Lars Folkestad

Risk scoring systems for adults admitted to the emergency department: a systematic review

BackgroundPatients referred to a medical admission unit (MAU) represent a broad spectrum of disease severity. In the interest of allocating resources to those who might potentially benefit most from clinical interventions, several scoring systems have been proposed as a triaging tool.Even though most scoring systems are not meant to be used on an individual level, they can support the more inexperienced doctors and nurses in assessing the risk of deterioration of their patients.We therefore performed a systematic review on the level of evidence of literature on scoring systems developed or validated in the MAU. We hypothesized that existing scoring systems would have a low level of evidence and only few systems would have been externally validated.MethodsWe conducted a systematic search using Medline, EMBASE and the Cochrane Library, according to the PRISMA guidelines, on scoring systems developed to assess medical patients at admission.The primary endpoints were in-hospital mortality or transfer to the intensive care unit. Studies derived for only a single or few diagnoses were excluded.The ability to identify patients at risk (discriminatory power) and agreement between observed and predicted outcome (calibration) along with the method of derivation and validation (application on a new cohort) were extracted.ResultsWe identified 1,655 articles. Thirty were selected for further review and 10 were included in this review.Eight systems used vital signs as variables and two relied mostly on blood tests.Nine systems were derived using regression analysis and eight included patients admitted to a MAU. Six systems used in-hospital mortality as their primary endpoint.Discriminatory power was specified for eight of the scoring systems and was acceptable or better in five of these. The calibration was only specified for four scoring systems. In none of the studies impact analysis or inter-observer reliability were analyzed.None of the systems reached the highest level of evidence.ConclusionsNone of the 10 scoring systems presented in this article are perfect and all have their weaknesses. More research is needed before the use of scoring systems can be fully implemented to the risk assessment of acutely admitted medical patients.

Bone geometry, density, and microarchitecture in the distal radius and tibia in adults with osteogenesis imperfecta type I assessed by high‐resolution pQCT

Osteogenesis imperfecta (OI) is a hereditary disorder characterized by decreased biosynthesis or impaired morphology of type I collagen that leads to decreased bone mass and increased bone fragility. We hypothesized that patients with OI have altered bone microstructure and bone geometry. In this cross‐sectional study we compared patients with type I OI to age‐ and gender‐matched healthy controls. A total of 39 (13 men and 26 women) patients with OI, aged 53 (range, 21–77) years, and 39 controls, aged 53 (range, 21–77) years, were included in the study. Twenty‐seven of the patients had been treated with bisphosphonates. High‐resolution peripheral quantitative computed tomography (HR‐pQCT) at the distal radius and distal tibia and dual‐energy X‐ray absorptiometry of total hip, femoral neck, trochanteric region, and the lumbar spine (L1–L4) were performed. The patients were shorter than the controls (159 ± 10 cm versus 170 ± 9 cm, p < 0.001), but had similar body weight. In OI, areal bone mineral density (aBMD) was 8% lower at the hip (p < 0.05) and 13% lower at the spine (p < 0.001) compared with controls. The trabecular volumetric bone mineral density (vBMD) was 28% lower in radius (p < 0.001) and 38% lower in tibia (p < 0.001) in OI compared with controls. At radius, total bone area was 5% lower in OI than in controls (p < 0.05). In the tibia, cortical bone area was 18% lower in OI (p < 0.001). In both radius and tibia the number of trabeculae was lower in patients compared to the controls (35% and 38%, respectively, p < 0.001 at both sites). Furthermore, trabecular spacing was 55% higher in OI in both tibia and radius (p < 0.001 at both sites) when compared with controls. We conclude that patients with type I OI have lower aBMD, vBMD, bone area, and trabecular number when compared with healthy age‐ and gender‐matched controls.

In-hospital resuscitation evaluated by in situ simulation: a prospective simulation study

BackgroundInterruption in chest compressions during cardiopulmonary resuscitation can be characterized as no flow ratio (NFR) and the importance of minimizing these pauses in chest compression has been highlighted recently. Further, documentation of resuscitation performance has been reported to be insufficient and there is a lack of identification of important issues where future efforts might be beneficial. By implementing in situ simulation we created a model to evaluate resuscitation performance. The aims of the study were to evaluate the feasibility of the applied method, and to examine differences in the resuscitation performance between the first responders and the cardiac arrest team.MethodsA prospective observational study of 16 unannounced simulated cardiopulmonary arrest scenarios was conducted. The participants of the study involved all health care personel on duty who responded to a cardiac arrest. We measured NFR and time to detection of initial rhythm on defibrillator and performed a comparison between the first responders and the cardiac arrest team.ResultsData from 13 out of 16 simulations was used to evaluate the ability of generating resuscitation performance data in simulated cardiac arrest. The defibrillator arrived after median 214 seconds (180-254) and detected initial rhythm after median 311 seconds (283-349). A significant difference in no flow ratio (NFR) was observed between the first responders, median NFR 38% (32-46), and the resuscitation teams, median NFR 25% (19-29), p < 0.001. The difference was significant even after adjusting for pulse and rhythm check and shock delivery.ConclusionThe main finding of this study was a significant difference between the first responders and the cardiac arrest team with the latter performing more adequate cardiopulmonary resuscitation with regards to NFR. Future research should focus on the educational potential for in-situ simulation in terms of improving skills of hospital staff and patient outcome.

The effect of aromatase inhibitors on bone metabolism.

Aromatase inhibitors increase the disease-free survival in patients with receptor-positive breast cancer. Aromatase is a cytochrome P450 enzyme complex catalysing the conversion of androgens to oestrogens. These properties cause a significant increase in bone loss. In this MiniReview, we present data from the aromatase inhibitor studies and the studies designed to investigate aromatase inhibitor effect on bone metabolism. At the cellular level, oestrogen has profound effects on both osteoblasts and osteoclasts. Oestrogen decreases the osteoblastic production of resorptive cytokines and simultaneously increases the production of antireceptive cytokines, which leads to increased osteoclastic apoptosis and increased osteoblastic activity. Aromatase inhibitors inhibit the endogenous production of oestrogen by 50-90%. Studies designed to look at the effect of aromatase inhibitors on bone mineral density have shown a significant decrease in bone mineral density of the femoral neck in the aromatase inhibitor groups compared to placebo groups. Placebo-controlled studies lack statistical power to detect changes in fracture incidence; however, aromatase inhibitors increase the incidence of fractures in comparison with tamoxifen. We conclude that treatment with aromatase inhibitors leads to an increased bone loss and thus an increase in the risk of fractures in women with breast cancer.

Complication with intraosseous access: scandinavian users' experience.

Introduction: Intraosseous access (IO) is indicated if vascular access cannot be quickly established during resuscitation. Complication rates are estimated to be low, based on small patient series, model or cadaver studies, and case reports. However, user experience with IO use in real-life emergency situations might differ from the results in the controlled environment of model studies and small patient series. We performed a survey of IO use in real-life emergency situations to assess users’ experiences of complications. Methods: An online questionnaire was sent to Scandinavian emergency physicians, anesthesiologists and pediatricians. Results: 1,802 clinical cases of IO use was reported by n=386 responders. Commonly reported complications with establishing IO access were patient discomfort/pain (7.1%), difficulties with penetration of periosteum with IO needle (10.3%), difficulties with aspiration of bone marrow (12.3%), and bended/broken needle (4.0%). When using an established IO access the reported complications were difficulties with injection fluid and drugs after IO insertion (7.4%), slow infusion (despite use of pressure bag) (8.8%), displacement after insertion (8.5%), and extravasation (3.7%). Compartment syndrome and osteomyelitis occurred in 0.6% and 0.4% of cases respectively. Conclusion: In users’ recollection of real-life IO use, perceived complications were more frequent than usually reported from model studies. The perceived difficulties with using IO could affect the willingness of medical staff to use IO. Therefore, user experience should be addressed both in education of how to use, and research and development of IOs.

Hypoglycemia-Related Electroencephalogram Changes are Independent of Gender, Age, Duration of Diabetes, and Awareness Status in Type 1 Diabetes

Introduction: Neuroglycopenia in type 1 diabetes mellitus (T1DM) results in reduced cognition, unconsciousness, seizures, and possible death. Characteristic changes in the electroencephalogram (EEG) can be detected even in the initial stages. This may constitute a basis for a hypoglycemia alarm device. The aim of the present study was to explore the characteristics of the EEG differentiating normoglycemia and hypoglycemia and to elucidate potential group differences. Methods: We pooled data from experiments in T1DM where EEG was available during both normoglycemia and hypoglycemia for each subject. Temporal EEG was analyzed by quantitative electroencephalogram (qEEG) analysis with respect to absolute amplitude and centroid frequency of the delta, theta, alpha, and beta bands, and the peak frequency of the unified theta-alpha band. To elucidate possible group differences, data were subsequently stratified by age group (± 50 years), gender, duration of diabetes (± 20 years), and hypoglycemia awareness status (normal/impaired awareness of hypoglycemia). Results: An increase in the log amplitude of the delta, theta, and alpha band and a decrease in the alpha band centroid frequency and the peak frequency of the unified theta-alpha band constituted the most significant hypoglycemia indicators (all p < .0001). The size of these qEEG changes remained stable across all strata. Conclusions: Hypoglycemia-associated EEG changes remain stable across age group, gender, duration of diabetes, and hypoglycemia awareness status. This indicates that it may be possible to establish a general algorithm for hypoglycemia detection based on EEG measures.

Capillary refill time: a study of interobserver reliability among nurses and nurse assistants.

Objectives The interobserver variability of capillary refill time (CRT) has been questioned. Earlier studies of interobserver variability of CRT have been on a large number of patients but with few observers. The objective of our study was to investigate how a large group of nurses and nurse assistants would grade CRT. Methods We recorded a video of the index finger of six medical patients and these were shown to nurses and nurse assistants. They were asked to record the CRT and whether they found this value to be normal. The data were analyzed using the Fleiss Kappa Coefficient Analysis and graded according to the Landis and Koch correlation. Correlation between the exact numbers was evaluated using interclass correlation. Results Nine nurse assistants and 37 nurses participated. The patients were aged between 44 and 87 years. All but one patient had a systolic blood pressure reading above 130 mmHg. All had arterial blood oxygen saturation above 92% and all but one had normal body temperature. The &kgr; value for normality was 0.56. The interclass correlation of measurement of CRT was 0.62. Conclusion This is the largest interobserver study of CRT when looking at the number of observers. We found an only moderate agreement for the exact value of CRT and a moderate agreement for normality. We believe that CRT should be used with caution in clinical practice.

Reasons for not using intraosseous access in critical illness

Aim To identify reasons for not using intraosseous access (IO) when intravenous access is difficult during resuscitation. Methods Questionnaire made available to members of selected Scandinavian medical societies. Results Of 759 responders to the questionnaire, 23.5% (n=178) had experienced one or more situations where there was a need for IO but none was placed. The most common stated reasons for not performing IO were a lack of equipment (48.3%), a lack of knowledge about the procedure (32.6%), and intravenous access preferred over IO (23.0%). Conclusions The main reasons for not using IO were lack of equipment and lack of training. The authors recommend increased training in IO use and greater availability of IO equipment for front-line staff in Scandinavian countries. The use of non-purpose-designed needles for IO should be evaluated.

How many training modalities are needed to obtain procedural confidence in intraosseous access? A questionnaire study.

Participants in advanced resuscitation courses are often expected to learn to perform intraosseous access (IO). But how many learning modalities are needed to achieve procedural confidence in IO? We distributed an online questionnaire to members of emergency medicine, paediatric and anaesthesiology societies in Scandinavia. The responders without real-life experience with IO (n=322) were classified as ‘not confident’ or ‘confident’ in IO. Of total responders 22.8% without training felt confident. Confidence increased to 74.8% after one training modality, 87.9% after two modalities, 98.7% after three modalities and 100% after four modalities (P<0.0001). Of total responders 89.5% who had ‘workshop or similar training with hands-on experience’ as sole teaching method was confident. Confidence in IO increases with the number of learning modalities. ‘Workshop or similar training with hands-on experience’ as single training modality seemed as effective as the combination of two modalities.

Level of training and experience in physicians performing interhospital transfers of adult patients in the internal medicine department

Aim: To establish the level of training doctors who participate in interhospital transfers in Denmark. Methods: A questionnaire was sent to every hospital department in Denmark with acute internal medicine admissions. Results: Eighty-nine internal medicine departments were contacted and 84 responded (response rate 94.4%). Of the 84 hospitals, 75 (89.3%) indicated that they perform interhospital transfers. Most transfers were performed by interns (61.3%) or senior house officers (10.7%) with only a few months’ experience in their current speciality. Training in interhospital transfer was offered by 24.0% of departments. When presented with cases of interhospital transfers of critically ill patients, 77.3% of the responders stated that their department would not follow guidelines when performing the transfer. Conclusions: The gap between recommended professional standards and current practice shows a need to establish educational programmes in interhospital transfer.