Clinical use of the manchester triage system in patients with dizziness - An observational study in the emergency department.

INTRODUCTION: Dizziness is a common symptom with diverse causes, including ear-nose-throat, internal, neurological, or psychiatric origins. While for most parts treatable in nonemergency settings, it can also signal time-critical conditions, like an unnoticed stroke, requiring prompt diagnosis and treatment to prevent lasting harm or death. The aim of this study was to evaluate the validity of the Manchester Triage System in classifying patients presenting with dizziness based on final diagnoses and patient outcomes, as no specific flow chart exists for this symptom in the MTS. METHODS: Monocentric, retrospective observational study. To test the validity of the MTS in the triage of dizziness patients, the treatment level was used as a surrogate parameter. We grouped the patients into outpatient, normal ward and intermediate care/intensive care unit (IMC/ICU) patients. Furthermore, we analyzed the dizziness patients in subgroups based on the origin of their dizziness to identify potential improvements for the MTS. Patients with dizziness and stroke, who represent the most vulnerable group of dizziness patients, were also evaluated separately. RESULTS: During the observation period, 2958 patients presented at the ED with the symptom dizziness and 52 017 without, who formed the reference group. When examining the relationship between triage level and subsequent treatment level, a larger deviation is observed compared to the reference group. The receiver operating characteristics (ROC) regarding hospital admission in general showed an area under the curve (AUC) in the subgroup with dizziness due to a central nervous system causes (n=838) of 0.69 (95% CI 0.65 - 0.72) and in the subgroup of dizziness by other organic cause (n=901), an AUC of 0.64 (95% CI 0.60 - 0.68). The reference group had an AUC 0.75 (95% CI 0.75 - 0.76) here. In relation to admission to IMC/ICU, the results were similar. The sensitivity of the MTS in terms of an adequate initial assessment of dizziness patients with stroke or transient ischemic attack (TIA) was 0.39, the specificity was 0.91 (reference group sensitivity 0.72, specificity 0.82). CONCLUSION: In terms of construct validity, the present study revealed that the use of MTS as a priority triage assessment tool was found to be less accurate in emergency patients with dizziness, particularly those diagnosed with stroke/TIA, when compared to other emergency patients.

Impaired humoral immunity to BQ.1.1 in convalescent and vaccinated patients.

Determining SARS-CoV-2 immunity is critical to assess COVID-19 risk and the need for prevention and mitigation strategies. We measured SARS-CoV-2 Spike/Nucleocapsid seroprevalence and serum neutralizing activity against Wu01, BA.4/5 and BQ.1.1 in a convenience sample of 1,411 patients receiving medical treatment in the emergency departments of five university hospitals in North Rhine-Westphalia, Germany, in August/September 2022. 62% reported underlying medical conditions and 67.7% were vaccinated according to German COVID-19 vaccination recommendations (13.9% fully vaccinated, 54.3% one booster, 23.4% two boosters). We detected Spike-IgG in 95.6%, Nucleocapsid-IgG in 24.0%, and neutralization against Wu01, BA.4/5 and BQ.1.1 in 94.4%, 85.0%, and 73.8% of participants, respectively. Neutralization against BA.4/5 and BQ.1.1 was 5.6- and 23.4-fold lower compared to Wu01. Accuracy of S-IgG detection for determination of neutralizing activity against BQ.1.1 was reduced substantially. We explored previous vaccinations and infections as correlates of BQ.1.1 neutralization using multivariable and Bayesian network analyses. Given a rather moderate adherence to COVID-19 vaccination recommendations, this analysis highlights the need to improve vaccine-uptake to reduce the COVID-19 risk of immune evasive variants. The study was registered as clinical trial (DRKS00029414).

The presentational flow chart "unwell adult" of the Manchester Triage System-Curse or blessing?

BACKGROUND: The presentational flow chart "unwell adult" of the Manchester Triage System (MTS) occupies a special role in this triage system, defined as the nonspecific presentation of an emergency patient. Current scientific studies show that a considerable proportion of emergency room patients present with so-called "nonspecific complaints". The aim of the present study is to investigate in detail the initial assessment of emergency patients triaged according to the presentational flow chart "unwell adult". METHODS: Monocentric, retrospective observational study. RESULTS: Data on 14,636 emergency department visits between March 12th and August 12th, 2019 were included. During the observation period, the presentational flow chart "unwell adult" was used 1,143 times and it was the third most frequently used presentational flow chart. Patients triaged with this flow chart often had unspecific complaints upon admission to the emergency department. Patients triaged with the "unwell adult" chart were often classified with a lower triage level. Notably, patients who died in hospital during the observation period frequently received low triage levels. The AUC for the MTS flow chart "unwell adult" and hospitalization in general for older patients (age ≥ 65 years) was 0.639 (95% CI 0.578-0.701), and 0.730 (95% CI 0.714-0.746) in patients triaged with more specific charts. The AUC for the MTS flow chart "unwell adult" and admission to ICU for older patients (age ≥65 years) was 0.631 (95% CI 0.547-0.715) and 0.807 (95% CI 0.790-0.824) for patients triaged with more specific flow charts. Comparison of the predictive ability of the MTS for in-hospital mortality in the group triaged with the presentational flow chart "unwell adult" revealed an AUC of 0.682 (95% CI 0.595-0.769) vs. 0.834 (95% CI 0.799-0.869) in the other presentational flow charts. CONCLUSION: The presentational flow chart "unwell adult" is frequently used by triage nurses for initial assessment of patients. Patient characteristics assessed with the presentational flow chart "unwell adult" differ significantly from those assessed with MTS presentational flow charts for more specific symptoms. The quality of the initial assessment in terms of a well-functioning triage priority assessment tool is less accurate than the performance of the MTS described in the literature.

Prospective Observational Multisite Study of Handover in the Emergency Department: Theory versus Practice.

INTRODUCTION: The handover process in the emergency department (ED) is relevant for patient outcomes and lays the foundation for adequate patient care. The aim of this study was to examine the current prehospital to ED handover practice with regard to content, structure, and scope. METHODS: We carried out a prospective, multicenter observational study using a specifically developed checklist. The steps of the handover process in the ED were documented in relation to qualification of the emergency medical services (EMS) staff, disease severity, injury patterns, and treatment priority. RESULTS: We documented and evaluated 721 handovers based on the checklist. According to ISBAR (Identification, Situation, Background, Assessment, Recommendation), MIST (Mechanism, Injuries, Signs/Symptoms, Treatment), and BAUM (Situation [German: Bestand], Anamnesis, Examination [German: Untersuchung], Measures), almost all handovers showed a deficit in structure and scope (99.4%). The age of the patient was reported 339 times (47.0%) at the time of handover. The time of the emergency onset was reported in 272 cases (37.7%). The following vital signs were transferred more frequently for resuscitation room patients than for treatment room patients: blood pressure (BP)/(all comparisons p < 0.05), heart rate (HR), oxygen saturation (SpO2) and Glasgow Coma Scale (GCS). Physicians transmitted these vital signs more frequently than paramedics BP, HR, SpO2, and GCS. A handover with a complete ABCDE algorithm (Airway, Breathing, Circulation, Disability, Environment/Exposure) took place only 31 times (4.3%). There was a significant difference between the occupational groups (p < 0.05). CONCLUSION: Despite many studies on handover standardization, there is a remarkable inconsistency in the transfer of information. A "hand-off bundle" must be created to standardize the handover process, consisting of a uniform mnemonic accompanied by education of staff, training, and an audit process.

Serum DNA hypermethylation in patients with bladder cancer: results of a prospective multicenter study.

BACKGROUND: Cell-free serum DNA levels are increased in patients with cancer, and at least partially, these DNA fragments are derived from cancer cells. A few reports indicated that methylated serum DNA in patients with bladder cancer (BCA) is a useful non-invasive biomarker. The purpose of this prospective multicenter study was to validate earlier studies. MATERIALS AND METHODS: In total, 227 consecutive participants (non-muscle invasive BCA, n=75; muscle-invasive BCA, n=20; transurethral bladder resection (TURB) without BCA, n=48; benign disease, n=31; healthy individuals, n=53), were recruited for this study. Cell-free serum DNA was isolated and digested with methylation-sensitive restriction-enzymes (Bsh1236I, HpaII and HinP1I) to quantify the amount of methylated (TIMP3, APC, RARB, TIG1, GSTP1, p14, p16, PTGS2 and RASSF1A) DNA fragments. RESULTS: The amount of methylated DNA was usually small (<10%), and the methylation frequencies varied for different genes (e.g. frequent: TIMP3; moderate: APC, RARB, TIG1; infrequent: p16, PTGS2, p14, RASSF1A, GSTP1). Methylation levels at each gene site and the number of methylated genes were increased in BCA compared to healthy individuals, but were similar in BCA and patients with non-malignant disease. The number of methylated genes allowed for discrimination (62% sensitivity, 89% specificity) of BCA patients from healthy individuals. DNA hypermethylation was not correlated with advanced stage or grade in patients with BCA. CONCLUSION: The detection of hypermethylated DNA in serum allows for discrimination of patients with BCA and healthy individuals, but there is no difference between patients with BCA and those with non-malignant disease, thereby limiting its value as a non-invasive biomarker.

Cell-free serum DNA in patients with bladder cancer: results of a prospective multicenter study.

BACKGROUND/AIM: Cell-free DNA may serve as a biomarker for patients with cancer; we designed our study to determine its potential in patients with bladder cancer (BCA). MATERIALS AND METHODS: Short ß-actin (ACTB)-106 and large ACTB-384 fragments were quantified using real time PCR (RT-PCR); the ratio of ACTB-384/ACTB-106 was defined as DNA integrity. We analyzed the serum from 95 patients with and from 132 without BCA. RESULTS: Patients with BCA had increased ACTB-106 levels and lower DNA integrity compared to patients without cancer. However, patients undergoing transurethral bladder resection (TURB) with histological exclusion of BCA had a similar ACTB-106 level and DNA integrity, as patients with BCA. Cell-free DNA was not correlated with smoker status, pT stage, grade or lymph node metastasis, or DNA integrity. There was a weak inverse correlation of age with DNA integrity in patients with BCA. CONCLUSION: Analysis of serum cell-free DNA levels and fragmentation patterns are of limited value regarding the identification of patients with BCA.