Publications

PURPOSE: Optic neuropathy is a leading cause of blindness. Autophagy activation has been reported following optic nerve injury, but its precise role remains unclear. We investigated the involvement of autophagy in the early stages of optic nerve injury and explored potential therapeutic strategies.

METHODS: A mouse optic nerve crush (ONC) model was established. Autophagy levels were assessed at different time points using electron microscopy and markers LC3 and Beclin-1. The relationship between autophagy and cell death was examined by Beclin-1 co-localization combined with TUNEL. Receptor-interacting protein (RIP3) knockout mice were used to determine its regulatory role in microglial autophagy-related cell death. Finally, the neuroprotective effect of inhibiting this pathway was evaluated with pharmacological inhibitors.

RESULTS: A peak in autophagy activation was observed 1 day after optic nerve injury. Beclin-1 was expressed across various cell populations, including retinal ganglion cells (RGCs), microglia, and astrocytes. Excessive autophagy activation induced cell death specifically in microglia, not in RGCs or astrocytes. Knockout of RIP3 significantly reduced microglial autophagy-related cell death and attenuated retinal neuroinflammation. Moreover, intravitreal administration of the RIP3 inhibitor GSK-872 or the autophagy inhibitor 3-MA reduced RGC death and improved visual function.

CONCLUSIONS: Autophagy-related cell death represents a novel mechanism of microglial activity. Targeting RIP3-mediated autophagy may provide a promising strategy for early intervention in optic neuropathies.

INTRODUCTION: Suicide rates in England and Wales remain consistently high, with 10.7 deaths recorded per 100,000 people. The North East had the highest suicide rate in seven of the 10 most recent years. The most common method of suicide is hanging, which accounts for 60% of deaths. This study compares the latest findings regarding hangings within the North East of England to a previous service evaluation within this area.

METHODS: A service evaluation taken from a comprehensive pre-hospital trauma audit database that included children was subdivided into three specific groups: out-of-hospital cardiac arrest (OHCA) due to hanging, strangulation and suffocation; attempted hanging, strangulation and suffocation (non-OHCA); and threatened hanging, strangulation and suffocation. Key findings within this evaluation are compared to a previous North East Ambulance Service evaluation, which covered the period from 1 December 2018 to 31 November 2020 and recorded 604 cases. This evaluation recorded a greater number of cases and highlighted that the number of hanging cases had doubled.

RESULTS: This study reports on hanging cases between 1 December 2020 and 29 February 2024 and includes 2001 cases. The number of cases increased from 0.8 per day in the previous evaluation to 1.6 cases per day. The data showed rises within the female population in both the non-OHCA and threatened categories. There was found to be a rise in patients who had made a previous suicide attempt by hanging. Two thirds of cases were found to be from the most deprived postcodes.

CONCLUSION: The number of hanging cases within the North East region continues to rise. The second evaluation included data recorded over the COVID-19 pandemic and national lockdown period and may suggest an increase in hanging attempts within vulnerable groups of patients. The data suggests a socio-economic link, which may account for the high numbers of hangings being recorded in the most deprived areas of the North East.

Despite decades of intense study, the spatiotemporal processing of letters in visual word recognition has yet to be elucidated, with the debate largely focusing on whether individual letters are processed serially or in parallel. The present study investigated the processing of individual letters and letter combinations through time in visual word recognition using displays where signal-to-noise ratio (SNR) varied randomly throughout a 200 ms exposure duration. In Experiment 1, SNR varied either homogeneously across all letters or independently for each letter position (cf. heterogeneous sampling). Reading accuracy was substantially greater with homogeneous than heterogeneous sampling. Experiment 2 again used heterogeneous sampling and classification images (CIs) were calculated for individual letter positions or conjunctions thereof, reflecting processing efficiency according to time during target exposure. These CIs or their Fourier transforms were passed to a classifier to assess differences in the result patterns across individual letter positions or their conjunctions. Overall, the present results indicate the following: (1) significant parallel letter processing capacity throughout exposure duration; (2) dissociable processing mechanisms for each letter position; and (3) letter position-specific mechanisms for letter conjunctions that are distinct from those for individual letters. The results also provide evidence relevant to the neural code underlying the perceptual mechanisms that were uncovered.

INTRODUCTION: The paramedic profession is developing at speed internationally. To stabilise this growth, the profession must produce, maintain and enhance its own evidence base. This requires doctoral-level training and development of paramedics to join and lead multidisciplinary research teams in order to produce robust science. The aim of this article is to provide an overview of paramedics across the globe who have completed, or are studying for, a doctoral-level qualification in the field of paramedicine.

METHODS: The Paramedic PhD registry - an English-language open-access voluntary submission platform established in November 2017 - was used as the primary source of data to inform this article. The registry relied on voluntary submissions of doctoral-level qualification details from the field of paramedicine, including doctorate title, details, institution, primary supervisor and date range. The registry was publicly available and received no funding or sponsorship. Paramedics, along with other clinical and non-clinical researchers, were able to submit their doctorate details to the registry at any time.

RESULTS: From its inception to February 2025, 305 doctorates have been registered on Paramedic PhD. Of these, 268 were from self-identified paramedics. These paramedics were spread across the United Kingdom (n = 80), Australia (n = 75), the United States (n = 27), Saudi Arabia (n = 21), Canada (n = 17) and South Africa (n = 13), along with 18 other countries. The earliest doctoral qualification by a paramedic was completed in 2002. Paramedics undertook the Doctor of Philosophy (n = 224), the Professional Doctorate (n = 32) and the Doctor of Education (n = 12) routes, with 129 registered as complete. The most popular categories were education (n = 55), professional development (n = 39) and cardiac arrest (n = 21).

CONCLUSION: As more paramedics focus their careers on research and the pursuit of doctoral-level qualifications, the volume and quality of evidence will continue to rise, improving outcomes for patients and staff across the globe.

INTRODUCTION: Pre-hospital research has unique challenges. Ambulance clinicians are required to enrol patients in research trials during emergency situations, often remote from the research team at time of recruitment. As newly qualified paramedics (NQPs) represent a significant and growing proportion of ambulance clinicians, it is important to establish whether they can safely and effectively recruit patients to clinical trials. This article reports a post-hoc analysis of the PACKMaN trial, a large, double-blind randomised controlled trial of an investigational medicinal product of ketamine versus morphine in the pre-hospital setting.

METHODS: Adverse events (AEs) and serious adverse events (SAEs) experienced by patients recruited to the PACKMaN trial, as well as protocol non-compliances (NCs) experienced by paramedics during the trial, were retrospectively analysed. We compared recruitment, incidence and type of AE, as well as incidence of SAEs and NCs dichotomised by paramedic experience.

RESULTS: Of the 458 patients, 259 (56.6%) and 199 (43.4%) were recruited by experienced paramedics and NQPs, respectively. Incidence of AEs was similar regardless of experience: experienced paramedics reported 128/259 (49.8%) and NQPs reported 91/199 (45.7%) (OR 0.86 95% CI [0.60-1.25]). Incidence of SAEs were slightly increased in the NQP group (8/199 (4.0%)), compared to experienced paramedics (4/259 (1.5%)); however, this was not statistically significant (OR 2.67, 95% CI [0.66-9.00]). NC was similar in both groups: experienced paramedics 3/259 (1.2%) and NQPs 6/199 (3.0%) (OR 2.65 95% CI [0.66-10.74]).

CONCLUSION: In a double-blind controlled trial of an investigational medicinal product, there was no statistical difference in the incidence of AEs or NCs between NQPs and experienced paramedics. NQPs made an important contribution to patient recruitment in this study, improving the generalisability. SAEs and NCs were rare, and patients received analgesics safely. There was no correlation between experience and AE likelihood, and no safety concerns identified arising from NQP participation. Our findings demonstrate that NQPs can safely recruit patients to clinical trials.

INTRODUCTION: Incidental findings are unexpected abnormal findings during routine care. Urgent and emergency care (UEC) professionals in emergency departments, ambulance services and urgent treatment centres are presented with opportunities for early intervention and could use incidental findings to reduce long-term disease burden. However, limited evidence exists regarding the identification and management of incidental findings, particularly in pre-hospital settings. This scoping review aimed to investigate existing primary research on incidental findings across UEC settings.

METHODS: Two databases were searched (MEDLINE Complete and CINAHL Complete) in June 2024. Two researchers screened results, performed reference and citation searching and reviewed full texts. Included studies underwent data extraction and critical appraisal before being synthesised narratively.

RESULTS: Initial searches yielded 245 records; 10 were included for full-text screening. An additional 418 articles were identified through reference and citation searching, of which 38 were included for full-text screening. Eighteen articles were included after screening, with an additional two added from another source. Articles explored incidental findings such as elevated blood pressure, atrial fibrillation, late-returning laboratory results and abnormal findings on sonography. Reported prevalence varied, with only 17.4% of patients with elevated blood pressure referred for follow-up, though 40.6% were later diagnosed with hypertension. New-onset atrial fibrillation was found in 2.7% of patients not transported by ambulance service. Between 47% and 68% of patients with abnormal sonographic findings were referred for further care.Incidental findings are moderately prevalent across UEC settings, but referrals for follow-up are inconsistent. Factors influencing referrals include patient demographics, ownership of findings, time constraints and clinician education.

CONCLUSION: Further research is required to understand socio-demographic characteristics and how they influence the decision to act on incidental findings. Streamlined low-effort referral mechanisms and clear delineation of responsibility may improve outcomes. Further research is needed, particularly in ambulance service practice, where findings differ from other settings and remain underexplored.

INTRODUCTION: This study explored emergency medical dispatchers' (EMDs) experiences of using the Medical Priority Dispatch System (MPDS) Protocol 24 (P24) to gain insights into its usability and appropriateness for triaging maternity calls.

METHODS: A semi-structured cross-sectional survey comprising a combination of 43 closed and open-ended questions was administered to EMDs in a large UK urban ambulance service. EMDs were invited to anonymously complete the questionnaire over a six-week period; a total of 89 EMDs responded. Six key themes were explored.

RESULTS: Participants felt confident in their knowledge of maternal emergencies, but desired further training (89.9%). When a part of the baby was visible (87.6%) and known complications with the current pregnancy (85.4%) were the clinical factors mostly associated with maternal emergencies and were already well accounted for by P24. The patient being alone (47.2%) or in a public place (42.7%) was seen as an increased risk. However, in general, participants were less likely to associate these non-clinical factors with maternity emergencies.Specific questions were reported to be challenging to elicit a clear answer from callers, particularly those around the presence of known high-risk complications (44.9%), contractions (60.7%), miscarriage (51.7%) or complications with a newborn (52.8%). P24 instructions could do more to assist with difficult calls (68.5%) and with calls related to miscarriage (49.4%) or termination (29.2%). Participants felt the acuity level associated with certain calls could be refined, such as those related to uncomplicated births (25.8%), first-trimester serious haemorrhage (18.0%) and abdominal pain <5 weeks with no tissue or foetus (7.9%).

CONCLUSION: Overall, participants felt that maternity emergencies were mostly identified well but that improvements could be made to both the P24 questions and instructions, and that further training would improve user experience. Future research should assess the diagnostic accuracy of P24 and determine, if necessary, which questions could be refined to improve the effectiveness of EMD triage of maternity emergencies.

INTRODUCTION: The Additional Roles Reimbursement Scheme expands roles, including that of paramedics, and funding into the existing workforce in primary care. This has been laid out in the five-year general practice contract reform framework, with the goal of transforming and evolving the way in which primary care is delivered. Paramedics are rotating from the ambulance service into primary care to help tackle workforce shortages. The aim of this qualitative study was to investigate the experience of those paramedics rotating into primary care from the ambulance service.

METHODS: This qualitative study utilised convenience sampling of paramedics who were on rotation in primary care within one ambulance service. Eight semi-structured interviews took place.

RESULTS: Three key themes of supervision, education and workforce planning were established. Day-to-day supervision was often seen; however, more formal supervision, such as having a designated mentor and completing the first-contact practitioner (FCP) portfolio, was inconsistent. There were clear core skill educational gaps between ambulance paramedics and those that work in primary care. A workforce model, and how this affects the wider system, was discussed, including issues of retention, decision making and referrals.

CONCLUSION: Inconsistent supervision in primary care for FCP roles is evident across disciplines, with physiotherapists acknowledging the same shortcomings. There is a need for more structured support, with access to a mentor / supervision with any FCP role. Within the primary care training period there is a need for a training needs analysis and educational days to support core skills gaps. Due to the positive workforce planning, it is seen that rotations in primary care help to retain staff and have some clear system benefits. To further this, an expansion of the rotations into other areas within the NHS should be considered.

INTRODUCTION: At the end of life, anticipatory or just-in-case (JIC) medications may help manage patients' symptoms. Sometimes, emergency ambulances attend patients for whom JIC medications have not been prescribed. In Wales, UK, a Welsh Ambulance Services University NHS Trust (WAST) JIC intervention was launched in May 2020 in response to COVID-19, to enable ambulance paramedics to administer JIC medications to patients for whom they had not previously been prescribed. The ambulance JIC intervention is an ongoing feature of WAST pre-hospital care but has received limited evaluation. This study will explore the rationale, usage, costs and views of stakeholders of the WAST JIC medications intervention.

METHODS: We will employ a multi-method observational study design that incorporates both quantitative and qualitative aspects, informed by implementation science. We will prepare a detailed description of the WAST JIC medications intervention, its rationale and its use. We will interview paramedics and doctors who have provided the intervention, as well as paid and informal carers who were present during the care episode. We will also hold a focus group with paramedics who have not administered the intervention and undertake a cost analysis to estimate costs and savings associated with the intervention. We will use descriptive statistics to analyse quantitative data and a framework approach for qualitative data.

CONCLUSION: This study, which focuses on the voices of patient advocates and practitioners, has the potential to shape future provision of this and similar services in WAST and other care providers.

INTRODUCTION: Ambulance clinicians manage a wide range of complex and often challenging clinical presentations. Despite spending significant time with patients during the pre-hospital phase, they rarely receive meaningful feedback on the diagnosis, progress or outcome of their patients from the hospital. This lack of structured feedback represents a missed opportunity for learning and emotional closure. To address this gap, Wexham Park Hospital (WPH) introduced a formal patient outcome feedback service for ambulance clinicians. This mixed-methods service evaluation aimed to explore the effectiveness and impact of the feedback service.

METHODS: An electronic questionnaire was distributed to all previous and present users of the feedback service. The questionnaire included 12 quantitative and qualitative items designed to explore users' experience. Quantitative data were analysed descriptively, while qualitative responses underwent thematic analysis by all authors to identify key themes of the service's impact.

RESULTS: A total of 101 questionnaires were completed and included in the analysis. Satisfaction with the service was very high: 98% of respondents reported being satisfied; 91% indicated that the feedback received was likely to influence their clinical practice; and 68% reported an impact on their mental well-being resulting from the feedback, assumed to be positive.Four domains of improved clinical care were identified by thematic analysis: diagnostic insight and knowledge development; clinical decision-making; confidence and professional growth; continued learning and reflection. The feedback was perceived to have a positive emotional and mental effect, providing clinicians with closure, peace of mind, reassurance and a reduction in uncertainty.

CONCLUSION: The service was viewed by users to enhance clinical practice, support well-being and improve patient care. It fostered confidence in diagnostic and decision-making skills, reduced anxiety and uncertainty and encouraged self-reflection and professional growth. We recommend that feedback services be implemented at facilities where pre-hospital teams interface with hospital care providers.