An Independent Evaluation of Four Quantitative Emergency Department Crowding Scales

Background Emergency department (ED) overcrowding has become a frequent topic of investigation. Despite a significant body of research, there is no standard definition or measurement of ED crowding. Four quantitative scales for ED crowding have been proposed in the literature: the Real‐time Emergency Analysis of Demand Indicators (READI), the Emergency Department Work Index (EDWIN), the National Emergency Department Overcrowding Study (NEDOCS) scale, and the Emergency Department Crowding Scale (EDCS). These four scales have yet to be independently evaluated and compared. Objectives The goals of this study were to formally compare four existing quantitative ED crowding scales by measuring their ability to detect instances of perceived ED crowding and to determine whether any of these scales provide a generalizable solution for measuring ED crowding. Methods Data were collected at two‐hour intervals over 135 consecutive sampling instances. Physician and nurse agreement was assessed using weighted κ statistics. The crowding scales were compared via correlation statistics and their ability to predict perceived instances of ED crowding. Sensitivity, specificity, and positive predictive values were calculated at site‐specific cut points and at the recommended thresholds. Results All four of the crowding scales were significantly correlated, but their predictive abilities varied widely. NEDOCS had the highest area under the receiver operating characteristic curve (AROC) (0.92), while EDCS had the lowest (0.64). The recommended thresholds for the crowding scales were rarely exceeded; therefore, the scales were adjusted to site‐specific cut points. At a site‐specific cut point of 37.19, NEDOCS had the highest sensitivity (0.81), specificity (0.87), and positive predictive value (0.62). Conclusions At the study site, the suggested thresholds of the published crowding scales did not agree with providers' perceptions of ED crowding. Even after adjusting the scales to site‐specific thresholds, a relatively low prevalence of ED crowding resulted in unacceptably low positive predictive values for each scale. These results indicate that these crowding scales lack scalability and do not perform as designed in EDs where crowding is not the norm. However, two of the crowding scales, EDWIN and NEDOCS, and one of the READI subscales, bed ratio, yielded good predictive power (AROC >0.80) of perceived ED crowding, suggesting that they could be used effectively after a period of site‐specific calibration at EDs where crowding is a frequent occurrence.     

Simulation model of renal replacement therapy: predicting future demand in England.

BACKGROUND: The demand for renal replacement therapy (RRT) in England has risen steadily, although from a lower base than many other developed countries. Predicting the future demand for RRT and the impact of factors such as the acceptance rate, transplant supply and patient survival, is required in order to inform the planning of such services. METHODS: A discrete event simulation model estimates the future demand for RRT in England in 2010 for a range of scenarios. The model uses current prevalence and current and projected future acceptance rates, survival rates and the transitions between modalities to predict future patient numbers. National population and mortality data, published literature and data from the UK Renal Registry and UK Transplant, are used to estimate unmet need for RRT, the impact of changing demography and incidence of Type 2 diabetes, patient haemodialysis (HD) survival and transplant supply. RESULTS: By 2010 the predicted prevalence will have increased from about 30,000 in 2000 to between 42 and 51,000 (900-1000 p.m.p.), an average annual growth of 4.5-6%. Changing transplant supply has a small effect on overall numbers but changes the proportion of patients with functioning graft by up to 8%. Even with an optimistic increase in transplant supply (11% p.a. for 5 years), numbers on HD will continue to rise substantially, especially in the elderly. The factors most influencing future patient numbers are the acceptance rate and dialysis survival. CONCLUSION: This model predicts a substantial growth in the RRT population to 2010 to a rate approaching 1000 p.m.p., particularly in the elderly and those on HD, with a steady state not being reached for at least 25 years.     

Serum 25-hydroxyvitamin D concentrations of free-living subjects consuming olestra

The effect of olestra on vitamin D status was assessed in a 6-wk, double-blind, placebo-controlled study involving 202 free-living adults. Subjects consumed a total of 20 g/d of olestra or triglycerides in cookies eaten at each meal. A 20-micrograms ergocalciferol capsule was taken with each morning meal. Serum 25-hydroxyergocalciferol (25-OHD2) concentrations rose from approximately 5.7 to 39.0 and 31.7 nmol/L in the placebo and olestra groups, respectively, at week 6. At week 6, 25-OHD2 contributed 46-54% to total serum 25-OHD concentration compared with 11% at baseline. The 19% decrease in serum 25-OHD2 concentrations produced by olestra in this study is equivalent to a decrease of approximately 1.2 nmol/L under nonsupplemented dietary conditions. Ingesting 20 g olestra/d in the diet is thus not expected to affect vitamin D nutritional status.     

Psychiatric morbidity in Hobart's dependent aged

Psychiatric morbidity in the dependent aged was studied in the elderly population of Hobart's nursing homes and long-stay hospitals. Only patients with home addresses in Hobart and who were admitted for the first time aged 70 years or over were included. Three hundred and twelve persons were interviewed with a standard interview, and an informant was interviewed when appropriate. The medical records were searched for diagnoses and drug treatments. Physical disability was rated on an ad hoc scale. Comparisons were made of the prevalence of dementia, depression and anxiety in different types of unit, and between these and two domiciliary samples, one of which received domiciliary nursing services (n = 100) and the other not (n = 100). The differential use of institutions by men and women, and a possible sex difference in the prevalence of dementia is discussed.     

Left ventricular outflow tract obstruction with mitral valve replacement in small ventricular cavities

The inference that mitral valve replacement (MVR) may produce left ventricular outflow tract (LVOT) obstruction has been made, but no comparative hemodynamic studies with various types of prostheses have been done. The purpose of the present study was to compare the gradients created across the LVOT with MVR in young sheep with small left ventricular cavities. Mitral valve replacement was accomplished using cardiopulmonary bypass and hypothermic cardioplegic arrest. Five animals were used for each of the following valves studied: 25-mm Ionescu-Shiley bovine pericardial valve, 25-mm Hancock porcine aortic valve, 2M-6120 28-mm Starr-Edwards ball-valve prosthesis, 25-mm Bj?rk-Shiley 60-degree flat tilting-disc prosthesis, and 25-mm St. Jude Medical hemidisc valve. Gradients across the LVOT were measured after MVR and then during infusion of isoproterenol hydrochloride (0.05 micrograms/kg/min). Following MVR, only the Starr-Edwards valve produced an LVOT gradient (32 +/- 23 mm Hg). Substantial gradients after MVR were seen, however, with isoproterenol administration with the Ionescu-Shiley (47 +/- 4 mm Hg), Hancock (13 +/- 8 mm Hg), and Starr-Edwards (65 +/- 30 mm Hg) valves but not with the low-profile valves (Bj?rk-Shiley and St. Jude Medical). The results of the present study demonstrate that MVR can produce LVOT obstruction. The greatest degree of obstruction was with the high-profile mechanical and bioprosthetic valves.     

Phospho-akt expression is associated with a favorable outcome in non-small cell lung cancer.

Akt, a Serine/Threonine protein kinase, mediates growth factor-associated cell survival. Constitutive activation of Akt (phosphorylated Akt, P-Akt) has been observed in several human cancers, including lung cancer and may be associated with poor prognosis and chemotherapy and radiotherapy resistance. The clinical relevance of P-Akt in non-small cell lung cancer (NSCLC) is not well described. In the present study, we examined 82 surgically resected snap-frozen and paraffin-embedded stage I to IIIA NSCLC samples for P-Akt and Akt by Western blotting and for P-Akt by immunohistochemistry. P-Akt protein levels above the median, measured using reproducible semiquantitative band densitometry, correlated with a favorable outcome (P = 0.007). Multivariate analysis identified P-Akt as a significant independent favorable prognostic factor (P = 0.004). Although associated with a favorable prognosis, high P-Akt levels correlated with high tumor grade (P = 0.02). Adenocarcinomas were associated with low P-Akt levels (P = 0.039). Akt was not associated with either outcome or clinicopathologic variables.Cytoplasmic (CP-Akt) and nuclear (NP-Akt) P-Akt tumor cell staining was detected in 96% and 42% of cases, respectively. Both CP-Akt and NP-Akt correlated with well-differentiated tumors (P = 0.008 and 0.017, respectively). NP-Akt also correlated with nodal metastases (P = 0.022) and squamous histology (P = 0.037).These results suggest P-Akt expression is a favorable prognostic factor in NSCLC. Immunolocalization of P-Akt, however, may be relevant as NP-Akt was associated with nodal metastases, a known poor prognostic feature in this disease. P-Akt may be a potential novel therapeutic target for the management of NSCLC.