Martin Gellerstedt

Manchester Triage in Sweden – Interrater reliability and accuracy

INTRODUCTION This study investigates the interrater reliability and the accuracy of Manchester Triage (MTS) at emergency departments in Western Sweden. METHODS A group of 79 nurses from seven emergency departments assessed simulated patient cases and assigned triage categories using the same principles as in their daily work. K statistics, accuracy, over-triage and under-triage were then analyzed. The nurses performed 1027 triage assessments. RESULTS The result showed an unweighted kappa value of 0.61, a linear weighted kappa value of 0.71, and a quadratic weighted kappa value of 0.81. The determined accuracy was 92% and 91% for the two most urgent categories, but significantly lower for the less urgent categories. CONCLUSIONS Patients in need of urgent care were identified in more than nine out of 10 cases. The high level of over-triage and under-triage in the less urgent categories resulted in low agreement and accuracy. This may suggest that the resources of emergency departments can be overused for non-urgent patients.

Patient‐reported genitourinary dysfunction after laparoscopic and open rectal cancer surgery in a randomized trial (COLOR II)

This article reports on patient‐reported sexual dysfunction and micturition symptoms following a randomized trial of laparoscopic and open surgery for rectal cancer.

Accommodation and the relationship to subjective symptoms with near work for young school children

The aim of this work was to study the relation between subjective symptoms at near and ocular accommodation in terms of the amplitude of accommodation and the relative accommodation. A secondary aim was to discuss the diagnosis of accommodative insufficiency. The chosen cohort was examined on two occasions with 1.8 years in between. The first examination included 72 children, 43 boys (mean age 8.1 years, ranging from 5.8 to 9.8) and 29 girls (mean age 8.3 years, ranging from 6.2 to 10.0). The second examination included 59 of these children, 34 boys (mean age 9.9 years, ranging from 7.8 to 11.7) and 25 girls (mean age 10.1 ranging from 8.0 to 11.8). Subjective symptoms at near work (headache, asthenopia, floating text, facility problems) were recorded and the amplitude and the relative accommodation, both positive and negative, were measured. The result from the questionnaire showed that at the first examination more than one‐third of the children (34.7%) reported at least one subjective symptom when doing near work and 42.4% at the second examination. No symptoms were found among children younger than 7.5 years, but for children between 7.5 and 10 years old at the first examination, the prevalence of at least one symptom was 47.2%. At the second examination, symptoms were reported also for the youngest children, i.e. from the age of 8 years. The discrimination ability for the amplitude of accommodation, both monocular and binocular, was significant. In the first examination the difference between the mean for the two groups (i.e. with and without at least one symptom) was around 2.00 D monocular and 3.00 D binocular. Corresponding figures from the second examination was a difference between the mean for the two groups of around 3.50 D monocular and nearly 4.00 D binocular. We suggest that accommodation measurements should be performed more routinely and regularly, maybe as screening, especially in children over 8 years of age.

The amplitude of accommodation in 6–10-year-old children – not as good as expected!

The aim of this study was to measure the amplitude of accommodation for junior level school children and to compare it with age‐expected values. A junior level school in Göteborg, Sweden, was randomly chosen and the amplitude of accommodation among 76 children aged 6–10 years was examined using Donders’ push‐up method. The results showed lower amplitude than expected in a large group of children. Results also showed lower amplitude than previously reported for this age group, especially under monocular conditions, which revealed an average dioptric difference from the expected value of −3.60 dioptres (D) right eye (mean 12.40 D, median 12.00 D, S.D. 3.7 D) and −3.50 D left eye (mean 12.50 D, median 12.70 D, S.D. 3.8 D) (p < 0.001 for both eyes). Consequently, we conclude that it cannot be assumed that the amplitude of accommodation is in the expected amplitude range for all children of these ages.

Health-related quality of life after laparoscopic and open surgery for rectal cancer in a randomized trial

Previous studies comparing laparoscopic and open surgical techniques have reported improved health‐related quality of life (HRQL). This analysis compared HRQL 12 months after laparoscopic versus open surgery for rectal cancer in a subset of a randomized trial.

Effect of laparoscopy on the risk of small-bowel obstruction: a population-based register study.

OBJECTIVE To investigate the incidence and risk factors for small-bowel obstruction (SBO) after certain surgical procedures. DESIGN A population-based retrospective register study. SETTING Small-bowel obstruction causes considerable patient suffering. Risk factors for SBO have been identified, but the effect of surgical technique (open vs laparoscopic) on the incidence of SBO has not been fully elucidated. PATIENTS The Inpatient Register held by the Swedish National Board of Health and Welfare was used. The hospital discharge diagnoses and registered performed surgical procedures identified data for cholecystectomy, hysterectomy, salpingo-oophorectomy, bowel resection, anterior resection, abdominoperineal resection, rectopexy, appendectomy, and bariatric surgery performed from January 1, 2002, through December 31, 2004. Data on demographic characteristics, comorbidity, previous abdominal surgery, and death were collected. MAIN OUTCOME MEASURES Episodes of hospital stay and surgery for SBO within 5 years after the index surgery. RESULTS A total of 108,141 patients were included. The incidence of SBO ranged from 0.4% to 13.9%. Multivariate analysis revealed age, previous surgery, comorbidity, and surgical technique to be risk factors for SBO. Laparoscopy exceeded other risk factors in reduction of the risk of SBO for most of the surgical procedures. CONCLUSIONS Open surgery seems to increase the risk of SBO at least 4 times compared with laparoscopy for most of the abdominal surgical procedures studied. Other factors such as age, previous abdominal surgery, and comorbidity are also of importance.

Interpretation of subjective symptoms in double-blind placebo-controlled food challenges : interobserver reliability

Background:  Subjective symptoms after food challenges are difficult to interpret and no standard is available. We discuss a strategy for how to interpret a diary. Furthermore, the interobserver reliability is evaluated.

A kinetic study in adults with food hypersensitivity assessed as eosinophil activation in fecal samples

Background Immune‐mediated food hypersensitivity affecting the gut is difficult to evaluate, and objective tools to diagnose local gastrointestinal (GI) inflammatory reactions are lacking.

Characteristics and outcome among patients who dial for the EMS due to chest pain

OBJECTIVES This study aims to describe patients who called for the emergency medical service (EMS) due to chest discomfort, in relation to gender and age. METHODS All patients who called the emergency dispatch centre of western Sweden due to chest discomfort, between May 2009 and February 2010, were included. Initial evaluation, aetiology and outcome are described as recorded in the databases at the dispatch centre, the EMS systems and hospitals. Patients were divided into the following age groups: ≤50, 51-64 and ≥65 years. RESULTS In all, 14,454 cases were enrolled. Equal proportions of men (64%) and women (63%) were given dispatch priority 1. The EMS clinicians gave priority 1 more frequently to men (16% versus 12%) and older individuals (10%, 15% and 14%, respective of age group). Men had a significantly higher frequency of central chest pain (83% versus 81%); circulatory compromise (34% versus 31%); ECG signs of ischaemia (17% versus 11%); a preliminary diagnosis of acute coronary syndrome (40% versus 34%); a final diagnosis of acute myocardial infarction (14% versus 9%) and any potentially life-threatening condition (18% versus 12%). Individuals aged ≥65 years were given a lower priority than individuals aged 51-64 years, despite poorer characteristics and outcome. In all, 78% of cases with a potentially life-threatening condition and 67% of cases that died within 30 days of enrolment received dispatch priority 1. Mortality at one year was 1%, 4% and 18% in each individual age group. CONCLUSION Men and the elderly were given a disproportionately low priority by the EMS.

Could a computer-based system including a prevalence function support emergency medical systems and improve the allocation of life support level?

Objectives To evaluate whether a computer-based decision support system could be useful for the emergency medical system when identifying patients with acute myocardial infarction (AMI) or life-threatening conditions and thereby improve the allocation of life support level. Methods Patients in the Municipality of Göteborg who dialled the dispatch centre due to chest pain during a period of 3 months. To analyse the relationship between patient characteristics (according to a case record form used during an interview) and the response variables (AMI or life-threatening condition), multivariate logistic regression was used. For each patient, the probability of AMI/life-threatening condition was estimated by the model. We used these probabilities retrospectively to allocate advanced life support or basic life support. This model allocation was then compared with the true allocation made by the dispatchers. Results The sensitivity, that is, the percentage of AMI patients allocated to advanced life support, was 85.7% in relation to the true allocation made by the dispatchers. The corresponding sensitivity regarding allocation made by the model was 92.4% (P=0.17). The specificity was also slightly higher for the model allocation than the dispatcher allocation. Among the 15 patients with AMI who were allocated to basic life support by the dispatchers, nine died (eight during and one after hospitalization). Among the eight patients with AMI allocated to basic life support by the model, only one patient died (in hospital) (P=0.02). Conclusion A computer-based decision support system including a prevalence function could be a valuable tool for allocating the level of life support. The case record form, however, used for the interview can be refined and a model based on a larger sample and confirmed in a prospective study is recommended.