Background: There are no predictors known that can identify COPD patients who will respond to tre... more Background: There are no predictors known that can identify COPD patients who will respond to treatment with ICS. Method: We investigated 30 patients (median age 65 (range 44-83, 12 females) with mild to moderately severe COPD. All patients had post bronchodilator FEV 1 /forced vital capacity ratio of less than 70% and a reversibility of less than 12% and 200 ml from baseline. We wanted to determine if airway responsiveness (AHR) to histamine and mannitol could predict who would respond to a 3-month course of ICS. Results: At baseline, all patients had AHR to histamine, but only 7 (23%) patients to mannitol. After 3 months of treatment with ICS, there was no significant change in spirometry or the quality of life when analysing all individuals together. However, FEV1% predicted improved from 67% (IQR12) to 79% (IQR16) in mannitol positive patients; whereas it was unchanged in the mannitol negative patients. The difference in the mean change of FEV1% predicted between the two groups was 12 (IQR13.5) and this was highly significant (pZ0.001). The improvement in quality of life (SGRQ 30 (IQR10.5) to 21 (IQR12; pZ0.01) was only significant in the patients positive to mannitol. Conclusion: We propose that AHR to mannitol could predict ICS-responsiveness in mild to moderately severe COPD patients. q
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2013
Background: Since drug-related emergency department (ED) visits are common among older adults, th... more Background: Since drug-related emergency department (ED) visits are common among older adults, the objectives of our study were to identify the frequency of drug-related problems (DRPs) among patients presenting to the ED with non-specific complaints (NSC), such as generalized weakness and to evaluate responsible drug classes. Methods: Delayed type cross-sectional diagnostic study with a prospective 30 day follow-up in the ED of the University Hospital Basel, Switzerland. From May 2007 until April 2009, all non-trauma patients presenting to the ED with an Emergency Severity Index (ESI) of 2 or 3 were screened and included, if they presented with non-specific complaints. After having obtained complete 30-day follow-up, two outcome assessors reviewed all available information, judged whether the initial presentation was a DRP and compared their judgment with the initial ED diagnosis. Acute morbidity ("serious condition") was allocated to individual cases according to predefined criteria.
To investigate diagnostic accuracy in patient histories involving nonspecific complaints and the ... more To investigate diagnostic accuracy in patient histories involving nonspecific complaints and the extent to which characteristics of physicians and structural properties of patient histories are associated with accuracy. Six histories of patients presenting to the emergency department (ED) with nonspecific complaints were provided to 112 physicians: 36 ED physicians, 50 internists, and 26 family practitioners. Physicians listed the 3 most likely diagnoses for each history and indicated which cue(s) they considered crucial. Four weeks later, a subset of 20 physicians diagnosed the same 6 histories again. For each history, experts had previously determined the correct diagnoses and the diagnostic cues. Accuracy ranged from 14% to 64% correct diagnoses (correct diagnosis listed as the most likely) and from 29% to 87% correct differential diagnoses (correct diagnosis listed in the differential). Acute care physicians (ED physicians and internists) included the correct diagnosis in the differential in, on average, 3.4 histories, relative to 2.6 for the family practitioners (P = 0.001, d = .75). Diagnostic performance was fairly reliable (r = .61, P < 0.001). Clinical experience was negatively correlated with diagnostic accuracy (r = -.25, P = 0.008). Two structural properties of patient histories-cue consensus and cue substitutability-were significantly associated with diagnostic accuracy, whereas case difficulty was not. Finally, prevalence of diagnosis also proved significantly correlated with accuracy. Average diagnostic accuracy in cases with nonspecific complaints far exceeds chance performance, and accuracy varies with medical specialty. Analyzing cue properties in patient histories can help shed light on determinants of diagnostic performance and thus suggest ways to enhance physicians' ability to accurately diagnose cases with nonspecific complaints.
The hypothalamic-pituitary-adrenal axis is activated in response to stress. One of the activated ... more The hypothalamic-pituitary-adrenal axis is activated in response to stress. One of the activated hypothalamic hormones is arginine vasopressin, a hormone involved in hemodynamics and osmoregulation. Copeptin, the C-terminal part of the arginine vasopressin precursor peptide, is a sensitive and stable surrogate marker for arginine vasopressin release. Measurement of copeptin levels has been shown to be useful in a variety of clinical scenarios, particularly as a prognostic marker in patients with acute diseases such as lower respiratory tract infection, heart disease and stroke. The measurement of copeptin levels may provide crucial information for risk stratification in a variety of clinical situations. As such, the emergency department appears to be the ideal setting for its potential use. This review summarizes the recent progress towards determining the prognostic and diagnostic value of copeptin in the emergency department.
Background: Community-acquired pneumonia (CAP) is the most frequent infection-related cause of de... more Background: Community-acquired pneumonia (CAP) is the most frequent infection-related cause of death. The reference standard to diagnose CAP is a new infiltrate on chest radiograph in the presence of recently acquired respiratory signs and symptoms. This study aims to evaluate the diagnostic and prognostic accuracy of clinical signs and symptoms and laboratory biomarkers for CAP.
American Journal of Respiratory and Critical Care Medicine, 2008
Pulmonary complications of hematopoietic stem cell transplantation include infections and graft-v... more Pulmonary complications of hematopoietic stem cell transplantation include infections and graft-versus-host diseases, such as idiopathic pneumonia syndrome (IPS). Conflicting data exist regarding the role of the interferon (IFN)-gamma-producing Th1 CD4(+) T-cell subset and IL-17A in IPS. To determine the role of IFN-gamma and IL-17A in the establishment of pulmonary graft-versus-host disease. A semiallogeneic murine model based on C57BL/6 x BALB/c as recipients with transplantation of BALB/c RAG2(-/-) bone marrow and transfer of different genetic knockout T cells (T-bet(-/-), IFN-gamma(-/-), IFN-gammaR(-/-)) on a BALB/c background. Lung tissue was examined for parenchymal changes and infiltrating cells by histology and fluorescence-activated cell sorter analysis. After transfer of semiallogeneic bone marrow together with donor CD4(+) T cells lacking IFN-gamma or T-bet-a T-box transcription factor controlling Th1 commitment-we found severe inflammation in the lungs, but no enhancement in other organs. In contrast, wild-type donor CD4(+) T cells mediated minimal inflammation only, and donor CD8(+) T cells were not required for IPS development. Mechanistically, the absence of IFN-gamma or IFN-gamma signaling in pulmonary parenchymal cells promoted expansion of IL-17A-producing CD4(+) T cells and local IL-17A release. In vivo depletion of IL-17A reduced disease severity. One mechanism of IFN-gamma protection against IPS is negative regulation of the expansion of pathogenic IL-17A-producing CD4(+) T cells through interaction with the IFN-gamma receptor on the pulmonary parenchymal cell population.
The accurate prediction of acute kidney injury (AKI) is an unmet clinical need. A combined assess... more The accurate prediction of acute kidney injury (AKI) is an unmet clinical need. A combined assessment of cardiac stress and renal tubular damage might improve early AKI detection. METHODS: A total of 372 consecutive patients presenting to the Emergency Department with lower respiratory tract infections were enrolled. Plasma B-type natriuretic peptide (BNP) and neutrophil gelatinase-associated lipocalin (NGAL) levels were measured in a blinded fashion at presentation. The potential of these biomarkers to predict AKI was assessed as the primary endpoint. AKI was defined according to the AKI Network classification. RESULTS: Overall, 16 patients (4%) experienced early AKI. These patients were more likely to suffer from preexisting chronic cardiac disease or diabetes mellitus. At presentation, BNP (334 pg/mL [130-1119] vs 113 pg/mL [52-328], P Ͻ.01) and NGAL (269 ng/mL [119-398] vs 96 ng/mL [60-199], P Ͻ.01) levels were significantly higher in AKI patients. The predictive accuracy of presentation BNP and NGAL levels was comparable (BNP 0.74; 95% confidence interval [CI], 0.64-0.84 vs NGAL 0.74; 95% CI, 0.61-0.87).
PRINCIPLES: Detection of elevated body temperature is critical in the early diagnosis of sepsis. ... more PRINCIPLES: Detection of elevated body temperature is critical in the early diagnosis of sepsis. Due to its convenience, infrared ear temperature measurement (IETM) has become the standard of care. Unfortunately, the limitations of this method are largely unexplored.
Because the volume of patient admissions to an emergency department (ED) cannot be precisely plan... more Because the volume of patient admissions to an emergency department (ED) cannot be precisely planned, the available resources may become overwhelmed at times ("crowding"), with resulting risks for patient safety. The aim of this study is to identify modern triage instruments and assess their validity and reliability. Review of selected literature retrieved by a search on the terms "emergency department" and "triage." Emergency departments around the world use different triage systems to assess the severity of incoming patients' conditions and assign treatment priorities. Our study identified four such instruments: the Australasian Triage Scale (ATS), the Canadian Triage and Acuity Scale (CTAS), the Manchester Triage System (MTS), and the Emergency Severity Index (ESI). Triage instruments with 5 levels are superior to those with 3 levels in both validity and reliability (p<0.01). Good to very good reliability has been shown for the best-studied instruments, CTAS and ESI (κ-statistics: 0.7 to 0.95), while ATS and MTS have been found to be only moderately reliable (κ-statistics: 0.3 to 0.6). MTS and ESI are both available in German; of these two, only the ESI has been validated in German-speaking countries. Five-level triage systems are valid and reliable methods for assessment of the severity of incoming patients' conditions by nursing staff in the emergency department. They should be used in German emergency departments to assign treatment priorities in a structured and dependable fashion.
In an emergency department, discharge communication represents a key step in medical care. The ef... more In an emergency department, discharge communication represents a key step in medical care. The efficiency of this doctor-patient interaction could be hampered by two bounds: The limited time in emergency care and patients' mind's limited capacity to encode, store and maintain information. Such limitations are the focus of this study. Specifically, we examine the number of items physicians deem crucial in a discharge communication and the necessary time estimated to present them. A vignette of a patient with chest pain was presented to 47 physicians (38 internists, 9 emergency physicians). Physicians were offered a list of 81 items possibly conveyed to patients and asked to select the important ones assuming a discharge interaction of 15 minutes. Additionally, 7 experts estimated the time required to communicate each item. Physicians' mean clinical experience was 10.1 years. From the list of 81 items, physicians selected, on average, 36 items (Range: 20-57). Experts rated the time necessary to communicate this subset to be 44.5 minutes - almost three times the preset 15 minutes. While emergency physicians, relative to internists, selected an insignificantly lower number of items (31.6 ± 6.2 vs. 37.4 ± 10.2), the time estimated for communicating the information was significantly shorter (36.9 ± 6.3 vs. 46.4 ± 13.5). Physicians in our study proved to be miscalibrated with regard to the number of items they could realistically discuss in a discharge communication. We conclude that there is an obvious need to train physicians in skills of implementing efficient discharge communication.
mortality. The primary cardiovascular complication of COPD is the development of pulmonary hypert... more mortality. The primary cardiovascular complication of COPD is the development of pulmonary hypertension following structural changes in the pulmonary vasculature, which are known to occur because of persistent pulmonary vasoconstriction in response to chronic hypoxia. 6
To date, no German triage tool with proven reliability and validity exists. The goal of this proj... more To date, no German triage tool with proven reliability and validity exists. The goal of this project is to translate and culturally adapt the Emergency Severity Index (ESI) and to assess reliability and validity of the German version. The ESI was translated following principles recommended for the translation and cultural adaptation of instruments. We performed a prospective, single-center cohort study. Reliability was assessed by calculating Cohen's weighted κ for agreement of 2 experts who reviewed the triage nurses' notes. To assess validity, associations of the number of resources, hospitalization, admission to intensive care, length of stay, and mortality with the assigned ESI level were investigated. Only small cultural adaptations had to be made during the translation process. Interrater agreement was high (κ(w) = 0.985) in a sample of 125 patients. For the assessment of validity, a sample of 2,114 patients was used. Spearman's rank correlation coefficient between ESI category and number of resources was ρ = -0.567. The association (Kendall's τ) between ESI category and disposition, and hospitalization was τ = -0.429 and τ = -0.453, respectively. The areas under the curves for the predictive ability of the ESI for hospitalization in general and hospitalization to an ICU were 0.788 and 0.856, respectively. The association between emergency department length of stay and ESI category was also significant (Kruskal-Wallis χ² = 450.8; df = 4; P < .001). Furthermore, the association between ESI category and survival probability was significant (log-rank χ² = 36.06; df = 3; P < .001). Translation of the ESI following guidelines was feasible and resulted in a reliable and valid German version.
Objectives: To the authors' knowledge, no prospectively validated, biomarker-based risk stratific... more Objectives: To the authors' knowledge, no prospectively validated, biomarker-based risk stratification tools exist for elderly patients presenting to the emergency department (ED) with nonspecific complaints (NSCs), such as generalized weakness, despite the fact that an acute serious disease often underlies nonspecific disease presentation. The primary purpose for this study was to validate the retrospectively derived model for outcome prediction using copeptin and peroxiredoxin 4 (Prx4), in a different group of patients, in a prospective fashion, in a multicenter setting. The secondary goals were to evaluate the potential contribution of the midregional portion of the precursor of adrenomedullin (MR-proADM) for outcome prediction and to investigate whether disposition decisions show promise for potential improvement by using biomarker levels in addition to a clinical assessment.
The measurement of cardiac troponin concentrations in the blood is a key element in the evaluatio... more The measurement of cardiac troponin concentrations in the blood is a key element in the evaluation of patients with suspected acute coronary syndromes, according to current guidelines, and contributes importantly to the ruling in or ruling out of acute myocardial infarction. The introduction of point-of-care testing for cardiac troponin has the potential to reduce turnaround time for assay results, compared with central laboratory testing, optimizing resource use. Although, in general, many point-of-care cardiac troponin tests are less sensitive than cardiac troponin tests developed for central laboratory-automated analyzers, point-of-care systems have been used successfully within accelerated protocols for the reliable ruling out of acute coronary syndromes, without increasing subsequent readmission rates for this condition. The impact of shortened assay turnaround times with point-of-care technology on length of stay in the emergency department has been limited to date, with most randomized evaluations of this technology having demonstrated little or no reduction in this outcome parameter. Accordingly, the point-of-care approach has not been shown to be cost-effective relative to central laboratory testing. Modeling studies suggest, however, that reengineering overall procedures within the emergency department setting, to take full advantage of reduced therapeutic turnaround time, has the potential to improve the flow of patients through the emergency department, to shorten discharge times, and to reduce cost. To properly evaluate the potential contribution of point-of-care technology in the emergency department, including its cost-effectiveness, future evaluations of point-of-care platforms will need to be embedded completely within a local decision-making structure designed for its use.
Medicine & Science in Sports & Exercise, 1997
The effect of gender and training on repeatability of cardiopulmonary exercise performance has no... more The effect of gender and training on repeatability of cardiopulmonary exercise performance has not been well defined. Therefore, we performed two bicycle exercise tests 1 wk apart in each of two groups: In 19 normal subjects (age 24 to 64 yr, 10 females), with a mean maximal oxygen uptake (VO2max) of 42 mL.kg-1.min-1, who had been in an ongoing training program including bicycle exercise, and in 19 untrained volunteers (23 to 54 yr, 11 females) with a mean VO2max of 36 mL.kg-1.min-1 (P < 0.05). Mean differences in physiologic variables measured during tests 1 and 2 were calculated. Repeatability coefficients were defined as 2 SD in percent of the means. In untrained subjects mean (+/- SD) maximal heart rate decreased by 4 +/- 5 beats.min-1 from the first to the second test (P < 0.05). VO2max and maximal work rate (Wmax) remained unchanged. No significant changes in these or other variables occurred in trained subjects. Repeatability coefficients for VO2max were 8 and 13% in trained and untrained subjects, respectively (P = NS). For Wmax the repeatability coefficient in untrained (11%) exceeded that in trained subjects (4%, P < 0.05). Repeatability coefficients did not differ among males and females. Our study provides normal values for repeatability of various parameters assessed during exercise testing and demonstrates that interpretation of performance during repeated tests has to account for training of the subjects.
Background: There are no predictors known that can identify COPD patients who will respond to tre... more Background: There are no predictors known that can identify COPD patients who will respond to treatment with ICS. Method: We investigated 30 patients (median age 65 (range 44-83, 12 females) with mild to moderately severe COPD. All patients had post bronchodilator FEV 1 /forced vital capacity ratio of less than 70% and a reversibility of less than 12% and 200 ml from baseline. We wanted to determine if airway responsiveness (AHR) to histamine and mannitol could predict who would respond to a 3-month course of ICS. Results: At baseline, all patients had AHR to histamine, but only 7 (23%) patients to mannitol. After 3 months of treatment with ICS, there was no significant change in spirometry or the quality of life when analysing all individuals together. However, FEV1% predicted improved from 67% (IQR12) to 79% (IQR16) in mannitol positive patients; whereas it was unchanged in the mannitol negative patients. The difference in the mean change of FEV1% predicted between the two groups was 12 (IQR13.5) and this was highly significant (pZ0.001). The improvement in quality of life (SGRQ 30 (IQR10.5) to 21 (IQR12; pZ0.01) was only significant in the patients positive to mannitol. Conclusion: We propose that AHR to mannitol could predict ICS-responsiveness in mild to moderately severe COPD patients. q
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2013
Background: Since drug-related emergency department (ED) visits are common among older adults, th... more Background: Since drug-related emergency department (ED) visits are common among older adults, the objectives of our study were to identify the frequency of drug-related problems (DRPs) among patients presenting to the ED with non-specific complaints (NSC), such as generalized weakness and to evaluate responsible drug classes. Methods: Delayed type cross-sectional diagnostic study with a prospective 30 day follow-up in the ED of the University Hospital Basel, Switzerland. From May 2007 until April 2009, all non-trauma patients presenting to the ED with an Emergency Severity Index (ESI) of 2 or 3 were screened and included, if they presented with non-specific complaints. After having obtained complete 30-day follow-up, two outcome assessors reviewed all available information, judged whether the initial presentation was a DRP and compared their judgment with the initial ED diagnosis. Acute morbidity ("serious condition") was allocated to individual cases according to predefined criteria.
To investigate diagnostic accuracy in patient histories involving nonspecific complaints and the ... more To investigate diagnostic accuracy in patient histories involving nonspecific complaints and the extent to which characteristics of physicians and structural properties of patient histories are associated with accuracy. Six histories of patients presenting to the emergency department (ED) with nonspecific complaints were provided to 112 physicians: 36 ED physicians, 50 internists, and 26 family practitioners. Physicians listed the 3 most likely diagnoses for each history and indicated which cue(s) they considered crucial. Four weeks later, a subset of 20 physicians diagnosed the same 6 histories again. For each history, experts had previously determined the correct diagnoses and the diagnostic cues. Accuracy ranged from 14% to 64% correct diagnoses (correct diagnosis listed as the most likely) and from 29% to 87% correct differential diagnoses (correct diagnosis listed in the differential). Acute care physicians (ED physicians and internists) included the correct diagnosis in the differential in, on average, 3.4 histories, relative to 2.6 for the family practitioners (P = 0.001, d = .75). Diagnostic performance was fairly reliable (r = .61, P < 0.001). Clinical experience was negatively correlated with diagnostic accuracy (r = -.25, P = 0.008). Two structural properties of patient histories-cue consensus and cue substitutability-were significantly associated with diagnostic accuracy, whereas case difficulty was not. Finally, prevalence of diagnosis also proved significantly correlated with accuracy. Average diagnostic accuracy in cases with nonspecific complaints far exceeds chance performance, and accuracy varies with medical specialty. Analyzing cue properties in patient histories can help shed light on determinants of diagnostic performance and thus suggest ways to enhance physicians' ability to accurately diagnose cases with nonspecific complaints.
The hypothalamic-pituitary-adrenal axis is activated in response to stress. One of the activated ... more The hypothalamic-pituitary-adrenal axis is activated in response to stress. One of the activated hypothalamic hormones is arginine vasopressin, a hormone involved in hemodynamics and osmoregulation. Copeptin, the C-terminal part of the arginine vasopressin precursor peptide, is a sensitive and stable surrogate marker for arginine vasopressin release. Measurement of copeptin levels has been shown to be useful in a variety of clinical scenarios, particularly as a prognostic marker in patients with acute diseases such as lower respiratory tract infection, heart disease and stroke. The measurement of copeptin levels may provide crucial information for risk stratification in a variety of clinical situations. As such, the emergency department appears to be the ideal setting for its potential use. This review summarizes the recent progress towards determining the prognostic and diagnostic value of copeptin in the emergency department.
Background: Community-acquired pneumonia (CAP) is the most frequent infection-related cause of de... more Background: Community-acquired pneumonia (CAP) is the most frequent infection-related cause of death. The reference standard to diagnose CAP is a new infiltrate on chest radiograph in the presence of recently acquired respiratory signs and symptoms. This study aims to evaluate the diagnostic and prognostic accuracy of clinical signs and symptoms and laboratory biomarkers for CAP.
American Journal of Respiratory and Critical Care Medicine, 2008
Pulmonary complications of hematopoietic stem cell transplantation include infections and graft-v... more Pulmonary complications of hematopoietic stem cell transplantation include infections and graft-versus-host diseases, such as idiopathic pneumonia syndrome (IPS). Conflicting data exist regarding the role of the interferon (IFN)-gamma-producing Th1 CD4(+) T-cell subset and IL-17A in IPS. To determine the role of IFN-gamma and IL-17A in the establishment of pulmonary graft-versus-host disease. A semiallogeneic murine model based on C57BL/6 x BALB/c as recipients with transplantation of BALB/c RAG2(-/-) bone marrow and transfer of different genetic knockout T cells (T-bet(-/-), IFN-gamma(-/-), IFN-gammaR(-/-)) on a BALB/c background. Lung tissue was examined for parenchymal changes and infiltrating cells by histology and fluorescence-activated cell sorter analysis. After transfer of semiallogeneic bone marrow together with donor CD4(+) T cells lacking IFN-gamma or T-bet-a T-box transcription factor controlling Th1 commitment-we found severe inflammation in the lungs, but no enhancement in other organs. In contrast, wild-type donor CD4(+) T cells mediated minimal inflammation only, and donor CD8(+) T cells were not required for IPS development. Mechanistically, the absence of IFN-gamma or IFN-gamma signaling in pulmonary parenchymal cells promoted expansion of IL-17A-producing CD4(+) T cells and local IL-17A release. In vivo depletion of IL-17A reduced disease severity. One mechanism of IFN-gamma protection against IPS is negative regulation of the expansion of pathogenic IL-17A-producing CD4(+) T cells through interaction with the IFN-gamma receptor on the pulmonary parenchymal cell population.
The accurate prediction of acute kidney injury (AKI) is an unmet clinical need. A combined assess... more The accurate prediction of acute kidney injury (AKI) is an unmet clinical need. A combined assessment of cardiac stress and renal tubular damage might improve early AKI detection. METHODS: A total of 372 consecutive patients presenting to the Emergency Department with lower respiratory tract infections were enrolled. Plasma B-type natriuretic peptide (BNP) and neutrophil gelatinase-associated lipocalin (NGAL) levels were measured in a blinded fashion at presentation. The potential of these biomarkers to predict AKI was assessed as the primary endpoint. AKI was defined according to the AKI Network classification. RESULTS: Overall, 16 patients (4%) experienced early AKI. These patients were more likely to suffer from preexisting chronic cardiac disease or diabetes mellitus. At presentation, BNP (334 pg/mL [130-1119] vs 113 pg/mL [52-328], P Ͻ.01) and NGAL (269 ng/mL [119-398] vs 96 ng/mL [60-199], P Ͻ.01) levels were significantly higher in AKI patients. The predictive accuracy of presentation BNP and NGAL levels was comparable (BNP 0.74; 95% confidence interval [CI], 0.64-0.84 vs NGAL 0.74; 95% CI, 0.61-0.87).
PRINCIPLES: Detection of elevated body temperature is critical in the early diagnosis of sepsis. ... more PRINCIPLES: Detection of elevated body temperature is critical in the early diagnosis of sepsis. Due to its convenience, infrared ear temperature measurement (IETM) has become the standard of care. Unfortunately, the limitations of this method are largely unexplored.
Because the volume of patient admissions to an emergency department (ED) cannot be precisely plan... more Because the volume of patient admissions to an emergency department (ED) cannot be precisely planned, the available resources may become overwhelmed at times ("crowding"), with resulting risks for patient safety. The aim of this study is to identify modern triage instruments and assess their validity and reliability. Review of selected literature retrieved by a search on the terms "emergency department" and "triage." Emergency departments around the world use different triage systems to assess the severity of incoming patients' conditions and assign treatment priorities. Our study identified four such instruments: the Australasian Triage Scale (ATS), the Canadian Triage and Acuity Scale (CTAS), the Manchester Triage System (MTS), and the Emergency Severity Index (ESI). Triage instruments with 5 levels are superior to those with 3 levels in both validity and reliability (p<0.01). Good to very good reliability has been shown for the best-studied instruments, CTAS and ESI (κ-statistics: 0.7 to 0.95), while ATS and MTS have been found to be only moderately reliable (κ-statistics: 0.3 to 0.6). MTS and ESI are both available in German; of these two, only the ESI has been validated in German-speaking countries. Five-level triage systems are valid and reliable methods for assessment of the severity of incoming patients' conditions by nursing staff in the emergency department. They should be used in German emergency departments to assign treatment priorities in a structured and dependable fashion.
In an emergency department, discharge communication represents a key step in medical care. The ef... more In an emergency department, discharge communication represents a key step in medical care. The efficiency of this doctor-patient interaction could be hampered by two bounds: The limited time in emergency care and patients' mind's limited capacity to encode, store and maintain information. Such limitations are the focus of this study. Specifically, we examine the number of items physicians deem crucial in a discharge communication and the necessary time estimated to present them. A vignette of a patient with chest pain was presented to 47 physicians (38 internists, 9 emergency physicians). Physicians were offered a list of 81 items possibly conveyed to patients and asked to select the important ones assuming a discharge interaction of 15 minutes. Additionally, 7 experts estimated the time required to communicate each item. Physicians' mean clinical experience was 10.1 years. From the list of 81 items, physicians selected, on average, 36 items (Range: 20-57). Experts rated the time necessary to communicate this subset to be 44.5 minutes - almost three times the preset 15 minutes. While emergency physicians, relative to internists, selected an insignificantly lower number of items (31.6 ± 6.2 vs. 37.4 ± 10.2), the time estimated for communicating the information was significantly shorter (36.9 ± 6.3 vs. 46.4 ± 13.5). Physicians in our study proved to be miscalibrated with regard to the number of items they could realistically discuss in a discharge communication. We conclude that there is an obvious need to train physicians in skills of implementing efficient discharge communication.
mortality. The primary cardiovascular complication of COPD is the development of pulmonary hypert... more mortality. The primary cardiovascular complication of COPD is the development of pulmonary hypertension following structural changes in the pulmonary vasculature, which are known to occur because of persistent pulmonary vasoconstriction in response to chronic hypoxia. 6
To date, no German triage tool with proven reliability and validity exists. The goal of this proj... more To date, no German triage tool with proven reliability and validity exists. The goal of this project is to translate and culturally adapt the Emergency Severity Index (ESI) and to assess reliability and validity of the German version. The ESI was translated following principles recommended for the translation and cultural adaptation of instruments. We performed a prospective, single-center cohort study. Reliability was assessed by calculating Cohen's weighted κ for agreement of 2 experts who reviewed the triage nurses' notes. To assess validity, associations of the number of resources, hospitalization, admission to intensive care, length of stay, and mortality with the assigned ESI level were investigated. Only small cultural adaptations had to be made during the translation process. Interrater agreement was high (κ(w) = 0.985) in a sample of 125 patients. For the assessment of validity, a sample of 2,114 patients was used. Spearman's rank correlation coefficient between ESI category and number of resources was ρ = -0.567. The association (Kendall's τ) between ESI category and disposition, and hospitalization was τ = -0.429 and τ = -0.453, respectively. The areas under the curves for the predictive ability of the ESI for hospitalization in general and hospitalization to an ICU were 0.788 and 0.856, respectively. The association between emergency department length of stay and ESI category was also significant (Kruskal-Wallis χ² = 450.8; df = 4; P < .001). Furthermore, the association between ESI category and survival probability was significant (log-rank χ² = 36.06; df = 3; P < .001). Translation of the ESI following guidelines was feasible and resulted in a reliable and valid German version.
Objectives: To the authors' knowledge, no prospectively validated, biomarker-based risk stratific... more Objectives: To the authors' knowledge, no prospectively validated, biomarker-based risk stratification tools exist for elderly patients presenting to the emergency department (ED) with nonspecific complaints (NSCs), such as generalized weakness, despite the fact that an acute serious disease often underlies nonspecific disease presentation. The primary purpose for this study was to validate the retrospectively derived model for outcome prediction using copeptin and peroxiredoxin 4 (Prx4), in a different group of patients, in a prospective fashion, in a multicenter setting. The secondary goals were to evaluate the potential contribution of the midregional portion of the precursor of adrenomedullin (MR-proADM) for outcome prediction and to investigate whether disposition decisions show promise for potential improvement by using biomarker levels in addition to a clinical assessment.
The measurement of cardiac troponin concentrations in the blood is a key element in the evaluatio... more The measurement of cardiac troponin concentrations in the blood is a key element in the evaluation of patients with suspected acute coronary syndromes, according to current guidelines, and contributes importantly to the ruling in or ruling out of acute myocardial infarction. The introduction of point-of-care testing for cardiac troponin has the potential to reduce turnaround time for assay results, compared with central laboratory testing, optimizing resource use. Although, in general, many point-of-care cardiac troponin tests are less sensitive than cardiac troponin tests developed for central laboratory-automated analyzers, point-of-care systems have been used successfully within accelerated protocols for the reliable ruling out of acute coronary syndromes, without increasing subsequent readmission rates for this condition. The impact of shortened assay turnaround times with point-of-care technology on length of stay in the emergency department has been limited to date, with most randomized evaluations of this technology having demonstrated little or no reduction in this outcome parameter. Accordingly, the point-of-care approach has not been shown to be cost-effective relative to central laboratory testing. Modeling studies suggest, however, that reengineering overall procedures within the emergency department setting, to take full advantage of reduced therapeutic turnaround time, has the potential to improve the flow of patients through the emergency department, to shorten discharge times, and to reduce cost. To properly evaluate the potential contribution of point-of-care technology in the emergency department, including its cost-effectiveness, future evaluations of point-of-care platforms will need to be embedded completely within a local decision-making structure designed for its use.
Medicine & Science in Sports & Exercise, 1997
The effect of gender and training on repeatability of cardiopulmonary exercise performance has no... more The effect of gender and training on repeatability of cardiopulmonary exercise performance has not been well defined. Therefore, we performed two bicycle exercise tests 1 wk apart in each of two groups: In 19 normal subjects (age 24 to 64 yr, 10 females), with a mean maximal oxygen uptake (VO2max) of 42 mL.kg-1.min-1, who had been in an ongoing training program including bicycle exercise, and in 19 untrained volunteers (23 to 54 yr, 11 females) with a mean VO2max of 36 mL.kg-1.min-1 (P < 0.05). Mean differences in physiologic variables measured during tests 1 and 2 were calculated. Repeatability coefficients were defined as 2 SD in percent of the means. In untrained subjects mean (+/- SD) maximal heart rate decreased by 4 +/- 5 beats.min-1 from the first to the second test (P < 0.05). VO2max and maximal work rate (Wmax) remained unchanged. No significant changes in these or other variables occurred in trained subjects. Repeatability coefficients for VO2max were 8 and 13% in trained and untrained subjects, respectively (P = NS). For Wmax the repeatability coefficient in untrained (11%) exceeded that in trained subjects (4%, P < 0.05). Repeatability coefficients did not differ among males and females. Our study provides normal values for repeatability of various parameters assessed during exercise testing and demonstrates that interpretation of performance during repeated tests has to account for training of the subjects.
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