Symptoms at presentation to the emergency department: Predicting outcomes and changing clinical practice?

BACKGROUND: The type and number of symptoms in emergency patients differ widely. It remains unclear, if outcomes can be predicted by the number of symptoms. Furthermore, it is unknown, whether clinical practice could be influenced by presenting symptoms. METHODS: Prospective observational study, performed in the emergency department of the University Hospital Basel, a tertiary hospital. A consecutive sample of patients was interviewed at presentation for a predefined set of 35 symptoms. The number of symptoms was correlated with outcomes using linear and logistic regression models. Clinical practice was observed using prospective data on disease severity ratings, triage category, use of resources, length-of-stay and follow-up presentations. RESULTS: Data of 3472 patients were analysed. The number of symptoms ranged between 1 and 25, the mean being 2.74. Women reported more symptoms than men. Age and comorbidity indices were not associated with the number of symptoms. After adjusting for age and gender, there was no correlation between the number of symptoms and adverse outcomes, such as ICU-admission or in-hospital mortality (OR: 1.03, CI: 0.88-1.18, P = .68). The number of symptoms at presentation was associated with hospitalisation, disease severity rating by patients and emergency physicians, triage categories, use of resources, length-of-stay and follow-up presentations. CONCLUSION: The number of symptoms did not correlate with the main adverse outcomes (ICU-admission and in-hospital mortality). However, clinical practice was influenced by the nature and number of symptoms. This was shown by associations with hospitalisation, length-of-stay, use of resources and follow-up presentations. Furthermore, the number of symptoms correlated with the caregivers' disease severity ratings and the attributed triage categories. This may indicate that caregivers respond to the number of symptoms by a higher investment in their immediate work-ups and later follow-ups.

A Population Genetics Perspective on Geminivirus Infection.

UNLABELLED: The selective accumulation of both DNA components of a bipartite geminivirus, Abutilon mosaic virus, was recorded during early systemic infection of Nicotiana benthamiana plants. Purified nuclei were diagnosed for viral DNA using hybridization specific for DNA A or DNA B to detect these individual genome components either alone or both simultaneously by dual-color staining. Although this virus needs both components for symptomatic infection, DNA A alone was transported to upper leaves, where it was imported into phloem nuclei and replicated autonomously. The coinfection with DNA A and DNA B revealed an independent spread of both molecules, which resulted in a stochastic distribution of DNA A- and DNA A/B-infected nuclei. A population genetics evaluation of the respective frequencies was compared to a model computation. This elucidated a surprisingly simple relationship between the initial frequencies of the viral DNA components and the number of susceptible cells during the course of early systemic infection. IMPORTANCE: For bipartite begomoviruses, DNA B-independent long-distance spread of DNA A has been described before, but it has never been shown whether viral DNA A alone invades nuclei of systemic tissues and replicates therein. This is demonstrated now for the first time. During infection with DNA A and DNA B, a similar solitary spread of DNA A can be recognized at early stages. We describe a population genetics model of how the hit probabilities of DNA A and DNA B for susceptible cells determine the relative frequencies of either genome component during the course of infection.

Construct validity of acute morbidity as a novel outcome for emergency patients.

OBJECTIVES: Validation of acute morbidity as a novel outcome in emergency medicine. METHODS: Construct validity of acute morbidity was established by comparison to other outcomes using linear and logistic regression models. RESULTS: Data of 4608 patients were analysed. 1869 patients (40.6%) fulfilled the criteria for acute morbidity. Using multivariate analyses, acute morbidity was associated with outcomes such as hospitalisation (OR: 11, 95%-CI 9-13), mortality (OR 15, 95%-CI 6-49), and ICU admission (OR: 46, 95%-CI 25-96). Reliability of the construct "acute morbidity" was estimated using Cohens Kappa, which was 0.96 for intra-rater and 0.94 for inter-rater reliability. CONCLUSION: Reliability of the framework for acute morbidity was high. Construct validity was shown by associations with hospitalisation, mortality, and ICU admission.

Risk of adverse outcome in patients referred by emergency medical services in Switzerland.

AIMS OF THE STUDY: Comparison of outcomes between different emergency medical services (EMS) is difficult and lacking in Switzerland. Therefore, knowledge about the inherent risks of EMS-referred patients is important. Targeted interventions may benefit these patients by optimising resource allocation. We therefore aimed to study outcomes in EMS-referred patients presenting to a Swiss emergency department (ED). METHODS: Prospective observational study in all patients presenting to the ED of Basel University Hospital. Mode of referral was recorded (EMS or other). Univariate and multivariate linear, Poisson and logistic regression models were used. Crude and age/gender adjusted associations between mode of referral and outcomes were calculated. Outcomes were shown for admission, length of stay (LOS), in-hospital, and 1-year mortality. RESULTS: Of 5634 patients presenting in the inclusion period, 4703 were screened, 4544 were included and 4287 were followed up for 365 days. Associations between EMS referral and several adverse outcomes were found and expressed as odds ratios (ORs) and geometric mean ratios (GMRs): hospital admission (OR 3.8, 95% CI 3.2-4.5; p <0.001), intensive care unit (ICU) admission (OR 4.2, 95% CI 3.2-5.5, p <0.001), ED-LOS (GMR 1.2, 95% CI 1.1-1.2; p <0.001), in-hospital mortality (OR 6.4, 95% CI 2.9-15.6; p <0.001) and 1-year mortality (OR 2.3, 95% CI 1.7-3.0; p <0.001). CONCLUSION: Patients referred by EMS have higher odds of admission to hospital and ICU, a longer ED LOS, and higher short- and long-term mortalities than the general ED population.