice can be bridged and learner experience will be significantly enhanced.

CONCLUSION: This article offers HE educators a series of recommendations for creating deeply immersive learning experiences for augmenting learner performance, and provides a new definition for HFS, which challenges the erroneous notion that 'high fidelity' represents 'high technology'.

INTRODUCTION: In the United Kingdom, ambulance services attempt resuscitation on 30,000 people per year, with fewer than 9% surviving and leaving hospital. Correct ventilation during out-of-hospital cardiac arrest (OHCA) is essential, as both hypo- and hyperventilation are linked to increased mortality. Despite this, ventilations are frequently given outside of recommended guidelines. Devices providing real-time feedback on ventilations aim to improve performance. While systematic reviews show that real-time feedback devices improve chest compression performance, evidence regarding ventilation feedback devices (VFDs) has not yet been synthesised. This literature review aimed to synthesise evidence on the effects of VFDs in OHCAs.

METHODS: Databases searched in March 2025 included MEDLINE, CINAHL and Embase. Inclusion criteria were papers published after 1 January 2018, in English, involving adults, focused on clinical practice or simulated OHCA and employing primary research with interventional study designs. The intervention criteria required a VFD that measured and provided feedback on both tidal volume and ventilation rate. Study quality was assessed using the Critical Appraisal Skills Programme checklist. Methods for synthesis included a narrative summary of findings.

RESULTS: The searches yielded 793 results. Nine studies met the inclusion criteria: seven simulation studies and two real-world studies. Simulation studies confirmed that ambulance clinicians often did not meet advanced life support guidelines for ventilations. Introducing VFDs significantly improved compliance, accuracy and precision of delivered ventilations in simulated OHCA scenarios. Real-world studies found an increase in ventilation compliance; however, the study examining patient outcomes was of low quality and did not find a statistically significant effect.

CONCLUSION: The evidence suggests that VFDs are beneficial in simulated OHCA. Real-world studies suggest that the increase in ventilation performance may not be as significant as shown in simulation studies, and their effect on clinical outcomes has not yet been adequately explored.

INTRODUCTION: Previous investigations reveal that protracted resuscitative efforts are associated with poorer long-term patient outcomes. Aside from certain patient characteristics and interventions, such as shockable rhythms, bystander CPR and early defibrillation, little is known about factors influencing resuscitation duration and time to return of spontaneous circulation (ROSC). We hypothesised that early public safety answering point (PSAP) call-receipt-to-pressor (PSAP-to-pressor) administration would decrease the pressor-to-ROSC interval and shorten low-flow duration. Our objective was to quantify the relationship between the PSAP-to-pressor and pressor-to-ROSC intervals.

METHODS: We conducted a retrospective analysis using the 2020 ESO dataset containing calls from January to December 2020. Adults with non-traumatic, bystander-witnessed arrests were included. A Cox proportional hazard model was used to determine the association between PSAP-to-pressor interval and pressor-to-ROSC interval while controlling for potential confounders. The end of the event was defined as ROSC, field termination of resuscitation or hospital arrival without ROSC. Patients without ROSC upon hospital arrival were right censored.

RESULTS: Overall, 10,093 patients had data sufficient for analysis. The mean age of the participants was 65.3 (±15.5) years and 64.5% were male. Presumed cardiac aetiology was present in 83.7% of arrests, 29.4% presented with a shockable rhythm and 35.9% attained ROSC. The mean PSAP-to-pressor and pressor-to-ROSC intervals were 16.2 (±5.0) and 14.6 (±11.1) minutes, respectively. The mean time from the first adrenaline administration to the end of the event was 32.7 (±1.0), 41.5 (±1.2) and 51.6 (±3.8) minutes for the 0-10-, 11-20- and 21-30-minute PSAP-to-pressor intervals, respectively (p <0.001). After controlling for confounders, the PSAP-to-pressor time interval was associated with decreased likelihood of ROSC (HR = 0.97 per minute, p <0.001). When stratified by 10-minute increments with 0-10 minutes as reference, PSAP-to-pressor was negatively associated with ROSC for the 11-20- (HR = 0.86, p = 0.002) and 21-30- (HR = 0.66, p <0.001) minute categories.

CONCLUSION: This retrospective analysis from a national database revealed that increasing delays to first adrenaline administration were associated with prolonged resuscitation duration after drug administration and decreasing likelihood of ROSC.