A common definition should be used in future studies of NSC

Non peer reviewe

Effect of age adjustment on two triage methods

Background Most emergency departments rely on acuity assessment, triage, to recognize critically ill patients that need urgent treatment, and to allocate resources according to need. The accuracy of commonly used triage instruments such as the Emergency Severity Index (ESI) is lower for older adults compared to young patients. We aim to examine, whether adjusting the triage category by age leads to improvement in sensitivity without excessive increase in patient numbers in the higher triage categories. The primary outcome measure was 3-day mortality and secondary outcomes were 30-day mortality, hospital admission, and HDU/ICU admissions. Methods We gathered data of all adult patients who had an unscheduled visit to any of our three emergency departments within one month. The data was analysed for 3-day mortality, 30-day mortality, hospital admission, and high dependency unit or intensive care unit (HDU/ICU) admission. The analysis was run for both the standard ESI triage method and a local 3-level Helsinki University Hospital (HUH) method. A further analysis was run for both triage methods with age adjustment. Net reclassification improvement values were calculated to demonstrate the effect of age adjustment. Results Thirteen thousand seven hundred fifty-nine patients met the study criteria, median age was 57. 3-day mortality AUCs for unadjusted HUH and ESI triage were 0.77 (0.65-0.88) and 0.72 (0.57-0.87); 30-day mortality AUCs were 0.64 (0.59-0.69) and 0.69 (0.64-0.73); hospital admission AUCs were 0.60 (0.68-0.71) and 0.66 (0.65-0.68) and HDU/ICU admission AUCs were 0.67 (0.64-0.70) and 0.82 (0.79-0.86), respectively. Age adjustment improved accuracy for 30-day mortality and hospital admission. With the threshold age of 80, AUCs for 30-day mortality were 0.73 (0.68-0.77) and 0.77 (0.73-0.81) and for hospital admission, 0.66 (0.65-0.67) and 0.72 (0.71-0.73) for the HUH and ESI triage. The effect was similar with all cut off ages. Conclusion Moving older adults into a more urgent triage category based on age, improved the triage instruments' performance slightly in predicting 30-day mortality and hospital admission without excessive increase in patient numbers in the higher triage categories. Age adjustment did not improve HDU/ICU admission or 3-day mortality prediction.Peer reviewe

Accuracy of Emergency Severity Index in older adults

Background and importance Emergency Severity Index is a five-level triage tool in the emergency department that predicts the need for emergency department resources and the degree of emergency. However, it is unknown whether this is valid in patients aged greater than or equal to 65 years. Objective The aim of the study was to compare the accuracy of the Emergency Severity Index triage system between emergency department patients aged 18-64 and greater than or equal to 65 years. Design, settings, and participants This was a retrospective observational cohort study of adults who presented to a Finnish emergency department between 1 February 2018 and 28 February 2018. All data were collected from electronic health records. Outcome measures and analysis The primary outcome was 3-day mortality. The secondary outcomes were 30-day mortality, hospital admission, high dependency unit or ICU admission, and emergency department length of stay. The area under the receiver operating characteristic curve and cutoff performances were used to investigate significant associations between triage categories and outcomes. The results of the two age groups were compared. Main results There were 3141 emergency department patients aged 18-64 years and 2370 patients aged greater than or equal to 65 years. The 3-day mortality area under the curve in patients aged greater than or equal to 65 years was greater than that in patients aged 18-64 years. The Emergency Severity Index was associated with high dependency unit/ICU admissions in both groups, with moderate sensitivity [18-64 years: 61.8% (50.9-71.9%); greater than or equal to 65 years: 73.3% (63.5-81.6%)] and high specificity [18-64 years: 93.0% (92.0-93.8%); greater than or equal to 65 years: 90.9% (90.0-92.1%)]. The sensitivity was high and specificity was low for 30-day mortality and hospital admission in both age groups. The emergency department length of stay was the longest in Emergency Severity Index category 3 for both age groups. There was no significant difference in accuracy between age groups for any outcome. Conclusion Emergency Severity Index performed well in predicting high dependency unit/ICU admission rates for both 18-64 years and greater than or equal to 65-year-old patients. It predicted the 3-day mortality for patients aged greater than or equal to 65 years with high accuracy. It was inaccurate in predicting 30-day mortality and hospital admission for both age groups.Peer reviewe

National Early Warning Score 2 (NEWS2) and 3-Level Triage Scale as Risk Predictors in Frail Older Adults in the Emergency Department

Background The aim of the emergency department (ED) triage is to recognize critically ill patients and to allocate resources. No strong evidence for accuracy of the current triage instruments, especially for the older adults, exists. We evaluated the National Early Warning Score 2 (NEWS2) and a 3-level triage assessment as risk predictors for frail older adults visiting the ED. Methods This prospective, observational study was performed in a Finnish ED. The data were collected in a six-month period and included were >= 75-year-old residents with Clinical Frailty Scale score of at least four. We analyzed the predictive values of NEWS2 and the three-level triage scale for 30-day mortality, hospital admission, high dependency unit (HDU) and intensive care unit (ICU) admissions, a count of 72-h and 30-day revisits, and ED length-of-stay (LOS). Results A total of 1711 ED visits were included. Median for age, CFS, LOS and NEWS2 were 85 years, 6 points, 6.2 h and 1 point, respectively. 30-day mortality was 96/1711. At triage, 69, 356 and 1278 of patients were assessed as red, yellow and green, respectively. There were 1103 admissions, of them 31 to an HDU facility, none to ICU. With NEWS2 and triage score, AUCs for 30-day mortality prediction were 0.70 (0.64-0.76) and 0.62 (0.56-0.68); for hospital admission prediction 0.62 (0.60-0.65) and 0.55 (0.52-0.56), and for HDU admission 0.72 (0.61-0.83) and 0.80 (0.70-0.90), respectively. The NEWS2 divided into risk groups of low, medium and high did not predict the ED LOS (p = 0.095). There was a difference in ED LOS between the red/yellow and as red/green patient groups (p <0.001) but not between the yellow/green groups (p = 0.59). There were 48 and 351 revisits within 72 h and 30 days, respectively. With NEWS2 AUCs for 72-h and 30-day revisit prediction were 0.48 (95% CI 0.40-0.56) and 0.47 (0.44-0.51), respectively; with triage score 0.48 (0.40-0.56) and 0.49 (0.46-0.52), respectively. Conclusions The NEWS2 and a local 3-level triage scale are statistically significant, but poor in accuracy, in predicting 30-day mortality, and HDU admission but not ED LOS or revisit rates for frail older adults. NEWS2 also seems to predict hospital admission.Peer reviewe

UriSed 3 PRO automated microscope in screening bacteriuria at region-wide laboratory organization

Background and aims: We assessed the possibility to rule out negative urine cultures by counting with UriSed 3 PRO (77 Elektmnika, Hungary) at Helsinki and Uusimaa Hospital District. Materials and methods: Bacteria counting of the UriSed 3 PRO automated microscope was verified with reference phase contrast microscopy against growth in culture. After acceptance into routine, results of bacteria and leukocyte counting from 56 426 specimens with eight UriSed 3 PRO instruments were compared against results from parallel samples cultured on chromogenic agar. Laboratory data including preanalytical details were accessed through the regional database of the Helsinki and Uusimaa Hospital District. Results: A combined sensitivity of 87-92% and a negative predictive value of 90-96% with a specificity of 54-50% was reached, depending on criteria. Preanalytical data (incubation time in bladder) combined with the way of urine collection would improve these figures if reliable. Conclusions: Complex patient populations, regional logistics and data interfases, and economics related to increased costs of additional particle counts against costs of screening cultures of all samples, did not support adaptation of a screening process of urine cultures. This conclusion was made locally, and may not be valid elsewhere.Peer reviewe

Nonspecific complaints in the emergency department - a systematic review

Background Nonspecific complaint (NSC) is a common presenting complaint in the emergency setting, especially in the elderly population. Individual studies have shown that it is associated with significant morbidity and mortality. This prognostic systematic review draws a synthesis of reported outcomes for patients presenting with NSC and compares them with outcomes for patients presenting with a specific complaint. Methods We conducted a literature search for publications, abstracts and conference presentations from Ovid, Scopus and Web of Science for the past 20 years. Studies were included which treated adult patients presenting to the Emergency Medical Services or Emergency Department with NSC. 2599 studies were screened for eligibility and quality was assessed using the SIGN assessment for bias tool. We excluded any low-quality studies, resulting in nine studies for quantitative analysis. We analysed the included studies for in-hospital mortality, triage category, emergency department length of stay, admission rate, hospital length of stay, intensive care admissions and re-visitation rate and compared outcomes to patients presenting with specific complaints (SC), where data were available. We grouped discharge diagnoses by ICD-10 category. Results We found that patients presenting with NSC were mostly older adults. Mortality for patients with NSC was significantly increased compared to patients presenting with SC [OR 2.50 (95% CI 1.40-4.47)]. They were triaged as urgent less often than SC patients [OR 2.12 (95% CI 1.08-4.16)]. Emergency department length of stay was increased in two out of three studies. Hospital length of stay was increased by 1-3 days. Admission rates were high in most studies, 55 to 84%, and increased in comparison to patients with SC [OR 3.86 (95% CI 1.76-8.47)]. These patients seemed to require more resources than patients with SC. The number for intensive care admissions did not seem to be increased. Data were insufficient to make conclusions regarding re-visitation rates. Discharge diagnoses were spread throughout the ICD-10 main chapters, infections being the most prevalent. Conclusions Patients with NSC have a high risk of mortality and their care in the Emergency Department requires more time and resources than for patients with SC. We suggest that NSC should be considered a major emergency presentation.Peer reviewe

Verification of UriSed 3 PRO automated urine microscope in regional laboratory environment

Background and aims: Ten UriSed 3 PRO automated microscopes (77 Elektronika, Hungary) were verified for nine HUSLAB laboratories with 160 000 annual urine samples. Materials and methods: Particle counting of the primary UriSed 3 PRO instrument (77 Elektronika, Hungary) was verified against reference visual microscopy with 463 urine specimens, and against urine culture on chromogenic agar plates with parallel 396 specimens. Nine secondary instruments were compared pairwise with the primary instrument. Results: Relative imprecisions compared to Poisson distribution, R(CV), were estimated to be 1.0 for white blood cell (WBC) and 1.5 for red blood cell (RBC) counts, respectively. Spearman's correlations against visual microscopy were rS = 0.94 for WBC, rS = 0.87 for RBC, and rS = 0.82 for squamous epithelial cell (SEC) counts. Agreement with visual microscopy (Cohen's weighted kappa) was 0.94 for WBC, 0.89 for RBC, 0.88 for SEC, 0.59 for combined casts, and 0.49 for non-squamous epithelial cells (NEC). Bacteria were detected with a sensitivity of 90% and specificity of 39 against culture at 107 CFB/L (104 CFU/mL). Created flagging limits allowed automated reporting for 70-75% of patient results. Conclusions: UriSed 3 PRO instruments were adopted into routine use after acceptance of the verification.Peer reviewe

Analysis of chemical warfare agent related chemicals in tissue samples within the CHEMSEA project

CHEMSEA, Chemical Munitions Search and Assessment, is a flagship project of the Baltic Sea Region Program and is partly financed by the European Union. The main focus of the project is to locate the dumped chemical warfare agents (CWAs) and sample the surrounding environment to assess the possible threat. The project lasts from the fall 2011 until 2014. CHEMSEA is a transnational collaboration including project partners and associated organizations, including governmental agencies and international organizations. Ocean waters are in a constant flux, making the study of effect of CWAs on fish and other marine biota a challenging task. For the evaluation of the risks of dumped CWAs, triphenylarsine (TPA), sulphur mustard (H), Adamsite (DM) and Clark I (DA) are thought to pose the highest realistic risk to marine biota. The exact effects of these chemicals are not known and no information is available for the detoxification rates of CWAs in fish tissues or other marine organism, such as mussels. During CHEMSEA project, cod and mussels were chosen for chemical analysis. Cod was sampled from different sites of Baltic Sea, covering official and suspected dumpsites as well as reference sites in the western and eastern Baltic Sea. Mussels were studied both in situ caging experiments and in vivo exposure experiments. For in situ experiment, cages were deployed at two different depths at two selected hotspot sites and one reference site in the Bornholm dumping area. Based on hydrographical data, the cages were placed at 35 m and 65 m depths at all stations. The poor oxygen conditions prevailing in the main CW dumping area made caging closer to the sea bottom unfeasible. In vivo experiment, mussels were exposed to mixtures of the arsenic-containing CWAs DA, DM and the tear gas α-chloroacetophenone. The main aim was to evaluate biological responses in mussels induced by CWA mixtures at environmentally relevant concentrations. For chemical analysis, cod urine, bile and muscle tissues were chosen in addition to the whole blue mussels from caging experiments and exposure studies. Sulphur mustard hydrolyses quickly into thiodiglycol (TDG) in aqueous environment. TDG was analysed from cod urine and bile and also from whole mussels. TDG could also be in its oxidised form as thiodiglycol sulfoxide so it was reduced to TDG at the beginning of sample preparation. Analyses were performed using combined gas chromatography–tandem mass spectrometry (GC–MS/MS) and the TDG was detected as its heptafluorobutyrylimidazole (HBFI) derivative. DM, DA and TPA were analysed as their oxidation products using liquid chromatography–tandem mass spectrometry (LC–MS/MS) from cod muscle and mussel samples. The sample preparation for these analyses is laborious and contains homogenization, multiple extractions and filtration. TDG was detected from notable amount of fish urine samples as background level and from few samples as higher level. For arsenic-containing compounds, only oxidized TPA was found from one fish muscle sample. Nothing was detected from caged mussels. However, high concentrations of oxidized DM and DA were measured from exposed mussels. Detailed results and conclusions will be discussed

Toxic effects of chemical warfare agent mixtures on the mussel Mytilus trossulus in the Baltic Sea: a laboratory exposure study

Baltic blue mussels (Mytilus trossulus) were implemented to assess potential toxicity, health impairments and bioaccumulation of dumped chemical warfare agents on marine benthic organisms. Mussels were collected from a pristine cultivation side and exposed under laboratory conditions to different mixtures of chemical warfare agents (CWAs) related phenyl arsenic compounds, Clark I and Adamsite as well as chloroacetophenone. Using a multi-biomarker approach, mussels were assessed thereafter for effects at different organisational levels ranging from geno-to cytotoxic effects, differences in enzyme kinetics and immunological responses. In an integrated approach, chemical analysis of water and tissue of the test organisms was performed in parallel. The results show clearly that exposed mussels bioaccumulate the oxidized forms of chemical warfare agents Clark I, Adamsite (DAox and DMox) and, to a certain extent, also chloroacetophenone into their tissues. Adverse effects in the test organisms at subcellular and functional level, including cytotoxic, immunotoxic and oxidative stress effects were visible. These acute effects occurred even at the lowest test concentration