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Terhalle L, Arntz L, Hoffmann F, Arnold I, Hafner L, Picking-Pitasch L, Zuppinger J, Delport Lehnen K, Leuppi J, Somasundaram R, Nickel CH, Bingisser R. Nonspecific stress biomarkers for mortality prediction in older emergency department patients presenting with falls: a prospective multicenter observational study. Intern Emerg Med 2024:10.1007/s11739-024-03693-6. [PMID: 38960969 DOI: 10.1007/s11739-024-03693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/21/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Older patients presenting to the emergency department (ED) after falling are increasingly prevalent. Falls are associated with functional decline and death. Biomarkers predicting short-term mortality might facilitate decisions regarding resource allocation and disposition. D-dimer levels are used to rule out thromboembolic disease, while copeptin and adrenomedullin (MR-proADM) may be used as measures of the patient`s stress level. These nonspecific biomarkers were selected as potential predictors for mortality. METHODS Prospective, international, multicenter, cross-sectional observation was performed in two tertiary and two regional hospitals in Germany and Switzerland. Patients aged 65 years or older presenting to the ED after a fall were enrolled. Demographic data, Activities of Daily Living (ADL), and D-dimers were collected upon presentation. Copeptin and MR-proADM levels were determined from frozen samples. Primary outcome was 30-day mortality; and secondary outcomes were mortality at 90, 180, and 365 days. RESULTS Five hundred and seventy-two patients were included. Median age was 83 [IQR 78, 89] years, 236 (67.7%) were female. Mortality overall was 3.1% (30 d), 5.4% (90 d), 7.5% (180 d), and 13.8% (365 d), respectively. Non-survivors were older, had a lower ADL index and higher levels of all three biomarkers. Elevated levels of MR-proADM and D-dimer were associated with higher risk of mortality. MR-proADM and D-dimer showed high sensitivity and low negative likelihood ratio regarding short-term mortality, whereas copeptin did not. CONCLUSION D-dimer and MR-proADM levels might be useful as prognostic markers in older patients presenting to the ED after a fall, by identifying patients at low risk of short-term mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02244983.
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Affiliation(s)
- Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Laura Arntz
- Emergency Department, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Hoffmann
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabelle Arnold
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Livia Hafner
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Joanna Zuppinger
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
- Emergency Department, Cantonal Hospital Basel-Landschaft, Liestal, Switzerland
| | - Karen Delport Lehnen
- Emergency Department, Cantonal Hospital Basel-Landschaft Campus Bruderholz, Binningen, Switzerland
| | - Jörg Leuppi
- Medical Faculty, University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | - Rajan Somasundaram
- Emergency Department, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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2
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Ivic R, Nurmi J, Kurland L, Vicente V, Lindström V, Djärv T, Kaartinen J, Castrén M, Bohm K. Soluble urokinase plasminogen activator receptor and lactate as prognostic biomarkers in patients presenting with non-specific chief complaints in the pre-hospital setting - the PRIUS-study. Scand J Trauma Resusc Emerg Med 2021; 29:116. [PMID: 34384460 PMCID: PMC8358910 DOI: 10.1186/s13049-021-00908-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency Medical Services (EMS) are faced daily with patients presenting with non-specific chief complaints (NSC). Patients presenting with NSCs often have normal vital signs. It has previously been established that NSCs may have a serious underlying condition that has yet to be identified. The aim of the current study was to determine if soluble urokinase plasminogen activator receptor (suPAR) and lactate could be used to identify serious conditions among patients presenting with NSCs to the EMS. The secondary aim was to describe the prognostic value for mortality in the group. METHOD A blinded prospective observational cohort study was conducted of patients brought to the ED by ambulance after calling the national emergency number 112 and who were assessed as having NSC by the EMS. Biomarkers were measured during index EMS assessment before transportation to the ED. Patients were followed via EMS and hospital electronic health records. Descriptive and logistic regression analyses were used. RESULTS A total of 414 patients were included, with a median age of 82 years. A serious condition was present in 15.2% of the patients. Elevated suPAR above 3 ng/ml had a positive likelihood ratio (LR+) of 1.17 and a positive predictive value (PPV) of 17.3% as being predictive of a prevalent serious condition. Elevated suPAR above 9 ng/ml had LR+ 4.67 and a PPV of 16.7% as being predictive of 30-day mortality. Lactate was not significantly predictive. CONCLUSION Pre-hospital suPAR and lactate cannot differentiate serious conditions in need of urgent treatment and assessment in the ED among patients presenting with non-specific chief complaints. suPAR has shown to be predictive of 30-day mortality, which could add some value to the clinical assessment. TRIAL REGISTRATION NCT03089359. Registered 20 March 2017, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03089359 .
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Affiliation(s)
- Robert Ivic
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. .,Academic Emergency Medical Service, Region Stockholm, Stockholm, Sweden.
| | - Jouni Nurmi
- Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Lisa Kurland
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department for Medical Sciences, Örebro University, Örebro, Sweden
| | - Veronica Vicente
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Veronica Lindström
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, division of nursing, Stockholm, Sweden.,Samariten Ambulance Stockholm, Stockholm, Sweden
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johanna Kaartinen
- Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Maaret Castrén
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Katarina Bohm
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Emergency Medicine, Södersjukhuset, Stockholm, Sweden
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3
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Disposition Decision Support by Laboratory Based Outcome Prediction. J Clin Med 2021; 10:jcm10050939. [PMID: 33804332 PMCID: PMC7957752 DOI: 10.3390/jcm10050939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/13/2021] [Accepted: 02/23/2021] [Indexed: 12/05/2022] Open
Abstract
Disposition is one of the main tasks in the emergency department. However, there is a lack of objective and reliable disposition criteria, and diagnosis-based risk prediction is not feasible at early time points. The aim was to derive a risk score (TRIAL) based on routinely collected baseline (TRIage level and Age) and Laboratory data—supporting disposition decisions by risk stratification based on mortality. We prospectively included consecutive patients presenting to the emergency department over 18 weeks. Data sets of routinely collected baseline (triage level and age) and laboratory data were used for multivariable logistic regression to develop the TRIAL risk score predicting mortality. Routine laboratory variables and disposition cut-offs were chosen beforehand by expert consensus. Risk stratification was based on low risk (<1%), intermediate risk (1–10%), and high risk (>10%) of in-hospital mortality. In total, 8687 data sets were analyzed. Variables identified to develop the TRIAL risk score were triage level (Emergency Severity Index), age, lactate dehydrogenase, creatinine, albumin, bilirubin, and leukocyte count. The area under the ROC curve for in-hospital mortality was 0.93. Stratification according to the TRIAL score showed that 67.5% of all patients were in the low-risk category. Mortality was 0.1% in low-risk, 3.5% in intermediate-risk, and 26.2% in high-risk patients. The TRIAL risk score based on routinely available baseline and laboratory data provides prognostic information for disposition decisions. TRIAL could be used to minimize admission in low-risk and to maximize observation in high-risk patients.
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4
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Bingisser R, Nickel CH. How should nonspecific complaints be defined? Comment to: "nonspecific complaints (NSCs) in the emergency department". Scand J Trauma Resusc Emerg Med 2020; 28:110. [PMID: 33176834 PMCID: PMC7659042 DOI: 10.1186/s13049-020-00805-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/28/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, CH-4031, Basel, Switzerland.
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, CH-4031, Basel, Switzerland
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5
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Kaeppeli T, Rueegg M, Dreher-Hummel T, Brabrand M, Kabell-Nissen S, Carpenter CR, Bingisser R, Nickel CH. Validation of the Clinical Frailty Scale for Prediction of Thirty-Day Mortality in the Emergency Department. Ann Emerg Med 2020; 76:291-300. [PMID: 32336486 DOI: 10.1016/j.annemergmed.2020.03.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/20/2020] [Accepted: 03/25/2020] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVE We validate the Clinical Frailty Scale by examining its independent predictive validity for 30-day mortality, ICU admission, and hospitalization and by determining its reliability. We also determine frailty prevalence in our emergency department (ED) as measured with the Clinical Frailty Scale. METHODS This was a prospective observational study including consecutive ED patients aged 65 years or older, from a single tertiary care center during a 9-week period. To examine predictive validity, association with mortality was investigated through a Cox proportional hazards regression; hospitalization and ICU transfer were investigated through multivariable logistic regression. We assessed reliability by calculating Cohen's weighted κ for agreement of experts who independently assigned Clinical Frailty Scale levels, compared with trained study assistants. Frailty was defined as a Clinical Frailty Scale score of 5 and higher. RESULTS A total of 2,393 patients were analyzed in this study, of whom 128 died. Higher frailty levels were associated with higher hazards for death independent of age, sex, and condition (medical versus surgical). The area under the curve for 30-day mortality prediction was 0.81 (95% confidence interval [CI] 0.77 to 0.85), for hospitalization 0.72 (95% CI 0.70 to 0.74), and for ICU admission 0.69 (95% CI 0.66 to 0.73). Interrater reliability between the reference standard and the study team was good (weighted Cohen's κ was 0.74; 95% CI 0.64 to 0.85). Frailty prevalence was 36.8% (n=880). CONCLUSION The Clinical Frailty Scale appears to be a valid and reliable instrument to identify frailty in the ED. It might provide ED clinicians with useful information for decisionmaking in regard to triage, disposition, and treatment.
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Affiliation(s)
- Tobias Kaeppeli
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Marco Rueegg
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Dreher-Hummel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Søren Kabell-Nissen
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | | | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland.
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6
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Sailer JM, Bleckwenn M. [Non specific complaints. Somatization disorder or somatic disease?]. MMW Fortschr Med 2020; 162:34-37. [PMID: 31960307 DOI: 10.1007/s15006-020-0057-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Johann Michael Sailer
- Instituts für Hausarztmedizin der Universität Bonn, Venusberg Campus 1, D-53127, Bonn, Deutschland.
| | - Markus Bleckwenn
- Medizinische Faktultät der Universität Leipzig, Leipzig, Deutschland
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7
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Gonzalez Del Castillo J, Wilson DC, Clemente-Callejo C, Román F, Bardés-Robles I, Jiménez I, Orviz E, Dastis-Arias M, Espinosa B, Tornero-Romero F, Giol-Amich J, González V, Llopis-Roca F. Biomarkers and clinical scores to identify patient populations at risk of delayed antibiotic administration or intensive care admission. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:335. [PMID: 31665092 PMCID: PMC6819475 DOI: 10.1186/s13054-019-2613-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/13/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The performance of blood biomarkers (mid-regional proadrenomedullin (MR-proADM), procalcitonin (PCT), C-reactive protein (CRP), and lactate) and clinical scores (Sequential Organ Failure Assessment (SOFA), National Early Warning Score (NEWS), and quick SOFA) was compared to identify patient populations at risk of delayed treatment initiation and disease progression after presenting to the emergency department (ED) with a suspected infection. METHODS A prospective observational study across three EDs. Biomarker and clinical score values were calculated upon presentation and 72 h, and logistic and Cox regression used to assess the strength of association. Primary outcomes comprised of 28-day mortality prediction and delayed antibiotic administration or intensive care (ICU) admission, whilst secondary outcomes identified subsequent disease progression. RESULTS Six hundred eighty-four patients were enrolled with hospitalisation, ICU admission, and infection-related 28-day mortality rates of 72.8%, 3.4%, and 4.4%, respectively. MR-proADM and NEWS had the strongest association with hospitalisation and the requirement for antibiotic administration, whereas MR-proADM alone had the strongest association with ICU admission (OR [95% CI]: 5.8 [3.1 - 10.8]) and mortality (HR [95% CI]: 3.8 [2.2 - 6.5]). Patient subgroups with high MR-proADM concentrations (≥ 1.77 nmol/L) and low NEWS (< 5 points) values had significantly higher rates of ICU admission (8.1% vs 1.6%; p < 0.001), hospital readmission (18.9% vs. 5.9%; p < 0.001), infection-related mortality (13.5% vs. 0.2%; p < 0.001), and disease progression (29.7% vs. 4.9%; p < 0.001) than corresponding patients with low MR-proADM concentrations. ICU admission was delayed by 1.5 [0.25 - 5.0] days in patients with high MR-proADM and low NEWS values compared to corresponding patients with high NEWS values, despite similar 28-day mortality rates (13.5% vs. 16.5%). Antibiotics were withheld in 17.4% of patients with high MR-proADM and low NEWS values, with higher subsequent rates of ICU admission (27.3% vs. 4.8%) and infection-related hospital readmission (54.5% vs. 14.3%) compared to those administered antibiotics during ED treatment. CONCLUSIONS Patients with low severity signs of infection but high MR-proADM concentrations had an increased likelihood of subsequent disease progression, delayed antibiotic administration or ICU admission. Appropriate triage decisions and the rapid use of antibiotics in patients with high MR-proADM concentrations may constitute initial steps in escalating or intensifying early treatment strategies.
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Affiliation(s)
- Juan Gonzalez Del Castillo
- Emergency Department, Hospital Clínico San Carlos, Madrid, Spain.,San Carlos Clinical Research Institute Hospital San Carlos (IdISSC), Madrid, Spain
| | - Darius Cameron Wilson
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain.
| | | | - Francisco Román
- Emergency Department, Short Stay Unit and Home Hospitalization Unit, Hospital General de Alicante, Alicante, Spain
| | | | - Inmaculada Jiménez
- Emergency Department, Short Stay Unit and Home Hospitalization Unit, Hospital General de Alicante, Alicante, Spain
| | - Eva Orviz
- Internal Medicine Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Macarena Dastis-Arias
- Clinical Laboratory Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Begoña Espinosa
- Emergency Department, Short Stay Unit and Home Hospitalization Unit, Hospital General de Alicante, Alicante, Spain
| | | | - Jordi Giol-Amich
- Emergency Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Veronica González
- Emergency Department, Short Stay Unit and Home Hospitalization Unit, Hospital General de Alicante, Alicante, Spain
| | - Ferran Llopis-Roca
- Emergency Department, Hospital Universitari de Bellvitge, Barcelona, Spain
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8
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Schultz M, Rasmussen LJH, Carlson N, Hasselbalch RB, Jensen BN, Usinger L, Eugen-Olsen J, Torp-Pedersen C, Rasmussen LS, Iversen KK. Risk assessment models for potential use in the emergency department have lower predictive ability in older patients compared to the middle-aged for short-term mortality - a retrospective cohort study. BMC Geriatr 2019; 19:134. [PMID: 31096925 PMCID: PMC6521424 DOI: 10.1186/s12877-019-1154-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 05/09/2019] [Indexed: 11/29/2022] Open
Abstract
Background Older patients is a complex group at increased risk of adverse outcomes compared to younger patients, which should be considered in the risk assessment performed in emergency departments. We evaluated whether the predictive ability of different risk assessment models for acutely admitted patients is affected by age. Methods Cohort study of middle-aged and older patients. We investigated the accuracy in discriminating between survivors and non-survivors within 7 days of different risk assessment models; a traditional triage algorithm, a triage algorithm with clinical assessment, vital signs, routine biomarkers, and the prognostic biomarker soluble urokinase plasminogen activator receptor (suPAR). Results The cohort included 22,653 (53.2%) middle-aged patients (age 40–69 years), and 19,889 (46.8%) older patients (aged 70+ years). Death within 7 days occurred in 139 patients (0.6%) in middle-aged patients and 596 (3.0%) of the older patients. The models based on vital signs and routine biomarkers had the highest area under the curve (AUC), and both were significantly better at discriminating 7-day mortality in middle-aged patients compared to older patients; AUC (95% CI): 0.88 (0.84–0.91), 0.75 (0.72–0.78), P < 0.01, and 0.86 (0.82–0.90), 0.76 (0.73–0.78), P < 0.001. In a subgroup of the total cohort (6.400 patients, 15.0%), the suPAR level was available. suPAR had the highest AUC of all individual predictors with no significant difference between the age groups, but further research in this biomarker is required before it can be used. Conclusion The predictive value was lower in older patients compared to middle-aged patients for all investigated models. Vital signs or routine biomarkers constituted the best models for predicting 7-day mortality and were better than the traditional triage model. Hence, the current risk assessment for short-term mortality can be strengthened, but modifications for age should be considered when constructing new risk assessment models in the emergency department. Electronic supplementary material The online version of this article (10.1186/s12877-019-1154-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Schultz
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730, Herlev, Denmark. .,Department of Internal Medicine and Geriatrics, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark.
| | | | | | - Rasmus Bo Hasselbalch
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730, Herlev, Denmark
| | - Birgitte Nybo Jensen
- Department of Emergency Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lotte Usinger
- Department of Internal Medicine and Geriatrics, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Christian Torp-Pedersen
- Department of Health, Science and Technology, Aalborg University Hospital, Aalborg, Denmark.,Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730, Herlev, Denmark
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Graziadio S, O’Leary RA, Stocken DD, Power M, Allen AJ, Simpson AJ, Price DA. Can mid-regional pro-adrenomedullin (MR-proADM) increase the prognostic accuracy of NEWS in predicting deterioration in patients admitted to hospital with mild to moderately severe illness? A prospective single-centre observational study. BMJ Open 2019; 8:e020337. [PMID: 30798282 PMCID: PMC6278796 DOI: 10.1136/bmjopen-2017-020337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To assess the value added to the National Early Warning Score (NEWS) by mid-regional pro-adrenomedullin (MR-proADM) blood level in predicting deterioration in mild to moderately ill people. DESIGN Prospective observational study. SETTING The Medical Admissions Suite of the Royal Victoria Infirmary, Newcastle. PARTICIPANTS 300 adults with NEWS between 2 and 5 on admission. Exclusion criteria included receiving palliative care, or admitted for social reasons or self-harming. Patients were enrolled between September and December 2015, and followed up for 30 days after discharge. OUTCOME MEASURE The primary outcome measure was the proportion of patients who, within 72 hours, had an acuity increase, defined as any combination of an increase of at least 2 in the NEWS; transfer to a higher-dependency bed or monitored area; death; or for those discharged from hospital, readmission for medical reasons. RESULTS NEWS and MR-proADM together predicted acuity increase more accurately than NEWS alone, increasing the area under the curve (AUC) to 0.61 (95% CI 0.54 to 0.69) from 0.55 (95% CI 0.48 to 0.62). When the confounding effects of presence of chronic obstructive pulmonary disease or heart failure and interaction with MR-proADM were included, the prognostic accuracy further increased the AUC to 0.69 (95% CI 0.63 to 0.76). CONCLUSIONS MR-proADM is potentially a clinically useful biomarker for deterioration in patients admitted to hospital with a mild to moderately severe acute illness, that is, with NEWS between 2 and 5. As a growing number of National Health Service hospitals are routinely recording the NEWS on their clinical information systems, further research should assess the practicality and use of developing a decision aid based on admission NEWS, MR-proADM level, and possibly other clinical data and other biomarkers that could further improve prognostic accuracy.
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Affiliation(s)
- Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Rachel Amie O’Leary
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
- Department of Infectious Diseases, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Michael Power
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - A Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle upon Tyne, UK
| | - A John Simpson
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle upon Tyne, UK
| | - David Ashley Price
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
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10
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Eckart A, Hauser SI, Kutz A, Haubitz S, Hausfater P, Amin D, Amin A, Huber A, Mueller B, Schuetz P. Combination of the National Early Warning Score (NEWS) and inflammatory biomarkers for early risk stratification in emergency department patients: results of a multinational, observational study. BMJ Open 2019; 9:e024636. [PMID: 30782737 PMCID: PMC6340461 DOI: 10.1136/bmjopen-2018-024636] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES The National Early Warning Score (NEWS) helps to estimate mortality risk in emergency department (ED) patients. This study aimed to investigate whether the prognostic value of the NEWS at ED admission could be further improved by adding inflammatory blood markers (ie, white cell count (WCC), procalcitonin (PCT) and midregional-proadrenomedullin (MR-proADM). DESIGN Secondary analysis of a multinational, observational study (TRIAGE study, March 2013-October 2014). SETTING Three tertiary care centres in France, Switzerland and the USA. PARTICIPANTS A total of 1303 adult medical patients with complete NEWS data seeking ED care were included in the final analysis. NEWS was calculated retrospectively based on admission data. MAIN OUTCOME MEASURES The primary outcome was all-cause 30-day mortality. Secondary outcome was intensive care unit (ICU) admission. We used multivariate regression analyses to investigate associations of NEWS and blood markers with outcomes and area under the receiver operating curve (AUC) as a measure of discrimination. RESULTS Of the 1303 included patients, 54 (4.1%) died within 30 days. The NEWS alone showed fair prognostic accuracy for all-cause 30-day mortality (AUC 0.73), with a multivariate adjusted OR of 1.26 (95% CI 1.13 to 1.40, p<0.001). The AUCs for the prediction of mortality using the inflammatory markers WCC, PCT and MR-proADM were 0.64, 0.71 and 0.78, respectively. Combining NEWS with all three blood markers or only with MR-proADM clearly improved discrimination with an AUC of 0.82 (p=0.002). Combining the three inflammatory markers with NEWS improved prediction of ICU admission (AUC 0.70vs0.65 when using NEWS alone, p=0.006). CONCLUSION NEWS is helpful in risk stratification of ED patients and can be further improved by the addition of inflammatory blood markers. Future studies should investigate whether risk stratification by NEWS in addition to biomarkers improve site-of-care decision in this patient population. TRIAL REGISTRATION NUMBER NCT01768494; Post-results.
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Affiliation(s)
- Andreas Eckart
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Stephanie Isabelle Hauser
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Alexander Kutz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sebastian Haubitz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of Infectious Diseases, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Pierre Hausfater
- Emergency Departement, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités UPMC-Univ Paris 06, UMRS INSERM 1166, IHUC ICAN, Paris, France
| | | | - Adina Amin
- Morton Plant Hospital, Clearwater, Florida, USA
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
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11
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Bingisser R, Nickel CH. Comment to: non-specific complaints at emergencydepartment presentation result in uncleardiagnoses and lengthened hospitalization: a prospective observational study. Scand J Trauma Resusc Emerg Med 2018; 26:99. [PMID: 30454016 PMCID: PMC6245531 DOI: 10.1186/s13049-018-0553-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 09/24/2018] [Indexed: 12/03/2022] Open
Affiliation(s)
- Roland Bingisser
- Department of Emergency Medicine, University Hospital Basel, Petersgraben 2, CH-4031, Basel, Switzerland.
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, Petersgraben 2, CH-4031, Basel, Switzerland
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12
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Schultz M, Rasmussen LJH, Andersen MH, Stefansson JS, Falkentoft AC, Alstrup M, Sandø A, Holle SLK, Meyer J, Törnkvist PBS, Høi-Hansen T, Kjøller E, Jensen BN, Lind M, Ravn L, Kallemose T, Lange T, Køber L, Rasmussen LS, Eugen-Olsen J, Iversen KK. Use of the prognostic biomarker suPAR in the emergency department improves risk stratification but has no effect on mortality: a cluster-randomized clinical trial (TRIAGE III). Scand J Trauma Resusc Emerg Med 2018; 26:69. [PMID: 30153859 PMCID: PMC6114851 DOI: 10.1186/s13049-018-0539-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/21/2018] [Indexed: 12/22/2022] Open
Abstract
Background Risk stratification of patients in the emergency department can be strengthened using prognostic biomarkers, but the impact on patient prognosis is unknown. The aim of the TRIAGE III trial was to investigate whether the introduction of the prognostic and nonspecific biomarker: soluble urokinase plasminogen activator receptor (suPAR) for risk stratification in the emergency department reduces mortality in acutely admitted patients. Methods The TRIAGE III trial was a cluster-randomized interventional trial conducted at emergency departments in the Capitol Region of Denmark. Eligible hospitals were required to have an emergency department with an intake of acute medical and surgical patients and no previous access to suPAR measurement. Three emergency departments were randomized; one withdrew shortly after the trial began. The inclusion period was from January through June of 2016 consisting of twelve cluster-periods of 3-weeks alternating between intervention and control and a subsequent follow-up of ten months. Patients were allocated to the intervention if they arrived in interventional periods, where suPAR measurement was routinely analysed at arrival. In the control periods suPAR measurement was not performed. The main outcome was all-cause mortality 10 months after arrival of the last patient in the inclusion period. Secondary outcomes included 30-day mortality. Results The trial enrolled a consecutive cohort of 16,801 acutely admitted patients; all were included in the analyses. The intervention group consisted of 6 cluster periods with 8900 patients and the control group consisted of 6 cluster periods with 7901 patients. After a median follow-up of 362 days, death occurred in 1241 patients (13.9%) in the intervention group and in 1126 patients (14.3%) in the control group. The weighted Cox model found a hazard ratio of 0.97 (95% confidence interval, 0.89 to 1.07; p = 0.57). Analysis of all subgroups and of 30-day all-cause mortality showed similar results. Conclusions The TRIAGE III trial found no effect of introducing the nonspecific and prognostic biomarker suPAR in emergency departments on short- or long-term all-cause mortality among acutely admitted patients. Further research is required to evaluate how prognostic biomarkers can be implemented in routine clinical practice. Trial registration clinicaltrials.gov, NCT02643459. Registered 31 December 2015. Electronic supplementary material The online version of this article (10.1186/s13049-018-0539-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Schultz
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark. .,Department of Internal medicine and Geriatrics, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark.
| | - Line Jee Hartmann Rasmussen
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Malene H Andersen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark
| | - Jakob S Stefansson
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Alexander C Falkentoft
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Morten Alstrup
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark
| | - Andreas Sandø
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark
| | - Sarah L K Holle
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark
| | - Jeppe Meyer
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Peter B S Törnkvist
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Thomas Høi-Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark
| | - Erik Kjøller
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark
| | - Birgitte Nybo Jensen
- Department of Emergency Medicine, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev ringvej 75, 2730, Herlev, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev ringvej 75, 2730, Herlev, Denmark
| | - Thomas Kallemose
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Theis Lange
- Department of Public Health, University of Copenhagen, Section of biostatistics, Øster Farimagsgade 5, 1014, Copenhagen, Denmark.,Center for Statistical Science, Peking University, No. 5 Yiheyuan Road Haidian District, Beijing, 100871, China
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Kasper Karmark Iversen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Ringvej 75, 2730, Herlev, Denmark.,Department of Emergency Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev ringvej 75, 2730, Herlev, Denmark
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13
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García-Peña C, Pérez-Zepeda MU, Robles-Jiménez LV, Sánchez-García S, Ramírez-Aldana R, Tella-Vega P. Mortality and associated risk factors for older adults admitted to the emergency department: a hospital cohort. BMC Geriatr 2018; 18:144. [PMID: 29914394 PMCID: PMC6006959 DOI: 10.1186/s12877-018-0833-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 06/10/2018] [Indexed: 11/18/2022] Open
Abstract
Background Older emergency department patients are more vulnerable than younger patients, yet many risk factors that contribute to the mortality of older patients remain unclear and under investigation. This study endeavored to determine mortality and factors associated with mortality in patients over 60 years of age who were admitted to the emergency departments of two general hospitals in Mexico City. Methods This is a hospital cohort study involving adults over 60 years of age admitted to the emergency department and who are beneficiaries of the Mexican Institute of Social Security and residents of Mexico City. All causes of mortality from the time of emergency department admission until a follow-up home visit after discharge were measured. Included risk factors were: socio-demographic, health-care related, mental and physical variables, and in-hospital care-related. Survival functions were estimated using Kaplan-Meier curves. Hazard ratios (HR) were derived from Cox regression models in a multivariate analysis. Results From the 1406 older adults who participated in this study, 306 (21.8%) did not survive. Independent mortality risk factors found in the last Cox model were age (HR = 1.02, 95% CI, 1.005–1.04; p = 0.01), length of stay in the ED (HR = 1.003, 95% CI = 0.99, 1.04; p = 0.006), geriatric care trained residents model in Hospital A (protective factor) (HR = 0.66, 95% CI = 0.46, 0.96; p = 0.031), and the FRAIL scale (HR of 1.34 95% CI, 1.02–1.76; p = 0.033). Conclusions Risk factors for mortality in patients treated at Mexican emergency departments are length of stay and variables related to frailty status.
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Affiliation(s)
- Carmen García-Peña
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico.
| | - Mario Ulises Pérez-Zepeda
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico
| | | | - Sergio Sánchez-García
- Unidad de Investigación en Epidemiología y Servicios de Salud, Área Envejecimiento, Mexico City, Mexico
| | | | - Pamela Tella-Vega
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico
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14
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Liguori I, Russo G, Curcio F, Bulli G, Aran L, Della-Morte D, Gargiulo G, Testa G, Cacciatore F, Bonaduce D, Abete P. Oxidative stress, aging, and diseases. Clin Interv Aging 2018; 13:757-772. [PMID: 29731617 PMCID: PMC5927356 DOI: 10.2147/cia.s158513] [Citation(s) in RCA: 1968] [Impact Index Per Article: 328.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Reactive oxygen and nitrogen species (RONS) are produced by several endogenous and exogenous processes, and their negative effects are neutralized by antioxidant defenses. Oxidative stress occurs from the imbalance between RONS production and these antioxidant defenses. Aging is a process characterized by the progressive loss of tissue and organ function. The oxidative stress theory of aging is based on the hypothesis that age-associated functional losses are due to the accumulation of RONS-induced damages. At the same time, oxidative stress is involved in several age-related conditions (ie, cardiovascular diseases [CVDs], chronic obstructive pulmonary disease, chronic kidney disease, neurodegenerative diseases, and cancer), including sarcopenia and frailty. Different types of oxidative stress biomarkers have been identified and may provide important information about the efficacy of the treatment, guiding the selection of the most effective drugs/dose regimens for patients and, if particularly relevant from a pathophysiological point of view, acting on a specific therapeutic target. Given the important role of oxidative stress in the pathogenesis of many clinical conditions and aging, antioxidant therapy could positively affect the natural history of several diseases, but further investigation is needed to evaluate the real efficacy of these therapeutic interventions. The purpose of this paper is to provide a review of literature on this complex topic of ever increasing interest.
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Affiliation(s)
- Ilaria Liguori
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Gennaro Russo
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Francesco Curcio
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Giulia Bulli
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Luisa Aran
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - David Della-Morte
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,San Raffaele Roma Open University, Rome, Italy
| | - Gaetano Gargiulo
- Division of Internal Medicine, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Gianluca Testa
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy.,Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Francesco Cacciatore
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy.,Azienda Ospedaliera dei Colli, Monaldi Hospital, Heart Transplantation Unit, Naples, Italy
| | - Domenico Bonaduce
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
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15
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Odermatt J, Meili M, Hersberger L, Bolliger R, Christ-Crain M, Briel M, Bucher HC, Mueller B, Schuetz P. Pro-Adrenomedullin predicts 10-year all-cause mortality in community-dwelling patients: a prospective cohort study. BMC Cardiovasc Disord 2017; 17:178. [PMID: 28676115 PMCID: PMC5496393 DOI: 10.1186/s12872-017-0605-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 06/22/2017] [Indexed: 01/20/2023] Open
Abstract
Background Several studies found mid-regional pro-adrenomedullin (ProADM), the prohormone of the cardiovascular protein adrenomedullin, to be strongly associated with short-term mortality, mostly in the inpatient setting. We evaluated associations of ProADM levels with 10-year mortality in community-dwelling primary care patients with respiratory tract infections. Methods This is a post-hoc analysis using clinical and biomarker data of 134 primary care patients with respiratory tract infections. ProADM was measured on admission and after 7 days in batch-analysis. 10-year follow-up data was collected by GP, patient and relative tracing through phone interviews. We calculated Cox regression models and area under the receiver operating characteristics curves to assess associations of ProADM with 10-year all-cause mortality. Results During the 10-year follow-up 6% of included patients died. Median baseline ProADM blood levels (nmol/l) were significantly higher in non-survivors compared to survivors (0.5, IQR 0.4–1.3; vs. 0.2, IQR 0.1–0.5; p = 0.02) and showed a significant association with 10-year all-cause mortality in an age-adjusted cox regression model (HR: 2.5, 95%-CI: 1.0–6.1, p = 0.04). ProADM levels on day 7 showed similar results. Conclusions This posthoc analysis found an association of elevated ProADM blood levels and 10-year all-cause mortality in a primary care cohort with respiratory tract infections. Due to the methodological limitations including incomplete data regarding follow-up information and biomarker measurement, this study warrants validation in future larger studies. Trial registration Current Controlled Trials, SRCTN73182671
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Affiliation(s)
- Jonas Odermatt
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Marc Meili
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Lara Hersberger
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Rebekka Bolliger
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Matthias Briel
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Basel-Stadt, Switzerland.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Heiner C Bucher
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Basel-Stadt, Switzerland
| | - Beat Mueller
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Philipp Schuetz
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland.
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16
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Gillmann HJ, Meinders A, Larmann J, Sahlmann B, Schrimpf C, Aper T, Lichtinghagen R, Teebken OE, Theilmeier G. Adrenomedullin Is Associated With Surgical Trauma and Impaired Renal Function in Vascular Surgery Patients. J Intensive Care Med 2017; 34:67-76. [PMID: 28110613 DOI: 10.1177/0885066616689554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND: Patients undergoing vascular surgery are prone to perioperative organ injury because of both higher prevalence of cardiovascular risk factors and the extent of surgery. Early detection of organ failure is essential to facilitate appropriate medical care. Midregional pro-adrenomedullin (MR-proADM) has been investigated in acute medical care settings to guide clinical decision-making regarding patient pathways and to identify patients prone to imminent cardiovascular or inflammatory complications. In this study, we evaluated the impact of perioperative MR-proADM levels as an early marker of perioperative cardiovascular and inflammatory stress reactions and kidney injury. METHODS: The study was conducted as a monocentric, prospective, noninterventional trial at Hannover Medical School, Germany. A total of 454 consecutive patients who underwent open vascular surgery were followed from the day prior to until 30 days after surgery. The composite primary end point was defined as the occurrence of major adverse cardiac events (MACEs), acute kidney injury (AKI), or systemic inflammatory response syndrome (SIRS). Measurements were correlated with both medical history and postoperative MACE, AKI, or SIRS using univariate and multivariate regression analysis. RESULTS: One hundred thirty-nine (31%) of the patients reached the primary end point within the study interval. Midregional pro-adrenomedullin change was associated with the combined primary end point and with the intensity of surgical trauma. Midregional pro-adrenomedullin change was increased in patients reaching the secondary end points, SIRS (optimal cutoff: 0.2 nmol/L) and AKI (optimal cutoff: 0.7 nmol/L), but not in patients with MACEs. CONCLUSION: Increased levels of MR-proADM within the perioperative setting (1) were linked to the invasiveness of surgery and (2) identified patients with ongoing loss of renal function. Increased MR-proADM levels may therefore identify a subgroup of patients prone to excessive cardiovascular stress but did not directly correlate with adverse cardiac events. Consistently low levels of MR-proADM may identify a subgroup of patients with acceptable low risk to guide discharge from high-density care units.
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Affiliation(s)
- Hans-Jörg Gillmann
- 1 Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Antje Meinders
- 1 Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Jan Larmann
- 1 Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.,2 Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Bianca Sahlmann
- 3 Department of Medicine, Perioperative Inflammation and Infection, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| | - Claudia Schrimpf
- 4 Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas Aper
- 4 Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- 5 Department of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Omke E Teebken
- 6 Department of Vascular Surgery, Klinikum Peine, Peine, Germany
| | - Gregor Theilmeier
- 3 Department of Medicine, Perioperative Inflammation and Infection, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
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17
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Liu SW, Sri-On J, Tirrell GP, Nickel C, Bingisser R. Serious conditions for ED elderly fall patients: a secondary analysis of the Basel Non-Specific Complaints study. Am J Emerg Med 2016; 34:1394-9. [DOI: 10.1016/j.ajem.2016.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/02/2016] [Accepted: 04/05/2016] [Indexed: 11/16/2022] Open
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18
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Assessment of Diagnostic and Prognostic Role of Copeptin in the Clinical Setting of Sepsis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3624730. [PMID: 27366743 PMCID: PMC4913060 DOI: 10.1155/2016/3624730] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/16/2016] [Indexed: 12/14/2022]
Abstract
The diagnostic and prognostic usefulness of copeptin were evaluated in septic patients, as compared to procalcitonin assessment. In this single centre and observational study 105 patients were enrolled: 24 with sepsis, 25 with severe sepsis, 15 with septic shock, and 41 controls, divided in two subgroups (15 patients with gastrointestinal bleeding and 26 with suspected SIRS secondary to trauma, acute coronary syndrome, and pulmonary embolism). Biomarkers were determined at the first medical evaluation and thereafter 24, 48, and 72 hours after admission. Definitive diagnosis and in-hospital survival rates at 30 days were obtained through analysis of medical records. At entry, copeptin proved to be able to distinguish cases from controls and also sepsis group from septic shock group, while procalcitonin could distinguish also severe sepsis from septic shock group. Areas under the ROC curve for copeptin and procalcitonin were 0.845 and 0.861, respectively. Noteworthy, patients with copeptin concentrations higher than the threshold value (23.2 pmol/L), calculated from the ROC curve, at admission presented higher 30-day mortality. No significant differences were found in copeptin temporal profile among different subgroups. Copeptin showed promising diagnostic and prognostic role in the management of sepsis, together with its possible role in monitoring the response to treatment.
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19
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Nickel CH, Kuster T, Keil C, Messmer AS, Geigy N, Bingisser R. Risk stratification using D-dimers in patients presenting to the emergency department with nonspecific complaints. Eur J Intern Med 2016; 31:20-4. [PMID: 27053291 DOI: 10.1016/j.ejim.2016.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 03/04/2016] [Accepted: 03/07/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with nonspecific complaints (NSC) such as generalized weakness present frequently to acute care settings. These patients are at risk of adverse health outcomes. The aim of our study was to test the hypothesis whether D-dimers are predictive for 30-day mortality in patients with NSCs. METHODS Delayed type cross-sectional diagnostic study with a 30-day follow-up period, registered with ClinicalTrials.gov (NCT00920491). This study took place in 2 EDs in Northwestern Switzerland. Patients were enrolled in the study if they were over 18years of age, gave informed consent, and if they presented with NSCs such as generalized weakness. D-dimer levels were determined at ED presentation. RESULTS The final study population consisted of 524 patients. Median age was 82years (IQR=75 to 87years); 40.5% were men. There were 489 survivors and 35 non-survivors at 30-day follow-up. Twenty-one (60%) of the non-survivors were males. D-dimer levels were significantly higher in non-survivors than in survivors (p<0.001). Univariate Cox regression models for D-dimer resulted in a C-index of 0.77 for prediction of mortality. A model including sex, age, Katz ADL and D-dimer in a multivariate Cox regression lead to a C-Index of 0.80. CONCLUSION D-dimer testing might be an effective risk stratification tool in patients with NSC by helping to identify patients at low risk of short-term mortality with a sensitivity of 0.97 and a negative likelihood ratio of 0.121. The use of D-dimers for risk stratification in patients with NSC should be confirmed with prospective studies.
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Affiliation(s)
- C H Nickel
- Emergency Department, University Hospital, Basel, Switzerland.
| | - T Kuster
- Emergency Department, University Hospital, Basel, Switzerland
| | - C Keil
- Emergency Department, University Hospital, Basel, Switzerland
| | - A S Messmer
- Emergency Department, University Hospital, Basel, Switzerland
| | - N Geigy
- Emergency Department, Kantonsspital Baselland, Liestal, Switzerland
| | - R Bingisser
- Emergency Department, University Hospital, Basel, Switzerland
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20
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Nickel CH, Messmer AS, Ghanim L, Ilsemann-Karakoumis J, Giersdorf S, Hertel S, Ernst S, Geigy N, Bingisser R. Adrenomedullin for Risk Stratification of Emergency Patients With Nonspecific Complaints: An Interventional Multicenter Pilot Study. Medicine (Baltimore) 2016; 95:e2395. [PMID: 26735540 PMCID: PMC4706260 DOI: 10.1097/md.0000000000002395] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Patients with nonspecific complaints (NSC) presenting to the emergency department (ED) are at risk of life-threatening conditions. New stress biomarkers such as the midregional portion of adrenomedullin (MR-proADM) promise to support decision-making. This study tested the following hypotheses: biomarker-assisted disposition of patients with NSC will not increase mortality. Second, discharge from the ED will increase if clinical risk assessment is combined with low MR-proADM levels. Third, inappropriate disposition to a lower level of care will decrease, if clinical assessment is combined with high MR-proADM levels, and fourth that this algorithm is feasible in the ED setting. Prospective, multicenter, randomized, controlled interventional feasibility study with a 30-day follow-up, including patients with NSC. Patients were randomly assigned to either the standard group (decision-making solely based on clinical assessment) or the Novum group (biomarker-assisted). Regarding disposition, patients were assigned to 1 of 3 risk classes: high-risk (admission to hospital), intermediate risk (community geriatric hospital), and low-risk patients (discharge). In the Novum group, in addition to clinical risk assessment, the information of the MR-proADM level was used. Unless there were overruling criteria, patients were transferred or discharged according to the risk assessment. Primary endpoint was 30-day mortality. Secondary endpoints were comparisons of patient disposition and related mortality rates, ED, and hospital length of stay and readmission. The final study cohort consisted of 398 patients (210 in the Standard group and 188 in the Novum group). Overruling, that is, disposition not according to the result of the proposed algorithm occurred in 51 cases. Baseline characteristics between Standard and Novum groups were similar. The mortality rate in the Novum group was 4.3%, as compared to the Standard group mortality of 6.2%, which was not significantly different (intention-to treat analysis). This was confirmed by the perprotocol analysis as well as by sensitivity analysis. For the secondary endpoints, no significant differences were detected. Biomarker-assisted disposition is safe in patients with NSC. Discharge rates did not increase. Feasibility could only partly be shown due to an unexpectedly high overruling rate. Inappropriate disposition to lower levels of care did not change. ClinicalTrials. gov Identifier: NCT00920491.
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Affiliation(s)
- Christian Hans Nickel
- From the Emergency Department, University Hospital, Basel (CHN, ASM, LG, JI-K, RB); Emergency Department, Kantonsspital Baselland, Liestal, Switzerland (NG); Research Department, Thermo Scientific Biomarkers, Hennigsdorf, Germany (SG, SH); and Emergency Department, Kantonsspital Olten, Olten, Switzerland (SE)
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Golbidi S, Frisbee JC, Laher I. Chronic stress impacts the cardiovascular system: animal models and clinical outcomes. Am J Physiol Heart Circ Physiol 2015; 308:H1476-98. [DOI: 10.1152/ajpheart.00859.2014] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/03/2015] [Indexed: 01/01/2023]
Abstract
Psychological stresses are associated with cardiovascular diseases to the extent that cardiovascular diseases are among the most important group of psychosomatic diseases. The longstanding association between stress and cardiovascular disease exists despite a large ambiguity about the underlying mechanisms. An array of possibilities have been proposed including overactivity of the autonomic nervous system and humoral changes, which then converge on endothelial dysfunction that initiates unwanted cardiovascular consequences. We review some of the features of the two most important stress-activated systems, i.e., the humoral and nervous systems, and focus on alterations in endothelial function that could ensue as a result of these changes. Cardiac and hematologic consequences of stress are also addressed briefly. It is likely that activation of the inflammatory cascade in association with oxidative imbalance represents key pathophysiological components of stress-induced cardiovascular changes. We also review some of the commonly used animal models of stress and discuss the cardiovascular outcomes reported in these models of stress. The unique ability of animals for adaptation under stressful conditions lessens the extrapolation of laboratory findings to conditions of human stress. An animal model of unpredictable chronic stress, which applies various stress modules in a random fashion, might be a useful solution to this predicament. The use of stress markers as indicators of stress intensity is also discussed in various models of animal stress and in clinical studies.
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Affiliation(s)
- Saeid Golbidi
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada; and
| | - Jefferson C. Frisbee
- Center for Cardiovascular and Respiratory Sciences, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Ismail Laher
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada; and
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Nickel C, Malinovska A, Bingisser R. Should weakness be subsumed to nonspecific complaints?—Correspondence in response to Bhalla et al. Am J Emerg Med 2015; 33:722-3. [DOI: 10.1016/j.ajem.2015.02.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/10/2015] [Indexed: 01/16/2023] Open
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Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, Hogan TM. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med 2015; 22:1-21. [PMID: 25565487 DOI: 10.1111/acem.12569] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/21/2014] [Accepted: 08/24/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVES A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death. METHODS A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome. RESULTS A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%. CONCLUSIONS Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.
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Affiliation(s)
- Christopher R. Carpenter
- The Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Erica Shelton
- The Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Susan Fowler
- The Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Brian Suffoletto
- The Department of Emergency Medicine; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Timothy F. Platts-Mills
- The Department of Emergency Medicine; University of North Carolina-Chapel Hill; Chapel Hill NC
| | - Richard E. Rothman
- The Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
| | - Teresita M. Hogan
- The Department of Emergency Medicine; University of Chicago; Chicago IL
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Searle J, Slagman A, Stockburger M, Vollert JO, Müller C, Muller R, Möckel M. Use of copeptin in emergency patients with cardiac chief complaints. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:393-402. [DOI: 10.1177/2048872614554197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Julia Searle
- Department of Cardiology and Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Mitte (CCM), Charité Universitätsmedizin Berlin, Germany
| | - Anna Slagman
- Department of Cardiology and Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Mitte (CCM), Charité Universitätsmedizin Berlin, Germany
| | | | | | - Christian Müller
- Department of Cardiology and Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Mitte (CCM), Charité Universitätsmedizin Berlin, Germany
| | - Reinhold Muller
- School of Public Health, James Cook University and Tropical Health Solutions Pty Ltd, Australia
| | - Martin Möckel
- Department of Cardiology and Division of Emergency Medicine, Campus Virchow Klinikum (CVK) and Campus Mitte (CCM), Charité Universitätsmedizin Berlin, Germany
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Misch F, Messmer AS, Nickel CH, Gujan M, Graber A, Blume K, Bingisser R. Impact of observation on disposition of elderly patients presenting to emergency departments with non-specific complaints. PLoS One 2014; 9:e98097. [PMID: 24871340 PMCID: PMC4037184 DOI: 10.1371/journal.pone.0098097] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 04/28/2014] [Indexed: 11/28/2022] Open
Abstract
Background Emergency Departments (EDs) have to cope with an increasing number of elderly patients, often presenting with non-specific complaints (NSC), such as generalized weakness. Acute morbidity requiring early intervention is present in the majority of patients with NSC. Therefore, an early and optimal disposition plan is crucial. The objective of this study was to prospectively study the disposition process of patients presenting to the ED with NSC. Methods For two years, all patients presenting with NSC presenting to an urban ED were screened and consecutively included. The initial disposition plan was compared to the effective transfer after observation. Optimal disposition was defined as a high accuracy regarding disposition of patients with acute morbidity to an internal medicine ward. Results The final study population consisted of 669 patients with NSC. Admission to internal medicine increased from 297 (44%) planned admissions to 388 (58%) effective admissions after observation. Conversely, transfers to geriatric community hospitals and discharges decreased from the initially planned 372 (56%) patients to 281 (42%) effectively transferred and discharged patients. The accuracy regarding disposition of patients with acute morbidity increased from 53% to 68% after observation. Conclusion Disposition planning in patients with NSC improves after observation, if defined by the accuracy regarding hospitalization of patients with acute morbidity. Further research should focus on risk stratification tools for timely disposition planning in order to reduce high admission rates for patients without acute morbidity and high readmission rates for discharged patients with non-specific complaints.
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Affiliation(s)
- Franziska Misch
- Emergency Department, University Hospital, Basel, Switzerland
| | | | | | - Madleina Gujan
- Emergency Department, University Hospital, Basel, Switzerland
| | - Andreas Graber
- Emergency Department, University Hospital, Basel, Switzerland
| | - Katharina Blume
- Emergency Department, University Hospital, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital, Basel, Switzerland
- * E-mail:
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