Use of overactive bladder anticholinergic medications associated with falls leading to emergency department visits: results from the ADRED study.

PURPOSE: Drug intake might be a modifiable factor for the individual fall-risk of older adults, and anticholinergic properties of drugs need to be considered. This study is aimed at analyzing the association of older adults' individual anticholinergic load with particular focus on use of overactive bladder anticholinergic medications with falls in multi-medicated patients. MATERIALS AND METHODS: Cases of the prospective, observational, multi-center study on adverse drug reactions leading to emergency departments (ADRED study) between 2015 and 2018 in Germany were analyzed comparing the exposure of overactive bladder anticholinergic medications on the chance to present with a fall with patients without exposure. Logistic regression analysis was used adjusting for pre-existing conditions, drug exposure, and the individual anticholinergic burden by drug use. To this end, a combination of seven expert-based anticholinergic rating scales was used. RESULTS: The anticholinergic burden was higher in patients with overactive bladder anticholinergic medications (median 2 [1; 3]) compared to not taking drugs of interest. Presenting with a fall was associated with overactive bladder anticholinergic medications (odds ratio (OR) 2.34 [95% confidence interval 1.14-4.82]). The use of fall-risk increasing drugs was likewise associated (OR 2.30 [1.32-4.00]). The anticholinergic burden itself seemed not to be associated with falls (OR 1.01 [0.90-1.12]). CONCLUSIONS: Although falls occur multifactorial in older adults and confounding by indication cannot be ruled out, the indication for a drug treatment should be decided with caution when other, non-pharmacological treatment options have been tried. GERMAN CLINICAL TRIAL REGISTER: DRKS-ID: DRKS00008979, registration date 01/11/2017.

The phenotype of adverse drug effects: Do emergency visits due to adverse drug reactions look different in older people? Results from the ADRED study.

AIMS: Older patients in particular suffer from adverse drug reactions (ADR) when presenting in the emergency department. We aimed to characterise the phenotype of those ADRs, to be able to recognise an ADR in older patients. METHODS: Cases of ADRs in emergency departments collected within the multicentre prospective observational study (ADRED) were analysed (n = 2215). We analysed ADR-associated diagnoses, symptoms and their risk profiles. We present frequencies and odds ratios (OR) with 95% confidence intervals for adults (18-64 years) compared to older adults (≥65 years; young-old 65-79, old-old ≥80 years) and regression coefficients (B) for each year of age. RESULTS: Most prominent differences were seen for drug-associated confusion, dehydration, and bradycardia (OR 6.70 [1.59-28.27], B .054; OR 6.02 [2.41-15.03], B .081, and 4.82 [2.21-10.54], B .040), more likely seen in older adults. Bleedings were reported in all age groups, but gastrointestinal bleedings occurred with more than doubled chance in older adults (OR 2.46 [1.77-3.41], B .030), likewise did other bleedings such as haemorrhage from respiratory passages (OR 2.89 [1.37-6.11], B.036). Falls were more likely in older adults (OR 2.84 [1.77-4.53], B .030), while dizziness was frequent in both age groups. CONCLUSION: Our data point to differences in symptoms of ADRs between adults and older individuals, with dangerous drug-associated phenomena in the older adult such as bleedings or falls. Physicians should consider drug-associated origins of symptoms in older adults with an increased risk for serious health problems.

Personalising drug safety-results from the multi-centre prospective observational study on Adverse Drug Reactions in Emergency Departments (ADRED).

PURPOSE: Adverse drug reactions (ADR) account for 5 to 7% of emergency department (ED) consultations. We aimed to assess medication risk profiles for ADRs leading to ED visits. METHODS: We analysed medication intake and patient demographics in a prospective multi-centre observational study collecting ADR cases in four large EDs in Germany. Odds ratios (OR) were calculated to relate drug classes taken to those suspicious for an ADR after a causality assessment. RESULTS: A total of 2215 cases of ED visits due to ADRs were collected. The median age of the cohort was 73 years; in median, six co-morbidities and an intake of seven drugs were documented. Antineoplastic/immunomodulating agents had the highest OR for being suspected for an ADR (OR 20.45, 95% CI 14.54-28.77), followed by antithrombotics (OR 2.94, 95% CI 2.49-3.47), antibiotics (OR 2.65, 95% CI 1.78-3.95), systemic glucocorticoids (OR 2.43, 95% CI 1.54-3.82) and drugs affecting the central nervous system (CNS), such as antipsychotics (OR 2.36, 95% CI 1.46-3.81), antidepressants (OR 2.10, 95% CI 1.57-2.83), antiparkinsonian medication (OR 2.11, 95% CI 1.15-3.84), opioids (OR 1.79, 95% CI 1.26-2.54) and non-opioid analgesics (OR 1.32, 95% CI 1.01-1.72). CONCLUSIONS: Patients experiencing ADRs leading to ED visits are commonly old, multi-morbid and multi-medicated. CNS drugs may be more relevant than prior expected. With calculating ORs, we could replicate involvement of antineoplastic agents, antithrombotics, antibiotics, systemic glucocorticoids and non-opioid analgesics as frequently suspected for ADRs in EDs. TRIAL REGISTRATION: DRKS-ID: DRKS00008979.

[Recommendations for emergency management of patients with permanent mechanical circulatory support : Consensus statement of DGTHG, DIVI, DGIIN, DGAI, DGINA, DGfK and DGK]. / Empfehlungen zum Notfallmanagement von Patienten mit permanenten Herzunterstützungssystemen : Konsensuspapier der DGTHG, DIVI, DGIIN, DGAI, DGINA, DGfK und DGK.

The prevalence of patients living with long-term mechanical circulatory support (MCS) is rapidly increasing due to improved technology, improved survival, reduced adverse event profiles, greater reliability and mechanical durability, and limited numbers of organs available for donation. Patients with long-term MCS are very likely to require emergency medical support due to MCS-associated complications (e.g., right heart failure, left ventricular assist device malfunction, hemorrhage and pump thrombosis) but also due to non-MCS-associated conditions. Because of the unique characteristics of mechanical support, management of these patients is complicated and there is very little literature on emergency care for these patients. The purpose of this national scientific statement is to present consensus-based recommendations for the initial evaluation and resuscitation of adult patients with long-term MCS.

Validity of the Manchester Triage System in patients with sepsis presenting at the ED: a first assessment.

BACKGROUND: The Manchester Triage System (MTS) does not have a specific presentational flow chart for sepsis. The goal of this investigation was to determine adequacy of acuity assignment for patients with sepsis presenting at the ED and triaged using the MTS. MATERIALS AND METHODS: This retrospective analysis included patients >16 presenting to an ED in Bonn, Germany, on the first 12 days of each month between June 2012 and March 2014. Patients were classified into one of three septic groups, or no sepsis. For those with sepsis, adequacy of acuity assignment was based on the criteria of the first consensus conference of the American College of Chest Physicians and Society of Critical Care Medicine, first published in 1992. Adequacy of prioritisation is expressed as sensitivity and likelihood ratio (LR-). RESULTS: Among 20 836 patients evaluated, 801 (3.8%) were septic; of these, 581 (72.5%) had sepsis, 194 (24.2%) had severe sepsis and 26 (3.2%) had severe sepsis with circulation dysfunction. Patients who met the criteria for sepsis were correctly prioritised with a sensitivity of 70.4% (95% CI 66.5 to 74.0). The LR- was 0.628 (95% CI 0.564 to 0.698). Patients with severe sepsis were appropriately prioritised with a sensitivity of 84.5% (95% CI 78.1 to 89.4), and LR- was 0.330 (95% CI 0.243 to 0.450). In the group with severe sepsis and circulation dysfunction, sensitivity of MTS was 61.5% (95% CI 39.3 to 79.8), and LR- was 0.466 (95% CI 0.286 to 0.757). CONCLUSIONS: The MTS has some weaknesses regarding priority levels in emergency patients with septic illness. Overall, target key symptoms (discriminators) which aim at identifying systemic infection and ascertaining vital parameters are insufficiently considered.

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.

["Long lie trauma" patients: retrospective analysis of a patient cohort presenting to a university hospital emergency department]. / Liegetrauma: retrospektive Analyse einer Patientenkohorte aus einer universitären Notaufnahme.

BACKGROUND: Patients discovered recumbent, helpless and incapacitated, awake or unresponsive are referred to as "long lie trauma" (LLT) in the German medical jargon. Yet, a characterization of this cohort is missing. METHODS: We retrospectively analyzed all LLT patients admitted to the emergency department of the University Hospital Cologne from July 2018 to December 2020. RESULTS: A total of 50 LLT patients (median age 76 years, median time on the ground 13.5 h) were identified. The FD was most often attributed to primary cerebral causes in 40% of the cases (20% ischemic stroke, 16% intracranial hemorrhage, 4% epilepsy), intoxication/overdose (12%), and trauma (10%). It was often associated with infection (52%), injury (22%), hypovolemia (66%), acute kidney injury (20%), and severe rhabdomyolysis (creatine kinase ≥ 5000 U/l, 21%) as well as severe hypothermia < 32 °C (20%). Overall, 69% of the patients were admitted to an intensive care unit and in-hospital mortality was 50%. CONCLUSION: The term "long lie trauma" describes a complex clinical situation, in which various conditions lead to an incapacitated state with acute onset, which then causes further adverse health effects. Trauma or tissue damage were no obligatory requirement in this syndrome. Considering the high morbidity and in-hospital mortality, patients should initially be treated in the emergency room by an interdisciplinary team.

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).

Aneurysmal Subarachnoid Hemorrhage during the Shutdown for COVID-19.

The aim was to evaluate hospitalization rates for aneurysmal subarachnoid hemorrhage (SAH) within an interdisciplinary multicenter neurovascular network (NVN) during the shutdown for the COVID-19 pandemic along with its modifiable risk factors. In this multicenter study, admission rates for SAH were compared for the period of the shutdown for the COVID-19 pandemic in Germany (calendar weeks (cw) 12 to 16, 2020), the periods before (cw 6-11) and after the shutdown (cw 17-21 and 22-26, 2020), as well as with the corresponding cw in the years 2015-2019. Data on all-cause and pre-hospital mortality within the area of the NVN were retrieved from the Department of Health, and the responsible emergency medical services. Data on known triggers for systemic inflammation, e.g., respiratory viruses and air pollution, were analyzed. Hospitalizations for SAH decreased during the shutdown period to one-tenth within the multicenter NVN. There was a substantial decrease in acute respiratory illness rates, and of air pollution during the shutdown period. The implementation of public health measures, e.g., contact restrictions and increased personal hygiene during the shutdown, might positively influence modifiable risk factors, e.g., systemic inflammation, leading to a decrease in the incidence of SAH.

[Primary assessment in the emergency department]. / Ersteinschätzungssysteme in der Zentralen Notaufnahme.

First goal in an emergency department must be the immediate recognition of patients at risk. The primary success of therapy depends mainly on whether a critical risk is identified immediately upon arrival at the central emergency department and appropriate therapy is initiated. In order to identify critical patients among the many patients with a wide range of diseases and, nurse-assisted initial assessment systems can help. The assessment thus represents a complex decision-making process to identify critically ill patients in times of high patient volume and limited resources.

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.

[Recommendations for emergency management of patients with permanent mechanical circulatory support : Consensus statement of DGTHG, DIVI, DGIIN, DGAI, DGINA, DGfK and DGK]. / Empfehlungen zum Notfallmanagement von Patienten mit permanenten Herzunterstützungssystemen : Konsensuspapier der DGTHG, DIVI, DGIIN, DGAI, DGINA, DGfK und DGK.

The prevalence of patients living with long-term mechanical circulatory support (MCS) is rapidly increasing due to improved technology, improved survival, reduced adverse event profiles, greater reliability and mechanical durability, and limited numbers of organs available for donation. Patients with long-term MCS are very likely to require emergency medical support due to MCS-associated complications (e.g., right heart failure, left ventricular assist device malfunction, hemorrhage and pump thrombosis) but also due to non-MCS-associated conditions. Because of the unique characteristics of mechanical support, management of these patients is complicated and there is very little literature on emergency care for these patients. The purpose of this national scientific statement is to present consensus-based recommendations for the initial evaluation and resuscitation of adult patients with long-term MCS.

Adverse Drug Reactions in the Emergency Department: Is There a Role for Pharmacogenomic Profiles at Risk?-Results from the ADRED Study.

Individual differences in required drug dosages exist based on the pharmacogenomic (PGx) profiles. This study aimed to assess associations between PGx profiles and adverse drug reactions (ADR) that lead to admissions to the emergency department (ED). ADR cases of the prospective multi-center observational trial in EDs (ADRED study) were analyzed (n = 776) together with the relevant PGx phenotypes of the enzymes CYP2D6, CYP2C19, CYP2C9, and VKORC1. Overall, the allele frequency distribution in this cohort did not differ from the population frequencies. We compared the frequencies of phenotypes in the subgroups with the drugs suspected of certain ADR, in the remaining cases. The frequency distribution of CYP2C19 differed for the ADR bleeding cases suspected of clopidogrel (p = 0.020). In a logistic regression analysis, higher CYP2C19 activity (OR (95% CI): 4.97 (1.73-14.27)), together with age (1.05 (1.02-1.08)), showed an impact on the clopidogrel-suspecting ADRs, when adjusting for the clinical parameters. There was a trend for an association of phenprocoumon-risk profiles (low VKORC1 or CYP2C9 activity) with phenprocoumon-suspecting ADRs (p = 0.052). The PGx impact on serious ADRs might be highest in drugs that cannot be easily monitored or those that do not provoke mild ADR symptoms very quickly. Therefore, patients that require the intake of those drugs with PGx variability such as clopidogrel, might benefit from PGx testing.

Validity of the Manchester Triage System in emergency patients receiving life-saving intervention or acute medical treatment-A prospective observational study in the emergency department.

RATIONALE, AIMS, AND OBJECTIVES: The spectrum of cases seen by emergency departments ranges from minor illnesses or injuries to complex diseases with high mortality. Some patients require life-saving interventions (LSIs) or therapeutic treatment for an acute illness to prevent an expected imminent life-threatening condition immediately upon arrival. No published study has evaluated the validity of the Manchester Triage System (MTS) in the context of immediate LSI or acute emergency treatment (AET). METHODS: The definition of LSI was based on a literature search. AET was defined by an expert panel based on current emergency guidelines and diagnostic guideline recommendations. In a 4-month observation period, an independent external observer documented all executed LSIs or AETs using a checklist. Sensitivity, negative predictive value, likelihood ratio negative (LR-), and accuracy of MTS triage level for the identification of patients receiving an LSI or AET were calculated. RESULTS: In 1762 patients, 40 (2.3%) LSIs and 89 (5.1%) AETs were observed. In the LSI group, sensitivity of MTS was 75.0%, negative predictive value (NPV) was 99.2% (95% CI: 98.7%-99.6%), LR- was 0.303 (95% CI: 0.189-0.487) and accuracy (ACC) was 98.5% (95% CI: 97.8%-98.9%). In the AET group, sensitivity was 82.0%, NPV was 98.9% (95% CI: 98.1%-99.3%), LR- was 0.206 (95% CI: 0.132-0.322), and ACC was 86.5% (95% CI: 84.9%-88.1%). CONCLUSION: The MTS is a valid instrument for a first assessment of emergency patients in critical condition upon arrival.

Management and outcome of epistaxis under direct oral anticoagulants: a comparison with warfarin.

BACKGROUND: Epistaxis is one of the more common reasons for emergency room visits. The main risk factor for epistaxis is anticoagulant therapy. Until recently, the main culprit was oral intake of a vitamin K antagonist, such as warfarin, which has a number of side effects. Even more recently, several direct oral anticoagulants, rivaroxaban and dabigatran, have been approved for use. We investigated the possible differences between treatment of epistaxis with direct oral anticoagulants and vitamin K antagonists. METHODS: We conducted a retrospective cohort study at a tertiary referral center in Germany. All patients who were admitted within a 1-year period were included. Patient files were used to obtain the information. RESULTS: Overall, 677 patients were included in our study. Of these, 159 had been treated with vitamin K antagonists and 49 with direct oral anticoagulants. There were no significant differences in terms of age (p = 0.592), sex (p = 0.372), vital signs, bloodwork, or location of bleeding (p = 0.372). Management of epistaxis between the groups was also comparable (p = 0.399), with similar hospital admission rates (37.1% vs 24.5%; p = 0.145) and duration of stay (3.5 ± 2.1 days vs 3.8 ± 3.3 days; p = 0.650). CONCLUSION: We found no evidence to suggest epistaxis is more severe or requires more invasive therapy in patients given direct oral anticoagulants. A significant proportion of patients on vitamin K antagonists were not within the target range for international normalized ratio, highlighting one of the main issues with oral anticoagulation by vitamin K antagonists.