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Heltborg A, Mogensen CB, Andersen ES, Cartuliares MB, Petersen ERB, Skovsted TA, Posth S, Graumann O, Lorentzen MJ, Hertz MA, Brasen CL, Skjøt-Arkil H. Diagnostic Performance of Plasma SP-D, KL-6, and CC16 in Acutely Hospitalised Patients Suspected of Having Community-Acquired Pneumonia-A Diagnostic Accuracy Study. Diagnostics (Basel) 2024; 14:1283. [PMID: 38928698 PMCID: PMC11202779 DOI: 10.3390/diagnostics14121283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Community-acquired pneumonia is a common cause of acute hospitalisation. Identifying patients with community-acquired pneumonia among patients suspected of having the disease can be a challenge, which causes unnecessary antibiotic treatment. We investigated whether the circulatory pulmonary injury markers surfactant protein D (SP-D), Krebs von den Lungen-6 (KL-6), and Club cell protein 16 (CC16) could help identify patients with community-acquired pneumonia upon acute admission. In this multi-centre diagnostic accuracy study, SP-D, KL-6, and CC16 were quantified in plasma samples from acutely hospitalised patients with provisional diagnoses of community-acquired pneumonia. The area under the receiver operator characteristics curve (AUC) was calculated for each marker against the following outcomes: patients' final diagnoses regarding community-acquired pneumonia assigned by an expert panel, and pneumonic findings on chest CTs. Plasma samples from 339 patients were analysed. The prevalence of community-acquired pneumonia was 63%. AUCs for each marker against both final diagnoses and chest CT diagnoses ranged between 0.50 and 0.56. Thus, SP-D, KL-6, and CC16 demonstrated poor diagnostic performance for community-acquired pneumonia in acutely hospitalised patients. Our findings indicate that the markers cannot readily assist physicians in confirming or ruling out community-acquired pneumonia.
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Affiliation(s)
- Anne Heltborg
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark (H.S.-A.)
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark
| | - Christian B. Mogensen
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark (H.S.-A.)
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark
| | - Eline S. Andersen
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark
- Department of Biochemistry and Immunology, Lillebaelt Hospital, University Hospital of Southern Denmark, 7100 Vejle, Denmark
| | - Mariana B. Cartuliares
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark (H.S.-A.)
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark
| | - Eva R. B. Petersen
- Department of Biochemistry and Immunology, Lillebaelt Hospital, University Hospital of Southern Denmark, 7100 Vejle, Denmark
- Department of Blood Tests, Biochemistry and Immunology, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark
| | - Thor A. Skovsted
- Department of Blood Tests, Biochemistry and Immunology, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark
| | - Stefan Posth
- Department of Clinical Research, University of Southern Denmark, 5230 Odense, Denmark
- Department of Emergency Medicine, Odense University Hospital, 5000 Odense, Denmark
| | - Ole Graumann
- Department of Radiology, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
| | - Morten J. Lorentzen
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark (H.S.-A.)
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark
| | - Mathias A. Hertz
- Department of Clinical Research, University of Southern Denmark, 5230 Odense, Denmark
- Department of Emergency Medicine, Odense University Hospital, 5000 Odense, Denmark
- Department of Infectious Diseases, Odense University Hospital, 5000 Odense, Denmark
| | - Claus L. Brasen
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark
- Department of Biochemistry and Immunology, Lillebaelt Hospital, University Hospital of Southern Denmark, 7100 Vejle, Denmark
| | - Helene Skjøt-Arkil
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark (H.S.-A.)
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark
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Cartuliares MB, Mogensen CB, Rosenvinge FS, Skovsted TA, Lorentzen MH, Heltborg A, Hertz MA, Kaldan F, Specht JJ, Skjøt-Arkil H. Community-acquired pneumonia: use of clinical characteristics of acutely admitted patients for the development of a diagnostic model - a cross-sectional multicentre study. BMJ Open 2024; 14:e079123. [PMID: 38816044 PMCID: PMC11141191 DOI: 10.1136/bmjopen-2023-079123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 05/20/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES This study aimed to describe the clinical characteristics of adults with suspected acute community-acquired pneumonia (CAP) on hospitalisation, evaluate their prediction performance for CAP and compare the performance of the model to the initial assessment of the physician. DESIGN Cross-sectional, multicentre study. SETTING The data originated from the INfectious DisEases in Emergency Departments study and were collected prospectively from patient interviews and medical records. The study included four Danish medical emergency departments (EDs) and was conducted between 1 March 2021 and 28 February 2022. PARTICIPANTS A total of 954 patients admitted with suspected infection were included in the study. PRIMARY AND SECONDARY OUTCOME The primary outcome was CAP diagnosis assessed by an expert panel. RESULTS According to expert evaluation, CAP had a 28% prevalence. 13 diagnostic predictors were identified using least absolute shrinkage and selection operator regression to build the prediction model: dyspnoea, expectoration, cough, common cold, malaise, chest pain, respiratory rate (>20 breaths/min), oxygen saturation (<96%), abnormal chest auscultation, leucocytes (<3.5×109/L or >8.8×109/L) and neutrophils (>7.5×109/L). C reactive protein (<20 mg/L) and having no previous event of CAP contributed negatively to the final model. The predictors yielded good prediction performance for CAP with an area under the receiver-operator characteristic curve (AUC) of 0.85 (CI 0.77 to 0.92). However, the initial diagnosis made by the ED physician performed better, with an AUC of 0.86 (CI 84% to 89%). CONCLUSION Typical respiratory symptoms combined with abnormal vital signs and elevated infection biomarkers were predictors for CAP on admission to an ED. The clinical value of the prediction model is questionable in our setting as it does not outperform the clinician's assessment. Further studies that add novel diagnostic tools and use imaging or serological markers are needed to improve a model that would help diagnose CAP in an ED setting more accurately. TRIAL REGISTRATION NUMBER NCT04681963.
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Affiliation(s)
- Mariana B Cartuliares
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Christian Backer Mogensen
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Flemming S Rosenvinge
- Department of Clinical Microbiology, Odense Universitetshospital, Odense, Denmark
- Research Unit of Clinical Microbiology, University of Southern Denmark, Odense, Denmark
| | - Thor Aage Skovsted
- Department of Biochemistry and Immunology, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Morten Hjarnø Lorentzen
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Anne Heltborg
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Mathias Amdi Hertz
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Frida Kaldan
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Jens Juel Specht
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Helene Skjøt-Arkil
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Matthews T, Rasmussen LJH, Ambler A, Danese A, Eugen-Olsen J, Fancourt D, Fisher HL, Iversen KK, Schultz M, Sugden K, Williams B, Caspi A, Moffitt TE. Social isolation, loneliness, and inflammation: A multi-cohort investigation in early and mid-adulthood. Brain Behav Immun 2024; 115:727-736. [PMID: 37992788 PMCID: PMC11194667 DOI: 10.1016/j.bbi.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/09/2023] [Accepted: 11/19/2023] [Indexed: 11/24/2023] Open
Abstract
Social isolation and loneliness have been associated with poor health and increased risk for mortality, and inflammation might explain this link. We used data from the Danish TRIAGE Study of acutely admitted medical patients (N = 6,144, mean age 60 years), and from two population-representative birth cohorts: the New Zealand Dunedin Longitudinal Study (N = 881, age 45) and the UK Environmental Risk (E-Risk) Longitudinal Twin Study (N = 1448, age 18), to investigate associations of social isolation with three markers of systemic inflammation: C-reactive protein (CRP), interleukin-6 (IL-6), and a newer inflammation marker, soluble urokinase plasminogen activator receptor (suPAR), which is thought to index systemic chronic inflammation. In the TRIAGE Study, socially isolated patients (those living alone) had significantly higher median levels of suPAR (but not CRP or IL-6) compared with patients not living by themselves. Social isolation prospectively measured in childhood was longitudinally associated with higher CRP, IL-6, and suPAR levels in adulthood (at age 45 in the Dunedin Study and age 18 in the E-Risk Study), but only suPAR remained associated after controlling for covariates. Dunedin Study participants who reported loneliness at age 38 or age 45 had elevated suPAR at age 45. In contrast, E-Risk Study participants reporting loneliness at age 18 did not show any elevated markers of inflammation. In conclusion, social isolation was robustly associated with increased inflammation in adulthood, both in medical patients and in the general population. It was associated in particular with systemic chronic inflammation, evident from the consistently stronger associations with suPAR than other inflammation biomarkers.
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Affiliation(s)
- Timothy Matthews
- School of Human Sciences, Faculty of Education, Health and Human Sciences, University of Greenwich, London, United Kingdom.
| | - Line Jee Hartmann Rasmussen
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA; Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Antony Ambler
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Andrea Danese
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; National and Specialist CAMHS Trauma and Anxiety Clinic, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark; ViroGates A/S, Birkerød, Denmark
| | - Daisy Fancourt
- Department of Behavioural Science and Health, University College London, United Kingdom
| | - Helen L Fisher
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; ESRC Centre for Society and Mental Health, King's College London, London, United Kingdom
| | - Kasper Karmark Iversen
- Department of Emergency Medicine, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark; Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin Schultz
- Department of Emergency Medicine, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Karen Sugden
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| | - Benjamin Williams
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| | - Avshalom Caspi
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA; Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Terrie E Moffitt
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA; Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
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Cartuliares MB, Søgaard SN, Rosenvinge FS, Mogensen CB, Hertz MA, Skjøt-Arkil H. Antibiotic Guideline Adherence at the Emergency Department: A Descriptive Study from a Country with a Restrictive Antibiotic Policy. Antibiotics (Basel) 2023; 12:1680. [PMID: 38136712 PMCID: PMC10740443 DOI: 10.3390/antibiotics12121680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Denmark has a low level of antimicrobial resistance (AMR). Patients hospitalized with suspected infection often present with unspecific symptoms. This challenges the physician between using narrow-spectrum antibiotics in accordance with guidelines or broad-spectrum antibiotics to compensate for diagnostic uncertainty. The aim of this study was to investigate adherence to a restrictive antibiotic guideline for the most common infection in emergency departments (EDs), namely community-acquired pneumonia (CAP). METHOD This multicenter descriptive cross-sectional study included adults admitted to Danish EDs with a suspected infection. Data were collected prospectively from medical records. RESULTS We included 954 patients in the analysis. The most prescribed antibiotics were penicillin with beta-lactamase inhibitor at 4 h (307 (32.2%)), 48 h (289 (30.3%)), and day 5 after admission (218 (22.9%)). The empirical antibiotic treatment guidelines for CAP were followed for 126 (31.3%) of the CAP patients. At 4 h, antibiotics were administered intravenously to 244 (60.7%) of the CAP patients. At day 5, 218 (54.4%) received oral antibiotics. CONCLUSION Adherence to CAP guidelines was poor. In a country with a restrictive antibiotic policy, infections are commonly treated with broad-spectrum antibiotics against recommendations.
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Affiliation(s)
- Mariana B. Cartuliares
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; (M.B.C.)
- Department of Regional Health Research, University of Southern Denmark, 6200 Aabenraa, Denmark
| | - Sara N. Søgaard
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; (M.B.C.)
- Department of Regional Health Research, University of Southern Denmark, 6200 Aabenraa, Denmark
| | - Flemming S. Rosenvinge
- Department of Clinical Microbiology, Odense University Hospital, 5000 Odense, Denmark
- Research Unit of Clinical Microbiology, Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Christian B. Mogensen
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; (M.B.C.)
- Department of Regional Health Research, University of Southern Denmark, 6200 Aabenraa, Denmark
| | - Mathias Amdi Hertz
- Department of Infectious Diseases, Odense University Hospital, University of Southern Denmark, 5000 Odense, Denmark
- Research Unit of Infectious Diseases, Department of Clinical Research, University of Southern, 5000 Odense, Denmark
| | - Helene Skjøt-Arkil
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; (M.B.C.)
- Department of Regional Health Research, University of Southern Denmark, 6200 Aabenraa, Denmark
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Cartuliares MB, Rosenvinge FS, Mogensen CB, Skovsted TA, Andersen SL, Østergaard C, Pedersen AK, Skjøt-arkil H. Evaluation of point-of-care multiplex polymerase chain reaction in guiding antibiotic treatment of patients acutely admitted with suspected community-acquired pneumonia in Denmark: A multicentre randomised controlled trial. PLoS Med 2023; 20:e1004314. [PMID: 38015833 PMCID: PMC10684013 DOI: 10.1371/journal.pmed.1004314] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/26/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Rapid and accurate detection of pathogens is needed in community-acquired pneumonia (CAP) to enable appropriate antibiotics and to slow the development of antibiotic resistance. We aimed to compare the effect of point-of-care (POC) polymerase chain reaction (PCR) detection of respiratory pathogens added to standard care with standard care only (SCO) on antibiotic prescriptions after acute hospital admission. METHODS AND FINDINGS We performed a superiority, parallel-group, open-label, multicentre, randomised controlled trial (RCT) in 3 Danish medical emergency departments (EDs) from March 2021 to February 2022. Adults acutely admitted with suspected CAP during the daytime on weekdays were included and randomly assigned (1:1) to POC-PCR (The Biofire FilmArray Pneumonia Panel plus added to standard care) or SCO (routine culture and, if requested by the attending physician, target-specific PCR) analysis of respiratory samples. We randomly assigned 294 patients with successfully collected samples (tracheal secretion 78.4% or expectorated sputum 21.6%) to POC-PCR (n = 148, 50.4%) or SCO (146, 49.6%). Patients and investigators owning the data were blinded to the allocation and test results. Outcome adjudicators and clinical staff at the ED were not blinded to allocation and test results but were together with the statistician, blinded to data management and analysis. Laboratory staff performing standard care analyses was blinded to allocation. The study coordinator was not blinded. Intention-to-treat and per protocol analysis were performed using logistic regression with Huber-White clustered standard errors for the prescription of antibiotic treatment. Loss to follow-up comprises 3 patients in the POC-PCR (2%) and none in the SCO group. Intention-to-treat analysis showed no difference in the primary outcome of prescriptions of no or narrow-spectrum antibiotics at 4 h after admission for the POC-PCR (n = 91, 62.8%) odds ratio (OR) 1.13; (95% confidence interval (CI) [0.96, 1.34] p = 0.134) and SCO (n = 87, 59.6%). Secondary outcomes showed that prescriptions were significantly more targeted at 4-h OR 5.68; (95% CI [2.49, 12.94] p < 0.001) and 48-h OR 4.20; (95% CI [1.87, 9.40] p < 0.001) and more adequate at 48-h OR 2.11; (95% CI [1.23, 3.61] p = 0.006) and on day 5 in the POC-PCR group OR 1.40; (95% CI [1.18, 1.66] p < 0.001). There was no difference between the groups in relation to intensive care unit (ICU) admissions OR 0.54; (95% CI [0.10, 2.91] p = 0.475), readmission within 30 days OR 0.90; (95% CI [0.43, 1.86] p = 0.787), length of stay (LOS) IRR 0.82; (95% CI [0.63, 1.07] p = 0.164), 30 days mortality OR 1.24; (95% CI [0.32, 4.82] p = 0.749), and in-hospital mortality OR 0.98; (95% CI [0.19, 5.06] p = 0.986). CONCLUSIONS In a setting with an already restrictive use of antibiotics, adding POC-PCR to the diagnostic setup did not increase the number of patients treated with narrow-spectrum or without antibiotics. POC-PCR may result in a more targeted and adequate use of antibiotics. A significant study limitation was the concurrent Coronavirus Disease 2019 (COVID-19) pandemic resulting in an unusually low transmission of respiratory virus. TRIAL REGISTRATION ClinicalTrials.gov (NCT04651712).
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Affiliation(s)
- Mariana Bichuette Cartuliares
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Aabenraa, Denmark
| | - Flemming Schønning Rosenvinge
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Microbiology, University of Southern Denmark, Odense, Denmark
| | - Christian Backer Mogensen
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Aabenraa, Denmark
| | - Thor Aage Skovsted
- Department of Biochemistry and Immunology, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Steen Lomborg Andersen
- Department of Clinical Microbiology, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Claus Østergaard
- Department of Clinical Microbiology, Lillebaelt Hospital, Vejle, Denmark
| | | | - Helene Skjøt-arkil
- Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Aabenraa, Denmark
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Hasselbalch RB, Schultz M, Schytz PA, Kristensen JH, Strandkjær N, Pries-Heje M, Carlson N, Schou M, Bundgaard H, Torp-Pedersen C, Iversen KK. Predictive and prognostic value of different cardiac troponin assays: a nationwide register-based cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:592-599. [PMID: 36264293 DOI: 10.1093/ehjqcco/qcac065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/03/2022] [Accepted: 10/17/2022] [Indexed: 09/13/2023]
Abstract
AIMS Guidelines do not differentiate between the available assays of cardiac troponin (cTn). We compared the prognostic and predictive ability of cTn assays. METHODS AND RESULTS This was a nationwide cohort study of patients with acute coronary syndrome (ACS) and ≥ 2 cTn measurements of one of four assays: Roche high-sensitivity cTnT (hs-cTnT), Abbott high sensitivity cTnI (hs-cTnI), Siemens Vista cTnI, and Siemens cTnI Ultra. Data were collected from Danish registries from 2009-18. Peak cTn concentration normalized to the 99th percentile was used. Outcomes were myocardial infarction (MI) during admission, one-year all-cause-, cardiovascular-, and non-cardiovascular mortality. Receiver operating characteristics and logistic regression calculating odds ratios (OR) were used. A total of 90 705 patients were included, of which 20 550 (23%) had MI. Siemens Vista cTnI was the strongest predictor of MI, Area under the curve (auc) 0.93 (95% CI 0.93-0.93). In 1 year 9012 (9.9%) of patients had died. An inverted U-shape relationship was observed between concentration of cTn and all-cause mortality. Hs-cTnT OR 21.3 (95% CI 18.4-24.8) at 2-5 times the 99th percentile and 12.1 (95% CI 10.3-14.1) for concentrations >100 times the 99th percentile. The inverted U-shape relationship was only present for non-cardiovascular mortality. The strongest predictor of cardiovascular mortality was hs-cTnT, OR 11.3 (95% CI 6.4-21.8) at 1-2 times the 99th percentile and 88.8 (95% CI 53.2-163.0) for concentrations >100 times the 99th percentile. CONCLUSION Siemens Vista cTnI was the strongest predictor of MI and hs-cTnT was the strongest predictor of mortality. An inverted U-shape relationship was observed between cTn concentration and non-cardiovascular mortality.
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Affiliation(s)
- Rasmus B Hasselbalch
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Martin Schultz
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Philip A Schytz
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Jonas H Kristensen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Nina Strandkjær
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Mia Pries-Heje
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
- The Danish Heart Foundation, Copenhagen 1120, Denmark
| | - Morten Schou
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hilleroed 3400, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen 2200, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
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Hasselbalch RB, Kristensen JH, Strandkjær N, Jørgensen N, Bundgaard H, Malmendal A, Iversen KK. Metabolomics of early myocardial ischemia. Metabolomics 2023; 19:33. [PMID: 37002479 PMCID: PMC10066099 DOI: 10.1007/s11306-023-01999-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 03/14/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Diagnosing myocardial infarction is difficult during the initial phase. As, acute myocardial ischemia is associated with changes in metabolic pathways, metabolomics may provide ways of identifying early stages of ischemia. We investigated the changes in metabolites after induced ischemia in humans using nuclear magnetic resonance spectroscopy (NMR). METHODS We included patients undergoing elective coronary angiography showing normal coronary arteries. These were randomized into 4 groups and underwent coronary artery occlusion for 0, 30, 60 or 90 s. Blood was collected over the next 3 h and analyzed using NMR. We used 2-way ANOVA of time from baseline- and treatment group to find metabolites that changed significantly following the intervention and principal component analysis (PCA) to investigate changes between the 90 s ischemia- and control groups at 15 and 60 min after intervention. RESULTS We included 34 patients. The most pronounced changes were observed in the lipid metabolism where 38 of 112 lipoprotein parameters (34%) showed a significant difference between the patients exposed to ischemia and the control group. There was a decrease in total plasma triglycerides over the first hour followed by a normalization. The principal component analysis showed a effects of the treatment after just 15 min. These effects were dominated by changes in high-density lipoprotein. An increase in lactic acid levels was detected surprisingly late, 1-2 h after the ischemia. CONCLUSION We investigated the earliest changes in metabolites of patients undergoing brief myocardial ischemia and found that ischemia led to changes throughout the lipid metabolism as early as 15 min post-intervention.
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Affiliation(s)
- Rasmus Bo Hasselbalch
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark.
- Department of Cardiology Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
- Department of Emergency Medicine, Department of Cardiology, Herlev and Gentofte Hospital, Borgmester Ib Juuls vej 1, Herlev, DK-2730, Denmark.
| | - Jonas Henrik Kristensen
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Cardiology Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nina Strandkjær
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Cardiology Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nicoline Jørgensen
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Cardiology Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders Malmendal
- Department of Science and Environment, Roskilde University, Roskilde, Denmark
| | - Kasper Karmark Iversen
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Cardiology Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Wireklint SC, Elmqvist C, Fridlund B, Göransson KE. A longitudinal, retrospective registry-based validation study of RETTS©, the Swedish adult ED context version. Scand J Trauma Resusc Emerg Med 2022; 30:27. [PMID: 35428351 PMCID: PMC9013139 DOI: 10.1186/s13049-022-01014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/31/2022] [Indexed: 12/04/2022] Open
Abstract
Background Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. The Rapid Emergency Triage and Treatment System (RETTS©), with annual updates, is the most applied triage system. However, the national implementation has been performed despite low scientific foundation for triage as a method, mainly related to the absence of adjustment to age and gender. Furthermore, there is a lack of studies of RETTS© in Swedish ED context, especially of RETTS© validity. Hence, the aim the study was to determine the validity of RETTS©. Methods A longitudinal retrospective register study based on cohort data from a healthcare region comprising two EDs in southern Sweden. Two editions of RETTS© was selected; year 2013 and 2016, enabling comparison of crude data, and adjusted for age-combined Charlson comorbidity index (ACCI) and gender. All patients ≥ 18 years visiting either of the two EDs seeing a physician, was included. Primary outcome was ten-day mortality, secondary outcome was admission to Intensive Care Unit (ICU). The data was analysed with descriptive, and inferential statistics. Results Totally 74,845 patients were included. There was an increase in patients allocated red or orange triage levels (unstable) between the years, but a decrease of admission, both to general ward and ICU. Of all patients, 1031 (1.4%) died within ten-days. Both cohorts demonstrated a statistically significant difference between the triage levels, i.e. a higher risk for ten-day mortality and ICU admission for patients in all triage levels compared to those in green triage level. Furthermore, significant statistically differences were demonstrated for ICU admission, crude as well as adjusted, and for adjusted data ten-day mortality, indicating that ACCI explained ten-day mortality, but not ICU admission. However, no statistically significant difference was found for the two annual editions of RETTS© considering ten-day mortality, crude data. Conclusion The annual upgrade of RETTS© had no statistically significant impact on the validity of the triage system, considering the risk for ten-day mortality. However, the inclusion of ACCI, or at least age, can improve the validity of the triage system. Graphical Abstract ![]()
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Prevalence of Prolonged Length of Stay in an Emergency Department in Urban Denmark: A Retrospective Health Records Repository Review. J Emerg Nurs 2022; 48:102.e1-102.e12. [PMID: 34996571 DOI: 10.1016/j.jen.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/20/2021] [Accepted: 08/18/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Prolonged length of stay in emergency departments is associated with increased hospitalization, hospital-acquired pressure ulcers, medication errors, and mortality. In acute admissions in Denmark in 2018, 67% of patients experienced waiting time from arrival to examination. This study aimed to estimate the prevalence of prolonged length of stay (≥6 hours) and identify risk factors related to input, throughput, and output components. METHODS A retrospective health records repository review included 4743 patients admitted to a single urban emergency department in Denmark in January 2019. Data collected from the electronic health record system repository included demographic and organizational characteristics and were analyzed using descriptive statistics and logistic regression. RESULTS Among patients admitted in the study period, 31% had a prolonged length of stay of ≥6 hours. Prolonged length of emergency department stay was associated with being female (male odds ratio [OR], 0.86; 95% confidence interval [CI], 0.75-0.98), treatment by medical service (OR, 4.25, 95% CI, 3.63-4.98) vs surgical or injury, triage acuity of 2-Orange (OR, 1.45; 95% CI, 1.18-1.78) or 3-Yellow (OR, 1.47; 95% CI, 1.23-1.75) on a 5-level scale, evening (OR, 1.44; 95% CI, 1.24-1.66) or night (OR, 2.36; 95% CI, 1.91-2.91) arrival, ages 56 to 80 (OR, 1.79; 95% CI, 1.52-2.11) and >81 (OR, 2.40; 95% CI, 1.99-2.88) years, and hospital admission (OR, 1.19; 95% CI, 1.04-1.38) vs discharge from the emergency department to home. DISCUSSION Female, elderly, and medical patients were each identified as at-risk characteristics for ≥6-hour length of stay in the emergency department. Acute care patient pathways in the emergency department, particularly for evening and night, with guideline-based care and system level improvements in patient flow are warranted. Further research with larger populations is needed to identify and support interventions to decrease prolonged length of stay.
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Wireklint SC, Elmqvist C, Göransson KE. An updated national survey of triage and triage related work in Sweden: a cross-sectional descriptive and comparative study. Scand J Trauma Resusc Emerg Med 2021; 29:89. [PMID: 34217351 PMCID: PMC8254961 DOI: 10.1186/s13049-021-00905-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 06/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. According to two national surveys from 2005 to 2011, triage was carried out with different triage scales and without guidelines or formal education. Furthermore, a review from 2010 questioned the scientific evidence for both triage as a method as well as the Swedish five level triage scale Medical Emergency Triage and Treatment System (METTS); nevertheless, METTS was applied in 65% of the EDs in 2011. Subsequently, METTS was renamed to Rapid Emergency Triage and Treatment System (RETTS©). The hypothesis for this study is that the method of triage is still applied nationally and that the use of METTS/RETTS© has increased. Hence, the aim is to describe the occurrence and application of triage and triage related work at Swedish Emergency Departments, in comparison with previous national surveys. METHODS In this cross-sectional study with a descriptive and comparative design, an electronic questionnaire was developed, based on questionnaire from previous studies. The survey was distributed to all hospital affiliated EDs from late March to the middle of July in 2019. The data was analysed with descriptive statistics, by IBM SPSS Statistics, version 26. RESULTS Of the 51 (75%) EDs partaking in the study, all (100%) applied triage, and 92% used the Swedish triage scale RETTS©. Even so, there was low concordance in how RETTS© was applied regarding time frames i.e., how long a patient in respective triage level could wait for assessment by a physician. Additionally, the results show a major diversion in how the EDs performed education in triage. CONCLUSION This study confirms that triage method is nationally implemented across Swedish EDs. RETTS© is the dominating triage scale but cannot be considered as one triage scale due to the variation with regard to time frames per triage level. Further, a diversion in introduction and education in the pivotal role of triage has been shown. This can be counteracted by national guidelines in what triage scale to use and how to perform triage education.
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Affiliation(s)
- Sara C Wireklint
- Emergency Department and Department of Research and Development, Region Kronoberg, Department of Health and Caring Sciences and Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, FoU Kronoberg, Sigfridsvägen 5, S-352 57, Växjö, Sweden.
| | - Carina Elmqvist
- Department of Research and Development, Region Kronoberg and Centre of Interprofessional Collaboration within Emergency Care (CICE) at the Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Katarina E Göransson
- Department of Medicine Solna, Karolinska Institutet and Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
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Lyngholm LE, Nickel CH, Kellett J, Chang S, Cooksley T, Brabrand M. A negative D-dimer identifies patients at low risk of death within 30 days: a prospective observational emergency department cohort study. QJM 2019; 112:675-680. [PMID: 31179506 DOI: 10.1093/qjmed/hcz140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/27/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the ability of a normal D-dimer level (<0.5 mg/l) to identify emergency department (ED) patients at low risk of 30-day all-cause mortality. DESIGN In this prospective observational study, D-dimer levels of adult medical patients were assessed at arrival to the ED. Data on 30-day survival status were extracted from the Danish Civil Registration System with complete follow-up. SETTING The Hospital of South West Jutland. PATIENTS All patients aged 18 years or older who required any blood sample on a clinical indication on arrival to the ED. Participants were required to give written informed consent before enrollment. MAIN RESULTS The study population of 1 518 patients with median age 66 years of which 49.4% were female. Of the 791 (52.1%) patients with normal D-dimer levels, 3 (0.4%) died within 30 days; one death resulted from an unrelated traumatic accident. Of the 727 (47.9%) patients with abnormal D-dimer levels (≥0.50 mg/l), 32 (4.4%) died within 30 days. Patients with normal D-dimer levels had a significantly lower 30-day mortality compared to patients with abnormal D-dimer levels (odds ratio 0.08, 95% CI 0.02-0.28): of the 35 patients who died within 30 days, 19 (54.3%) had normal or near normal vital signs when first assessed. CONCLUSION Normal D-dimer levels identified patients at low risk of 30-day mortality. Since most patients who died within 30 days presented with normal or near normal vital signs, D-dimer levels appear to provide additional prognostic information.
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Affiliation(s)
- L E Lyngholm
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Switzerland
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
| | - S Chang
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark
- Department of Clinical Biochemistry, Hospital of South West Jutland, Denmark
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, UK
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
- Department of Emergency Medicine, Odense University Hospital, Denmark
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Do prehospital providers and emergency nurses agree on triage assignment?: an efficacy study. Eur J Emerg Med 2019; 26:29-33. [PMID: 28915163 DOI: 10.1097/mej.0000000000000503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the agreement on triage level between prehospital providers and emergency department (ED) nurses in clinical practice when using the same triage system. The objectives were as follows: (a) What is the agreement of triage between prehospital providers and ED nurses, when using Danish Emergency Process Triage (DEPT) correctly? (b) Which part of the triage process yields the highest agreement regarding the final triage? METHODS The study was a prospective and observational efficacy study. Patients transported to the ED by ambulances were included. They were triaged by prehospital providers while being transported by ambulance to the ED, and by ED nurses upon arrival. Triage was done using the DEPT - a five-level triage system based on vital signs and a presenting complaint algorithm. An agreement analysis was performed. RESULTS DEPT was used correctly by both professions in 292 patients. In 182 (62%) patients the prehospital providers and the ED nurses agreed on the same triage level. This equals to κ=0.47 [95% confidence interval (CI): 0.41-0.56]. When considering the triage based on vital signs the agreement was 72% (κ=0.46; 95% CI: 0.41-0.47), and based on presenting complaint the agreement was 46% (κ=0.41; 95% CI: 0.37-0.44). CONCLUSION There was a moderate interrater agreement on triage assignment between ED nurses and prehospital providers. They agreed on final triage more often if they agreed on triage based on vital signs rather than presenting complaints.
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Hasselbalch RB, Pries-Heje M, Schultz M, Plesner LL, Ravn L, Lind M, Greibe R, Jensen BN, Høi-Hansen T, Carlson N, Torp-Pedersen C, Rasmussen LS, Iversen K. The Copenhagen Triage Algorithm is non-inferior to a traditional triage algorithm: A cluster-randomized study. PLoS One 2019; 14:e0211769. [PMID: 30716123 PMCID: PMC6361446 DOI: 10.1371/journal.pone.0211769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 01/19/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Triage systems with limited room for clinical judgment are used by emergency departments (EDs) worldwide. The Copenhagen Triage Algorithm (CTA) is a simplified triage system with a clinical assessment. Methods The trial was a non-inferiority, two-center cluster-randomized crossover study where CTA was compared to a local adaptation of Adaptive Process Triage (ADAPT). CTA involves initial categorization based on vital signs with a final modification based on clinical assessment by an ED nurse. We used 30-day mortality with a non-inferiority margin at 0.5%. Predictive performance was compared using Receiver Operator Characteristics. Results We included 45,347 patient visits, 23,158 (51%) and 22,189 (49%) were triaged with CTA and ADAPT respectively with a 30-day mortality of 3.42% and 3.43% (P = 0.996) a difference of 0.01% (95% CI: -0.34 to 0.33), which met the non-inferiority criteria. Mortality at 48 hours was 0.62% vs. 0.71%, (P = 0.26) and 6.38% vs. 6.61%, (P = 0.32) at 90 days for CTA and ADAPT. CTA triaged at significantly lower urgency level (P<0.001) and was superior in predicting 30-day mortality, Area under the curve: 0.67 (95% CI 0.65–0.69) compared to 0.64 for ADAPT (95% CI 0.62–0.66) (P = 0.03). There were no significant differences in rate of admission to the intensive care unit, length of stay, waiting time nor rate of readmission within 30 or 90 days. Conclusion A novel triage system based on vital signs and a clinical assessment by an ED nurse was non-inferior to a traditional triage algorithm by short term mortality, and superior in predicting 30-day mortality. Trial registration Clinicaltrials.gov NCT02698319
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Affiliation(s)
| | - Mia Pries-Heje
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Martin Schultz
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | | | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Greibe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Thomas Høi-Hansen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Nicholas Carlson
- Department of Cardiology, Gentofte Hospital, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Health, Science and Technology, Aalborg University and Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
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Soluble Urokinase Plasminogen Activator Receptor (suPAR) as an Added Predictor to Existing Preoperative Risk Assessments. World J Surg 2018; 43:780-790. [PMID: 30390135 DOI: 10.1007/s00268-018-4841-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Risk assessment strategies, such as using the American Society of Anesthesiologists (ASA) physical status classification, attempt to identify surgical high-risk patients. Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker reflecting overall systemic inflammation and immune activation, and it could potentially improve the identification of high-risk surgical patients. METHODS We included patients acutely admitted to the emergency department who subsequently underwent surgery within 90 days of admission. Patients were stratified into low-risk or high-risk groups, according to ASA classification (ASAlow: ASA I-II; ASAhigh: ASA III-VI) and suPAR level, measured at admission (suPARhigh above and suPARlow below 5.5 ng/ml), respectively. Pre-specified complications were identified in national registries and electronic medical records. The association between ASA classification, suPAR level, CRP and the rate of postoperative complications was analyzed with logistic regression and Cox regression analyses, estimating odds ratios and hazard ratios (HRs). RESULTS During 90-day follow-up from surgery, 31 (7.0%) patients died and 158 (35.6%) patients had postoperative complications. After adjusting for age, sex, and ASA classification, the HR for 90-day postoperative mortality was 2.5 (95% CI 1.6-4.0) for every doubling of suPAR level. suPAR was significantly better than CRP at predicting mortality and all complications (P = 0.0036 and P = 0.0041, respectively). Combining ASA classification and suPAR level significantly improved prediction of mortality and the occurrence of a postoperative complication within 90 days after surgery (P < 0.0001). CONCLUSION Measuring suPAR levels in acutely admitted patients may aid in identifying high-risk patients and improve prediction of postoperative complications.
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Robert R, Beaussier M, Pateron D, Ecoffey C, Denys F, Honnart D, Misset B, Reignier J, Perrigault PF, Guidet B, Kerever S, Guiot P. Recommandations pour le fonctionnement des unités de surveillance continue dans les établissements de santé. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Robert R, Beaussier M, Pateron D, Ecoffey C, Denys F, Honnart D, Misset B, Reignier J, Perrigault PF, Guidet B, Kerever S, Guiot P. Recommandations pour le fonctionnement des unités de surveillance continue dans les établissements de santé. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Utility of multiple rule out CT screening of high-risk atraumatic patients in an emergency department-a feasibility study. Emerg Radiol 2018; 25:357-365. [PMID: 29455390 DOI: 10.1007/s10140-018-1584-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Several large trials have evaluated the effect of CT screening based on specific symptoms, with varying outcomes. Screening of patients with CT based on their prognosis alone has not been examined before. For moderate-to-high risk patients presenting in the emergency department (ED), the potential gain from a CT scan might outweigh the risk of radiation exposure. We hypothesized that an accelerated "multiple rule out" CT screening of moderate-to-high risk patients will detect many clinically unrecognized diagnoses that affect change in treatment. METHOD Patients ≥ 40 years, triaged as high-risk or moderate-to-high risk according to vital signs, were eligible for inclusion. Patients were scanned with a combined ECG-gated and dual energy CT scan of cerebrum, thorax, and abdomen. The impact of the CT scan on patient diagnosis and treatment was examined prospectively by an expert panel. RESULTS A total of 100 patients were included in the study, (53% female, mean age 73 years [age range, 43-93]). The scan lead to change in treatment or additional examinations in 37 (37%) patients, of which 24 (24%) were diagnostically significant, change in acute treatment in 11 (11%) cases and previously unrecognized malignant tumors in 10 (10%) cases. The mean size specific radiation dose was 15.9 mSv (± 3.1 mSv). CONCLUSION Screening with a multi-rule out CT scan of high-risk patients in an ED is feasible and result in discovery of clinically unrecognized diagnoses and malignant tumors, but at the cost of radiation exposure and downstream examinations. The clinical impact of these findings should be evaluated in a larger randomized cohort.
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Kristensen M, Iversen AKS, Gerds TA, Østervig R, Linnet JD, Barfod C, Lange KHW, Sölétormos G, Forberg JL, Eugen-Olsen J, Rasmussen LS, Schou M, Køber L, Iversen K. Routine blood tests are associated with short term mortality and can improve emergency department triage: a cohort study of >12,000 patients. Scand J Trauma Resusc Emerg Med 2017; 25:115. [PMID: 29179764 PMCID: PMC5704435 DOI: 10.1186/s13049-017-0458-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 11/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prioritization of acutely ill patients in the Emergency Department remains a challenge. We aimed to evaluate whether routine blood tests can predict mortality in unselected patients in an emergency department and to compare risk prediction with a formalized triage algorithm. METHODS A prospective observational cohort study of 12,661 consecutive admissions to the Emergency Department of Nordsjælland University Hospital during two separate periods in 2010 (primary cohort, n = 6279) and 2013 (validation cohort, n = 6383). Patients were triaged in five categories by a formalized triage algorithm. All patients with a full routine biochemical screening (albumin, creatinine, c-reactive protein, haemoglobin, lactate dehydrogenase, leukocyte count, potassium, and sodium) taken at triage were included. Information about vital status was collected from the Danish Central Office of Civil registration. Multiple logistic regressions were used to predict 30-day mortality. Validation was performed by applying the regression models on the 2013 validation cohort. RESULTS Thirty-day mortality was 5.3%. The routine blood tests had a significantly stronger discriminative value on 30-day mortality compared to the formalized triage (AUC 88.1 [85.7;90.5] vs. 63.4 [59.1;67.5], p < 0.01). Risk stratification by routine blood tests was able to identify a larger number of low risk patients (n = 2100, 30-day mortality 0.1% [95% CI 0.0;0.3%]) compared to formalized triage (n = 1591, 2.8% [95% CI 2.0;3.6%]), p < 0.01. CONCLUSIONS Routine blood tests were strongly associated with 30-day mortality in acutely ill patients and discriminatory ability was significantly higher than with a formalized triage algorithm. Thus routine blood tests allowed an improved risk stratification of patients presenting in an emergency department.
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Affiliation(s)
- Michael Kristensen
- Department of Emergency Medicine, Sjællands Universitetshospital Køge, Køge, Denmark.,Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Kristine Servais Iversen
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Rebecca Østervig
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Danker Linnet
- Department of Anaesthesia, Sjællands Universitetshospital Køge, Køge, Denmark
| | - Charlotte Barfod
- Department of Anaesthesia, Centre of Head and Orthopaedics Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Jakob Lundager Forberg
- Department of Prehospital and In-Hospital Emergency Medicine - Helsingborg Hospital, Helsingborg, Sweden
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, Copenhagen University Hospital, Copenhagen, Denmark. .,Department of Cardiology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark.
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Hasselbalch RB, Plesner LL, Pries-Heje M, Ravn L, Lind M, Greibe R, Jensen BN, Rasmussen LS, Iversen K. The Copenhagen Triage Algorithm: a randomized controlled trial. Scand J Trauma Resusc Emerg Med 2016; 24:123. [PMID: 27724978 PMCID: PMC5057417 DOI: 10.1186/s13049-016-0312-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/30/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Crowding in the emergency department (ED) is a well-known problem resulting in an increased risk of adverse outcomes. Effective triage might counteract this problem by identifying the sickest patients and ensuring early treatment. In the last two decades, systematic triage has become the standard in ED's worldwide. However, triage models are also time consuming, supported by limited evidence and could potentially be of more harm than benefit. The aim of this study is to develop a quicker triage model using data from a large cohort of unselected ED patients and evaluate if this new model is non-inferior to an existing triage model in a prospective randomized trial. METHODS The Copenhagen Triage Algorithm (CTA) study is a prospective two-center, cluster-randomized, cross-over, non-inferiority trial comparing CTA to the Danish Emergency Process Triage (DEPT). We include patients ≥16 years (n = 50.000) admitted to the ED in two large acute hospitals. Centers are randomly assigned to perform either CTA or DEPT triage first and then use the other triage model in the last time period. The CTA stratifies patients into 5 acuity levels in two steps. First, a scoring chart based on vital values is used to classify patients in an immediate category. Second, a clinical assessment by the ED nurse can alter the result suggested by the score up to two categories up or one down. The primary end-point is 30-day mortality and secondary end-points are length of stay, time to treatment, admission to intensive care unit, and readmission within 30 days. DISCUSSION If proven non-inferior to standard DEPT triage, CTA will be a faster and simpler triage model that is still able to detect the critically ill. Simplifying triage will lessen the burden for the ED staff and possibly allow faster treatment. TRIAL REGISTRATION Clinicaltrials.gov: NCT02698319 , registered 24. of February 2016, retrospectively registered.
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Affiliation(s)
| | | | - Mia Pries-Heje
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Greibe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Lars S. Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
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Sandø A, Schultz M, Eugen-Olsen J, Rasmussen LS, Køber L, Kjøller E, Jensen BN, Ravn L, Lange T, Iversen K. Introduction of a prognostic biomarker to strengthen risk stratification of acutely admitted patients: rationale and design of the TRIAGE III cluster randomized interventional trial. Scand J Trauma Resusc Emerg Med 2016; 24:100. [PMID: 27491822 PMCID: PMC4974743 DOI: 10.1186/s13049-016-0290-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/27/2016] [Indexed: 12/22/2022] Open
Abstract
Background Several biomarkers have shown to carry prognostic value beyond current triage algorithms and may aid in initial risk stratification of patients in the emergency department (ED). It has yet to be established if information provided by biomarkers can be used to prevent serious complications or deaths. Our aim is to determine whether measurement of the blood level of the biomarker soluble urokinase plasminogen activator receptor (suPAR) can enhance early risk stratification leading to reduced mortality, lower rate of complications, and improved patient flow in acutely admitted adult patients at the ED. The main hypothesis is that the availability of suPAR can reduce all-cause mortality, assessed at least 10 months after admission, by drawing attention towards patients with an unrecognized high risk, leading to improved diagnostics and treatment. Methods The study is designed as a cross-over cluster randomized interventional trial. SuPAR is measured within 2 h after admission and immediately reported to the treating physicians in the ED. All ED physicians are educated in the prognostic capabilities of suPAR prior to the inclusion period. The inclusion period began January 11th 2016 and ends June 6th 2016. The study aims to include 10.000 patients in both the interventional and control arm. The results will be presented in 2017. Discussion The present article aims to describe the design and rationale of the TRIAGE III study that will investigate whether the availability of prognostic information can improve outcome in acutely admitted patients. This might have an impact on health care organization and decision-making. Trial registration The trial is registered at clinicaltrials.gov (ID NCT02643459, November 13, 2015) and at the Danish Data Protection agency (ID HGH-2015-042 I-Suite no. 04087).
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Affiliation(s)
- Andreas Sandø
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Martin Schultz
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark.,Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Erik Kjøller
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Birgitte Nybo Jensen
- Department of Emergency Medicine, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Theis Lange
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark
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