Causes of death among non-urgent patients in the emergency department who die within 30 days.

INTRODUCTION: Patients triaged as non-urgent in the emergency department constitute a diverse group with a low mortality rate assumed to be able to wait three hours for a physician. Little is known about the causes of death of non-urgent patients who die shortly after admission. We examined whether deaths among non-urgent patients were preventable. METHOD: Using data from the Copenhagen Triage Algorithm Study, we conducted a review of electronic medical records of all patients triaged as non-urgent who died within 30 days of presentation and constructed short summaries. These summaries were reviewed by two senior physicians who determined whether each death was expected or unexpected. The unexpected deaths were further assessed as unrelated or related to admission and if related as preventable or unpreventable. Any disagreements were settled by a third senior physician. RESULTS: Among the patients triaged as non-urgent, 335 of 14,655 (2%) died within 30 days. When comparing biomarkers and age, the non-urgent patients resembled the patients in other triage categories who died within 30 days. Most deaths were expected or not preventable (96%). The preventable deaths (n = 13, 4%) were among older patients with comorbidities. Causes of death were sudden cardiac arrest (n = 3), infection (n = 4), kidney failure (n = 1), electrolyte derangement (n = 1) and unknown (n = 4). CONCLUSION: Preventable deaths among non-urgent patients were rare and no overrepresentation was observed of specialties or diseases. FUNDING: Trygfonden. CLINICALTRIALS: gov:NCT02698319.

Real-time quintic Hermite interpolation for robot trajectory execution.

This paper presents a real-time joint trajectory interpolation system for the purpose of frequency scaling the low cycle time of a robot controller, allowing a Python application to real-time control the robot at a moderate cycle time. Interpolation is based on quintic Hermite piece-wise splines. The splines are calculated in real-time, in a piecewise manner between the high-level, long cycle time trajectory points, while sampling of these splines at an appropriate, shorter cycle time for the real-time requirement of the lower-level system. The principle is usable in general, and the specific implementation presented is for control of the Panda robot from Franka Emika. Tracking delay analysis is presented based on a cosine trajectory. A simple test application has been implemented, demonstrating real-time feeding of a pre-calculated trajectory for cutting with a knife. Estimated forces on the robot wrist are recorded during cutting and presented in the paper.

Abnormal routine blood tests as predictors of mortality in acutely admitted patients.

BACKGROUND: This study aimed to improve early risk stratification in the emergency department by creating a simple blood test score based on routine biomarkers and assess its predictive ability for 30-day mortality of acutely admitted patients. METHODS: This was a secondary analysis of data from the TRIAGE II study. It included unselected acutely admitted medical and surgical patients, who had albumin, C-reactive protein, creatinine, haemoglobin, leukocytes, potassium, sodium and thrombocytes levels analysed upon admission. Patients were classified according to the number of biomarker results outside the reference range into four risk groups termed "very low", "low", "intermediate", and "high" with 0-1, 2-3, 4-5 and 6-8 abnormal biomarker results, respectively. Logistic regression was used to calculate odds ratios for 30-day mortality and receiver operating characteristic was used to test the discriminative value. The primary analysis was done in patients triaged with ADAPT (Adaptive Process Triage). Subsequently, we analysed two other cohorts of acutely admitted patients. RESULTS: The TRIAGE II cohort included 17,058 eligible patients, 30-day mortality was 5.2%. The primary analysis included 7782 patients. Logistic regression adjusted for age and sex showed an OR of 24.1 (95% CI 14.9-41.0) between the very low- and the high-risk group. The area under the curve (AUC) was 0.79 (95% CI 0.76-0.81) for the blood test score in predicting 30-day mortality. The subsequent analyses confirmed the results. CONCLUSIONS: A blood test score based on number of routine biomarkers with an abnormal result was a predictor of 30-day mortality in acutely admitted patients.

Early Discharge from the Emergency Department Based on Soluble Urokinase Plasminogen Activator Receptor (suPAR) Levels: A TRIAGE III Substudy.

OBJECTIVE: Using biomarkers for early and accurate identification of patients at low risk of serious illness may improve the flow in the emergency department (ED) by classifying these patients as nonurgent or even suitable for discharge. A potential biomarker for this purpose is soluble urokinase plasminogen activator receptor (suPAR). We hypothesized that availability of suPAR might lead to a higher proportion of early discharges. DESIGN: A substudy of the interventional TRIAGE III trial, comparing patients with a valid suPAR measurement at admission to those without. The primary endpoint was the proportion of patients discharged alive from the ED within 24 hours. Secondary outcomes were length of hospital stay, readmissions, and mortality within 30 days. SETTING: EDs at two university hospitals in the Capital Region of Denmark. PARTICIPANTS: 16,801 acutely admitted patients were included. MEASUREMENTS AND MAIN RESULTS: The suPAR level was available in 7,905 patients (suPAR group), but not in 8,896 (control group). The proportion of patients who were discharged within 24 hours of admittance was significantly higher in the suPAR group compared to the control group (50.2% (3,966 patients) vs. 48.6% (4,317 patients), P = 0.04). Furthermore, the mean length of hospital stay in the suPAR group was significantly shorter compared to that in the control group (4.3 days (SD 7.4) vs. 4.6 days (SD 9.4), P = 0.04). In contrast, the readmission rate within 30 days was significantly higher in the suPAR group (10.6% (839 patients) vs. 8.8% (785 patients), P < 0.001). Among patients discharged within 24 hours, there was no significant difference in the readmission rate or mortality within 30 days. Readmission occurred in 8.5% (336 patients) vs. 7.7% (331 patients) (P = 0.18) and mortality in 1.3% (52 patients) vs. 1.8% (77 patients) (P = 0.08) for the suPAR group and control group, respectively. CONCLUSION: These post hoc analyses demonstrate that the availability of the prognostic biomarker suPAR was associated with a higher proportion of discharge within 24 hours and reduced length of stay, but more readmissions. In patients discharged within 24 hours, there was no difference in readmission or mortality. TRIAL REGISTRATION OF THE MAIN TRIAL: This trial is registered with NCT02643459.

Availability of suPAR in emergency departments may improve risk stratification: a secondary analysis of the TRIAGE III trial.

INTRODUCTION: Soluble urokinase plasminogen activator receptor (suPAR) is a prognostic and nonspecific biomarker associated with short-term mortality in emergency department (ED) patients. Therefore, the blood level of suPAR might be usable for identification of patients at high- and low risk, shortly after arrival at the ED. Here, we investigate the value of adding suPAR to triage and how this may impact on risk stratification regarding mortality. METHODS: The analyses were performed on the TRIAGE III cohort. Patients were triaged in four groups: Red, Orange, Yellow, and Green. Outcome was all-cause mortality within seven days. Discriminative abilities of triage and suPAR on mortality were assessed using the area under the curve (AUC) for receiver operating characteristics (ROC) curves. A suPAR cut-off value was generated using the Youden's index. Patients were subsequently reclassified one triage level up if the suPAR level was above this cut-off and one level down if the suPAR level was below that value. RESULTS: The study included 4420 patients with an available triage category and suPAR measurement. suPAR was significantly better in predicting mortality than triage; AUC (95% confidence interval): 0.85 (0.80-0.89) vs. 0.71 (0.64-0.78), P < 0.001. Combining suPAR and triage yielded an AUC of 0.87 (0.82-0-93). The Youden's cut-off of suPAR was 5.9 ng/mL and reclassified triage using this value resulted in a more accurate risk stratification regarding hospital admission and mortality. CONCLUSION: Addition of suPAR to triage potentially improves prediction of short-term mortality. Measurement of suPAR in relation to the triage process may allow a more accurate identification of ED patients at risk. TRIAL REGISTRATION: Clinicaltrials.gov , NCT02643459. Registered 31 December 2015. https://clinicaltrials.gov/ct2/show/NCT02643459?cond=NCT02643459&rank=1 .

The Copenhagen Triage Algorithm is non-inferior to a traditional triage algorithm: A cluster-randomized study.

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.

Use of the prognostic biomarker suPAR in the emergency department improves risk stratification but has no effect on mortality: a cluster-randomized clinical trial (TRIAGE III).

BACKGROUND: Risk stratification of patients in the emergency department can be strengthened using prognostic biomarkers, but the impact on patient prognosis is unknown. The aim of the TRIAGE III trial was to investigate whether the introduction of the prognostic and nonspecific biomarker: soluble urokinase plasminogen activator receptor (suPAR) for risk stratification in the emergency department reduces mortality in acutely admitted patients. METHODS: The TRIAGE III trial was a cluster-randomized interventional trial conducted at emergency departments in the Capitol Region of Denmark. Eligible hospitals were required to have an emergency department with an intake of acute medical and surgical patients and no previous access to suPAR measurement. Three emergency departments were randomized; one withdrew shortly after the trial began. The inclusion period was from January through June of 2016 consisting of twelve cluster-periods of 3-weeks alternating between intervention and control and a subsequent follow-up of ten months. Patients were allocated to the intervention if they arrived in interventional periods, where suPAR measurement was routinely analysed at arrival. In the control periods suPAR measurement was not performed. The main outcome was all-cause mortality 10 months after arrival of the last patient in the inclusion period. Secondary outcomes included 30-day mortality. RESULTS: The trial enrolled a consecutive cohort of 16,801 acutely admitted patients; all were included in the analyses. The intervention group consisted of 6 cluster periods with 8900 patients and the control group consisted of 6 cluster periods with 7901 patients. After a median follow-up of 362 days, death occurred in 1241 patients (13.9%) in the intervention group and in 1126 patients (14.3%) in the control group. The weighted Cox model found a hazard ratio of 0.97 (95% confidence interval, 0.89 to 1.07; p = 0.57). Analysis of all subgroups and of 30-day all-cause mortality showed similar results. CONCLUSIONS: The TRIAGE III trial found no effect of introducing the nonspecific and prognostic biomarker suPAR in emergency departments on short- or long-term all-cause mortality among acutely admitted patients. Further research is required to evaluate how prognostic biomarkers can be implemented in routine clinical practice. TRIAL REGISTRATION: clinicaltrials.gov, NCT02643459 . Registered 31 December 2015.

Utility of multiple rule out CT screening of high-risk atraumatic patients in an emergency department-a feasibility study.

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.

Central regional anaesthesia in patients with aortic stenosis - a systematic review.

INTRODUCTION: Aortic stenosis is a valvular lesion that poses several haemodynamic challenges for the anaesthesiologist. The use of central regional anaesthesia is traditionally regarded as contraindicated in patients with severe aortic stenosis due to its sympatholytic effect, potentially causing loss of vascular tone and ultimately diminished cardiac output. The aim of this paper was to review current literature to find evidence for or against the use of neuroaxial blockade in patients with aortic stenosis. METHODS: We searched PubMed for relevant articles, using the following MeSH terms: "aortic valve stenosis", "epidural anesthesia", "spinal anesthesia" and "epidural analgesia". Only English language literature was included. Papers concerning aortic stenosis and obstetrical anaesthesia were excluded. RESULTS: There are no randomised clinical trials on the subject, and existing literature is extremely sparse. Four retrospective studies and eight case reports counting a total of ten patients were found. All report successful use of neuroaxial blockade in patients with aortic stenosis, without severe haemodynamic alterations. In addition, data indicate that postepidural analgesia improves outcome compared with conventional analgesia. CONCLUSIONS: To the best of our knowledge, there is no clinical evidence supporting the notion that central regional anaesthesia has any adverse effects on patients with aortic stenosis. Carefully managed neuroaxial blockade could become a useful alternative to general anaesthesia in this patient group. However, evidence is sparse and of questionable quality. Large prospective randomised clinical trials are required to establish best practise.

The Copenhagen Triage Algorithm: a randomized controlled trial.

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.

Analgesic effect of ultrasound-guided transversus abdominis plane block after total abdominal hysterectomy: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To assess the effect of bilateral ultrasound-guided transversus abdominis plane block with ropivacaine compared with placebo as part of a multimodal analgesic regimen. DESIGN: A randomized, double-blind, placebo-controlled trial following the CONSORT criteria. SETTING: Hvidovre University Hospital. PATIENTS: Forty-six women scheduled for total abdominal hysterectomy. INTERVENTION: Women received either ropivacaine 0.75%, 20 mL (n = 24) or 0.9% saline, 20 mL (n = 24) in the transversus abdominis plane on each side. MAIN OUTCOME MEASURES: Primary outcome was the 24-h postoperative morphine consumption. Secondary outcomes were pain scores at rest and during coughing, postoperative nausea and vomiting at 1, 2, 4, 6, 8, and 24 h, and time to first mobilization. RESULTS: There was no difference in the mean 24-h postoperative morphine consumption between the two groups (p = 0.733). The ropivacaine group had significantly lower median pain scores at 1 h (p = 0.008) and 2 h (p = 0.027) postoperatively at rest and at 8 h (p = 0.028) during coughing. There was no significant difference in other secondary outcomes. CONCLUSION: There was no reduction in 24-h morphine consumption when using an ultrasound-guided transversus abdominis plane block in women undergoing total abdominal hysterectomy. As part of a multimodal regimen the transversus abdominis plane block showed some effect on pain scores at rest only in the early postoperative period.

[Fatal complication of haemorrhoidal banding].

Rubber band ligation (RBL) is a common procedure for treating haemorrhoids. We present a case of a previously healthy young man admitted with symptoms of pain, urinary difficulties and perineal oedema seven days after having had a RBL. The initial examination was unremarkable and the patient was discharged. Twelve hours later he was readmitted due to continued pain, but despite surgery and aggressive intensive treatment the patient deteriorated rapidly and eventually succumbed to fulminant pelvic sepsis. Sepsis is a rare but severe complication after haemorrhoid treatment.

[Preoperative assessment of surgical patients with hypertension arterialis]. / Præoperativ vurdering af patienter med hypertension.

Almost one out of four patients referred for non cardiac surgery presents preoperatively with hypertensio arterialis (HA). The risk of perioperative cardiovascular complication increases with the grade of HA and the coexistence of end organ damage. This paper is a review of the current knowledge of HA and anaesthesia. It is recommended that patients with grade I and II HA proceed for surgery. But the evidence for patients with grade III HA is less clear. Patients without end organ damage can proceed for surgery, while patients with end organ damage should be stabilized before surgery.

[Targeted training in peripheral nerve blockade]. / Målrettet uddannelse i anlæggelse af perifer nerveblokade.

Peripheral nerve blockade (PNB) is an important part of the anaesthesiologist's armamentarium. It constitutes an alternative to general anaesthesia, thus it is important that all anaesthesiologists have adequate skills in this area. Lack of sufficient experience during training makes many graduates uncomfortable about performing PNB. An answer to this problem is to provide adequate education in PNB in the early stage of postgraduate training. This article presents how we, at our institution, have set up a PNB program that provides value.

[Survival following lightning strike and treatment of sequelae]. / Overlevelse efter lynnedslag og behandling af tilstødende komplikationer.

Lightning strike is an unpredictable weather phenomenon which can cause a variety of injuries to the human body. We present a case report with a 24-year-old male football player, who survived prolonged cardiac arrest after a lighting strike and then presented with multiple organ dysfunction due to cellular swelling, extreme rhabdomyolysis and global hypoperfusion. We describe the clinical observations, therapy and injuries which may be expected. Furthermore, the pathophysiology and factors influencing the survival of this patient are discussed.

Is there any interaction between domestic radon exposure and air pollution from traffic in relation to childhood leukemia risk?

BACKGROUND: In a recent population-based case-control study using 2,400 cases of childhood cancer, we found a statistically significant association between residential radon and acute lymphoblastic leukemia risk. HYPOTHESIS: Traffic exhaust in the air enhances the risk association between radon and childhood leukemia. METHODS: We included 985 cases of childhood leukemia and 1,969 control children. We used validated models to calculate residential radon and street NO(x) concentrations for each home. Conditional logistic regression analyses were used to analyze the effect of radon on childhood leukemia risk within different strata of air pollution and traffic density. RESULTS: The relative risk for childhood leukemia in association with a 10(3) Bq/m(3)-years increase in radon was 1.77 (1.11, 2.82) among those exposed to high levels of NO(x) and 1.23 (0.79, 1.91) for those exposed to low levels of NO(x) (p(interaction,) 0.17). Analyses for different morphological subtypes of leukemia and within different strata of traffic density showed a non-significant pattern of stronger associations between radon and childhood leukemia within strata of higher traffic density at the street address. INTERPRETATION: Air pollution from traffic may enhance the effect of radon on the risk of childhood leukemia. The observed tendency may also be attributed to chance.

Domestic radon and childhood cancer in Denmark.

BACKGROUND: Higher incidence rates of childhood cancer and particularly leukemia have been observed in regions with higher radon levels, but case-control studies have given inconsistent results. We tested the hypothesis that domestic radon exposure increases the risk for childhood cancer. METHODS: We identified 2400 incident cases of leukemia, central nervous system tumor, and malignant lymphoma diagnosed in children between 1968 and 1994 in the Danish Cancer Registry. Control children (n = 6697) were selected from the Danish Central Population Registry. Radon levels in residences of children and the cumulated exposure of each child were calculated as the product of exposure level and time, for each address occupied during childhood. RESULTS: Cumulative radon exposure was associated with risk for acute lymphoblastic leukemia (ALL), with rate ratios of 1.21 (95% confidence interval = 0.98-1.49) for levels of 0.26 to 0.89 x 10(3) Bq/m3-years and 1.63 (1.05-2.53) for exposure to >0.89 x 10(3) Bq/m3-years, when compared with <0.26 x 10(3) Bq/m3-years. A linear dose-response analysis showed a 56% increase in the rate of ALL per 10(3) Bq/m3-years increase in exposure. The association with ALL persisted in sensitivity analyses and after adjustment for potential confounders. No association was found with the other types of childhood cancer. CONCLUSIONS: This study suggests that domestic radon exposure increases the risk for ALL during childhood but not for other childhood cancers.

Prediction of 222Rn in Danish dwellings using geology and house construction information from central databases.

A linear regression model has been developed for the prediction of indoor (222)Rn in Danish houses. The model provides proxy radon concentrations for about 21,000 houses in a Danish case-control study on the possible association between residential radon and childhood cancer (primarily leukaemia). The model was calibrated against radon measurements in 3116 houses. An independent dataset with 788 house measurements was used for model performance assessment. The model includes nine explanatory variables, of which the most important ones are house type and geology. All explanatory variables are available from central databases. The model was fitted to log-transformed radon concentrations and it has an R(2) of 40%. The uncertainty associated with individual predictions of (untransformed) radon concentrations is about a factor of 2.0 (one standard deviation). The comparison with the independent test data shows that the model makes sound predictions and that errors of radon predictions are only weakly correlated with the estimates themselves (R(2) = 10%).