Christian Backer Mogensen

Incidence, Clinical Presentation, and Outcome of Progressive Multifocal Leukoencephalopathy in HIV-Infected Patients during the Highly Active Antiretroviral Therapy Era: A Nationwide Cohort Study

BACKGROUND Human immunodeficiency virus (HIV) infection predisposes to progressive multifocal leukoencephalopathy (PML). Here, we describe the incidence, presentation, and prognosis of PML in HIV-1-infected patients during the period before highly active antiretroviral therapy (HAART) (1995-1996) and during the early HAART (1997-1999) and late HAART (2000-2006) periods. METHODS Patients from a nationwide population-based cohort of adult HIV-1-infected individuals were included. We calculated incidence rates of PML and median survival times after diagnosis. We also described neurological symptoms at presentation and follow-up. RESULTS Among 4,649 patients, we identified 47 patients with PML. The incidence rates were 3.3, 1.8, and 1.3 cases per 1000 person-years at risk in 1995-1996, 1997-1999, and 2000-2006, respectively. The risk of PML was significantly associated with low CD4(+) cell count, and 47% of cases were diagnosed by means of brain biopsy or polymerase chain reaction analysis for JC virus. The predominant neurological symptoms at presentation were coordination disturbance, cognitive defects, and limb paresis. Thirty-five patients died; the median survival time was 0.4 years (95% confidence interval [CI], 0.0-0.7) in 1995-1996 and 1.8 years (95% CI, 0.6-3.0) in both 1997-1999 and 2000-2006. CD4(+) cell count >50 cells/microL at diagnosis of PML was significantly associated with reduced mortality. CONCLUSIONS The incidence of PML in HIV-infected patients decreased after the introduction of HAART. Survival after PML remains poor. In the management of PML, the main focus should be on prophylactic measures to avoid immunodeficiency.

Point of care technology or standard laboratory service in an emergency department: is there a difference in time to action? A randomised trial

BackgroundEmergency Departments (ED) have a high flow of patients and time is often crucial. New technologies for laboratory analysis have been developed, including Point of Care Technologies (POCT), which can reduce the transport time and time of analysis significantly compared with central laboratory services. However, the question is if the time to clinical action is also reduced if a decisive laboratory answer is available during the first contact between the patient and doctor. The present study addresses this question: Does a laboratory answer, provided by POCT to the doctor who first attends the patient on admission, change the time to clinical decision in commonly occurring diseases in an ED compared with the traditional service from a central laboratory?MethodsWe performed a randomised clinical trial with parallel design and allocation ratio 1:1. The eligibility Criteria were: All patients referred from General Practitioner or another referring doctor suspected for a deep venous thrombosis (DVT), acute coronary syndrome (ACS), acute appendicitis (AA) or acute infection (ABI). The outcome measure was the time spend from the blood sample was taken to a clinical decision was made.ResultsThe study period took place in October--November 2009 and from February to April 2010. 239 patients were eligible for the study. There was no difference between the groups suspected for DVT, ACS and AA, but a significant reduction in time for the ABI group (p:0.009), where the median time to decision was reduced from 7 hours and 33 minutes to 4 hours and 38 minutes when POCT was used. Only in the confirmation of ABI the time to action was significantly shorter.ConclusionsFast laboratory answers by POCT in an ED reduce the time to clinical decision significantly for bacterial infections. We suggest further studies which include a sufficient number of patients on deep venous thrombosis, acute appendicitis and acute coronary syndrome.

Blood sample tube transporting system versus point of care technology in an emergency department; effect on time from collection to reporting? A randomised trial

BackgroundTime is a crucial factor in an emergency department and the effectiveness of diagnosing depends on, among other things, the accessibility of rapid reported laboratory test results; i.e.: a short turnaround time (TAT). Former studies have shown a reduced time to action when point of care technologies (POCT) are used in emergency departments. This study assesses the hypothesis, that using Point of Care Technology in analysing blood samples versus tube transporting blood samples for laboratory analyses results in shorter time from the blood sample is collected to the result is reported in an emergency department.MethodsThe study was designed as a randomised controlled trial with consecutive allocation into two groups and rated 1:1. Blood samples were collected on all included patients and then randomised into either POCT analyses or tube transporting for central laboratory analyses.ResultsBlood samples from a total of 319 patients were included.The mean time from collecting to reporting was 24 minutes for the POCT analysis and 70 minutes for the tube transported analysis. An unpaired Students t-test showed a significant reduction in time from collecting to reporting using POCT (p<.0001).ConclusionWe found a significantly reduced time from collecting to reporting using Point of Care Technology (POCT) in an emergency department compared to tube transported blood samples for central laboratory analyses.

MRSA screening in emergency department detects a minority of MRSA carriers.

INTRODUCTION Methicillin-resistant Staphylococcus areus (MRSA) is an emerging problem. The Danish Health and Medicines Authority (HMA) has developed a question-based screening tool to identify patients with MRSA. The tool has three parts: questions on general risk situations, special risk situations and individual risk factors. The emergency departments (ED) play a key role in the prevention of in-hospital spreading of MRSA. The aim of the present study was to estimate the prevalence of MRSA among all admitted ED patients to assess how many patients should be swab-tested for MRSA and isolated and to evaluate the ability of the HMA screening tool to detect MRSA. METHODS Patients who were more than ten years old answered all the HMA questions on general and specific risk situations and individual risk factors for MRSA, and a swab was obtained for MRSA culture. RESULTS A total of 1,945 patients were admitted and 73% participated. Indications for swab testing for MRSA were present in 8%. The general risk situation questions identified 3% for isolation due to suspicion of MRSA. A total of 11 patients had a positive MRSA swab culture (0.9%). Among the isolated patients, 3% had MRSA, 97% would have been isolated unnecessarily, while 91% of the MRSA patients would not have been isolated. The general risk situation questions had a sensitivity of 18-27% and the whole questionnaire had a sensitivity of 55% for the detection of MRSA patients. CONCLUSIONS The majority of MRSA carriers who are acutely admitted to the ED will remain undetected. FUNDING Hospital of Southern Jutland. TRIAL REGISTRATION not relevant.

The effect on physical performance of a functional assessment and immediate rehabilitation of acutely admitted elderly patients with reduced functional performance: the design of a randomised clinical trial

Introduction Illness and hospitalisation, even of short duration, pose separate risks for permanently reduced functional performance in elderly medical patients. Functional assessment in the acute pathway will ensure early detection of declining performance and form the basis for mobilisation during hospitalisation and subsequent rehabilitation. For optimal results rehabilitation should begin immediately after discharge.The aim of this study is to investigate the effect of a systematic functional assessment in the emergency department (ED) of elderly medical patients with reduced functional performance when combined with immediate postdischarge rehabilitation. Method and analysis The study is a two-way factorial randomised clinical trial. Participants will be recruited among patients admitted to the ED who are above 65 years of age with reduced functional performance. Patients will be randomly assigned to one of four groups: (1) functional assessment and immediate rehabilitation; (2) functional assessment and rehabilitation as usual; (3) assessment as usual and immediate rehabilitation; (4) assessment and rehabilitation as usual. Primary outcome 30 s chair-stand test administered at admission and 3 weeks after discharge. Ethics and dissemination The study has been approved by the Regional Scientific Ethical Committees of Southern Denmark in February 2014. The study findings will be published in peer-reviewed journals and presented at national and international conferences. Trial registration number: ClinicalTrials.gov Identifier: NCT02062541.

Time delay to surgery for appendicitis: no difference between surgical assessment unit and emergency department

Background In Denmark, emergency departments (EDs) are replacing acute surgical and medical units. The aim of this study was to compare the trajectory of patients undergoing surgery on the suspicion of appendicitis in a surgical assessment unit (SAU) and EDs with an observation unit, respectively. The primary outcome measure was the time from hospital arrival-to-decision for surgery. Materials and methods A comparative retrospective study with a cross-sectional design and a before-and-after design was carried out during January 2011 to December 2012 at a SAU and an ED at a university hospital (U-SAU and U-ED) and at an ED at a regional hospital (R-ED). Data included time of arrival, decision for surgery, surgery and discharge, and number of blood tests. Results In total, 250 patients were included. Time to decision for surgery was 4.50, 4.95, and 4.63 h (P=0.58) in the U-SAU, R-ED, and U-ED, respectively. Time from decision for surgery to start of surgery was 4.60, 3.29, and 4.12 h in the U-SAU, R-ED, and U-ED, respectively. The difference was significant between the U-SAU and R-ED (P=0.05) and between R-ED and U-ED (P=0.03). Time from surgery to discharge from the hospital was 17.88, 19.28, and 15.13 h in the U-SAU, R-ED, and U-ED, respectively. The difference was significant between the EDs (P=0.02). Significantly more blood tests were performed in the EDs than in the U-SAU. Conclusion The introduction of EDs with observation units did not influence time to decision for surgery, but more blood tests were performed.

Discharge from an emergency department observation unit and a surgical assessment unit: experiences of patients with acute abdominal pain

AIMS AND OBJECTIVES To investigate the experiences of patients with acute abdominal pain at discharge from an emergency department observation unit compared with discharge from a surgical assessment unit. BACKGROUND The increase in emergency department observation units has increased short-term admissions and changed the patient journey from admission and discharge from specialised wards staffed by specialist nurses to admission and discharge from units staffed by emergency nurses. DESIGN A comparative qualitative interview study. METHODS The study included 20 patients: 10 from an emergency department observation unit and 10 from a surgical assessment unit, and took a phenomenological-hermeneutic approach. Patients were interviewed at discharge and three months later. RESULTS More patients from the emergency department observation unit experienced readiness for discharge and had plans for follow-up, compared with patients from the surgical assessment unit. In the surgical assessment unit, more patients were readmitted, had unanswered questions after three months and experienced a follow-up visit at the general practitioner as insufficient. More patients from the surgical assessment unit reported receiving useful self-care advice, compared with those from the emergency department observation unit. CONCLUSION The experience of emergency department observation unit patients on discharge and follow-up was that the health professionals were more supportive, compared with surgical assessment unit patients, who felt discharge occurred too early, but with more preparation for independent home self-care. These results are an important factor in the patient experience of discharge from hospital and may reflect differences in specialisation of the nurses. RELEVANCE TO CLINICAL PRACTICE Units discharging patients with acute abdominal pain could be inspired by scheduled fast-track surgery programmes with structured information about admission, treatment and follow-up and easy access to relevant health professionals after discharge.

Discrete event simulation modelling for an improved patient flow at the Emergency Department, Sygehus Lillebælt, Kolding

Background The process of ongoing centralization of acute hospitals in Denmark enforces a number of challenges to be addressed. Staff levels must be adjusted not only in order to fulfil the new rules for specialists’ presence at the Emergency Department (ED), but also to meet the imposed time requirements regarding the first patient contact with a specialist along with the requirement of making an action diagnosis within 4 hours after arrival. Patient arrivals and pathways are grouped in accordance with the so called Standardized Time-based Patient Pathways (STPs) under development. The main goal of the project is the development of an analytical tool designed to facilitate qualified decisionmaking with respect to the dimensioning of the ED with respect to e.g. staffing in view of the imposed time requirements.

Infectious Gastroenteritis and the Need for Strict Contact Precaution Procedures in Adults Presenting in the Emergency Department: a Danish Register-based Study

BACKGROUND Acute infectious gastroenteritis requires contact precautions to prevent spread. On acute admission, the cause of diarrhoea is unknown, so the decision regarding which patients to isolate has to be made on clinical information with a risk of inexpedient use of contact precautions. AIM To investigate how often gastroenteritis occurs (and therefore how often the need for isolation has to be assessed) in Danish emergency departments, and how often patients have to remain on contact precautions according to the results of faecal samples. METHODS This Danish register-based retrospective cohort study on adults in Danish emergency departments used three data sources: discharge diagnoses from the Danish National Patient Register; microbiological results from faecal samples provided in the emergency department; and the causes of hospital admission based on the chief complaint. FINDINGS Among 66,885 acute admissions, 4.3% of patients had at least one feature of gastroenteritis: admission with diarrhoea as the chief complaint (1.6%); microbiological examination of faecal sample (2.8%); and discharged with a diagnosis of gastroenteritis (1.7%). Nineteen percent of those who had a faecal sample tested were found to have norovirus or Clostridium difficile, and needed to remain on strict contact precautions. CONCLUSION The initiation of contact precautions has to be assessed for 4.3% of all emergency department patients; 19% of the patients who had a faecal sample tested had highly contagious gastroenteritis and required strict contact precautions. Further studies are needed to develop tools to determine which patients to isolate.

Clinical features and prognosis of patients with acute non-specific chest pain in emergency and cardiology departments after the introduction of high-sensitivity troponins: a prospective cohort study

Objectives To determine the incidence of clinical, cardiac-related endpoints and mortality among patients presenting to an emergency or cardiology department with non-specific chest pain (NSCP), and who receive testing with a high-sensitivity troponin. A second objective was to identify risk factors for the above-noted endpoints during 12 months of follow-up. Design A prospective multicentre study. Setting Emergency and cardiology departments in Southern Denmark. Subjects The study enrolled 1027 patients who were assessed for acute chest pain in an emergency or cardiology department, and in whom a myocardial infarction or another obvious reason for chest pain had been ruled out. Patients were enrolled from September 2014 to June 2015 and followed for 1 year. Main outcome measures Clinical, cardiac-related endpoints (cardiac-related death, acute myocardial infarction, unstable angina and coronary revascularisation) and all-cause mortality. Results Over a period of 1 year, cardiac-related endpoints were found in 19 patients (1.9%): 0 patients experienced cardiac-related death, 2 (0.2%) had myocardial infarction, 4 (0.4%) had unstable angina pectoris and 17 (1.7%) underwent coronary revascularisation. All-cause mortality was observed in seven patients (0.7%). When compared with the general population, the standardised mortality ratio did not differ. The risk factors associated with the study endpoints included male gender, body mass index >25 kg/m2, previous known coronary artery disease, hypertension, hypercholesterolaemia, diabetes mellitus and the use of statins. A total of 73% of the endpoints occurred in males. Conclusion The prognosis for patients with NSCP is favourable, with a 1-year mortality after discharge that is comparable with the background population. Few clinical endpoints took place during follow-up, and those that did were predominantly in males.