Ambulante Entlassung aus der Notfallstation

Notfall + Rettungsmedizin - Die Entlassung aus der Notfallstation in die ambulante Weiterbehandlung stellt den größten Teil des „outflow“ aus den Notfallstationen dar. Um die...     

High Fluctuation Between Anticoagulants,Frequent Off-Label Dosing,and No Difference Concerning Outcomes: Results of a Real-Life Cohort Study

BackgroundRecently published studies indicated a high proportion of patients taking direct oral anticoagulants (DOACs) are off-label under- or overdosed. The present study aimed at investigating whether off-label dosages are corrected over time and whether off-label doses are associated with differences in bleeding rates, ischemic stroke, or venous thromboembolism.MethodsIn this retrospective cohort study, patients presenting to our emergency department between January 1 and December 31, 2018, with therapeutic oral anticoagulation were included (ie, vitamin-K antagonists [VKAs], rivaroxaban, apixaban, edoxaban, and dabigatran) and follow-up for a maximum of 2 years until December 31, 2019, was made. Detailed chart reviews were performed for each case concerning characteristics, indication, bleeding complications, or changes in the used substance or dosage.ResultsWe reviewed 2588 consultations of 1228 patients receiving therapeutic oral anticoagulation. During the maximum follow-up period of 2 years vitamin K antagonists and rivaroxaban lost the largest proportions in favor of apixaban. The overall distribution of dosage correctness remained almost unimproved (correct dosing in 62.5%, underdosing in 23.6%, coverdosing in 13.9%).The corresponding outcomes did not differ with respect to bleeding events, ischemic stroke, or venous thromboembolism among various anticoagulants as well as between correct and off-label doses.ConclusionsA rising proportion of existing oral anticoagulation regimes was changed to apixaban, while the proportion of off-label dosages of all oral anticoagulants remained stable. No difference in bleeding rates, de novo strokes, or thromboembolisms was found between anticoagulants as well as between correct and off-label doses.     

Diuretic-induced hyponatremia and osteoporotic fractures in patients admitted to the emergency department

Objective

Hyponatremia is a complication of diuretic treatment and has been recently identified as a novel factor associated with osteoporosis and fractures. The impact of diuretic-associated electrolyte disorders on osteoporotic fractures (OF) has rarely been studied systematically.

Design and setting

We conducted a study in patients presenting to the emergency department at the University Hospital Bern. In this retrospective case series analysis of prospectively gathered data, over a 2-year period we identified 10,823 adult (≥50 years) outpatients with a measured baseline serum sodium, at admission to the hospital. OF patients were compared to a control group without fractures using standard statistical methods.

Results

Four hundred and eighty (5%) patients had 547 OF. The OF group had a higher mean age (73 vs. 68 years, p < 0.0001), smaller proportion of men (37% vs. 58%, p < 0.0001), higher hospitalisation rate (83% vs. 62%, p < 0.0001) and longer hospital stay (8 vs. 6 days, p < 0.0001). Any diuretic agent (p < 0.0001), loop diurietics (p = 0.02), spironolactone (p = 0.02) and amiloride (p < 0.01) were used significantly more in OF patients, but not thiazides (p = 0.68). The prevalence of hyponatremia increased significantly (p < 0.0001) with the number of diuretics taken. Advanced age (odds ratio [OR] 1.04, p < 0.0001), hyponatremia (OR 1.46, p = 0.011) higher serum creatinine (OR 1.53, p = 0.0001), furosemide use alone (OR 1.40, p = 0.01) and co-treatment with amiloride (OR 2.22, p = 0.02) were associated with a higher risk for OF.

Conclusions

This study highlights the clinical association of hyponatremia during the use of certain diuretics (i.e. furosemide or in combination, i.e. amiloride) with an increased risk of osteoporosis associated fractures. Although evidence-based data is currently lacking a pragmatic approach concerning hyponatremia monitoring and correction appears reasonable in selected groups of patients.     

Modelling the dynamics of expiratory airflow to describe chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterized by expiratory airflow limitation, but current diagnostic criteria only consider flow till the first second and are therefore strongly debated. We aimed to develop a data-based individualized model for flow decline and to explore the relationship between model parameters and COPD presence. A second-order transfer function model was chosen and the model parameters (namely the two poles and the steady state gain (SSG)) from 474 individuals were correlated with COPD presence. The capability of the model to predict disease presence was explored using 5 machine learning classifiers and tenfold cross-validation. Median (95 % CI) poles in subjects without disease were 0.9868 (0.9858–0.9878) and 0.9333 (0.9256–0.9395), compared with 0.9929 (0.9925–0.9933) and 0.9082 (0.9004–0.9140) in subjects with COPD (p < 0.001 for both poles). A significant difference was also found when analysing the SSG, being lower in COPD group 3.8 (3.5–4.2) compared with 8.2 (7.8–8.7) in subjects without (p < 0.0001). A combination of all three parameters in a support vector machines corresponded with highest sensitivity of 85 %, specificity of 98.1 % and accuracy of 88.2 % to COPD diagnosis. The forced expiration of COPD can be modelled by a second-order system which parameters identify most COPD cases. Our approach offers an additional tool in case FEV₁/FVC ratio-based diagnosis is doubted.     

Sleep misperception,EEG characteristics and Autonomic Nervous System activity in primary insomnia: A retrospective study on polysomnographic data

Misperception of Sleep Onset Latency, often found in Primary Insomnia, has been cited to be influenced by hyperarousal, reflected in EEG- and ECG-related indices. The aim of this retrospective study was to examine the association between Central Nervous System (i.e. EEG) and Autonomic Nervous System activity in the Sleep Onset Period and the first NREM sleep cycle in Primary Insomnia (n = 17) and healthy controls (n = 11). Furthermore, the study examined the influence of elevated EEG and Autonomic Nervous System activity on Stage2 sleep-protective mechanisms (K-complexes and sleep spindles). Confirming previous findings, the Primary Insomnia-group overestimated Sleep Onset Latency and this overestimation was correlated with elevated EEG activity. A higher amount of beta EEG activity during the Sleep Onset Period was correlated with the appearance of K-complexes immediately followed by a sleep spindle in the Primary Insomnia-group. This can be interpreted as an extra attempt to protect sleep continuity or as a failure of the sleep-protective role of the K-complex by fast EEG frequencies following within one second. The strong association found between K-alpha (K-complex within one second followed by 8–12 Hz EEG activity) in Stage2 sleep and a lower parasympathetic Autonomic Nervous System dominance (less high frequency HR) in Slow-wave sleep, further assumes a state of hyperarousal continuing through sleep in Primary Insomnia.     

The Bernese ankle rules: a fast, reliable test after low-energy, supination-type malleolar and midfoot trauma

BACKGROUND: Trauma of the midfoot and ankle joint are among the most commonly treated injuries in the emergency unit. The "Ottawa ankle rules" were introduced in 1992 to lower the amount of radiographs based on a standardized clinical examination. The weakness of the "rules" is the low specificity reported in several clinical studies. METHOD: We introduced a new indirect stress technique to examine the ankle and the midfoot after low-energy, supination-type trauma, avoiding direct palpation of the injured region. RESULTS: In 354 prospectively documented patients, the Bernese ankle test produced a sensitivity of 100% and a specificity of 91%. CONCLUSION: Compared with the original Ottawa ankle rules, the number of false-positive findings could be significantly reduced, resulting in a reduction of 84% in radiographs after low-energy, supination-type trauma ankle and midfoot trauma. Further investigations have to be performed to prove whether these findings are reproducible within other clinical settings, which could result in major cost savings for the health care system.     

The clinical correlation of temporal bone fractures and spiral computed tomographic scan: a prospective and consecutive study at a level I trauma center

BACKGROUND: Undetected temporal bone fractures (TBFs) can lead to complications such as hearing loss, facial nerve paralysis, otorrhea, or otorhinorrhea, and can be the cause of life-threatening bacterial meningitis and can easily be missed. METHODS: We prospectively studied patients with head trauma between January 2000 and January 2001. All patients were examined by the attending trauma physician and then underwent cranial helical computed tomographic (CT) scan independent of clinical findings and Glasgow Coma Scale (GCS) score to determine the proportion of TBFs that would have been missed if diagnosis had been based only on clinical evaluation. RESULTS: Three-hundred fifty consecutive patients with head trauma were studied during the 12-month period (GCS score: range, 3-15; median, 13). In 34 (9.7%) of these patients, 38 TBF (30 unilateral and 4 bilateral) were diagnosed by CT scan. However, clinical signs of TBF were present in only 22 of the 34 patients (65%). All missed TBFs were unilateral. Of the patients with missed TBFs, 8 of 20 (40%) had GCS scores of 14 to 15, 1 of 8 (12.5%) had a GCS score of 9 to 13, and 3 of 6 (50%) had GCS scores < 9. Four of 34 (12%) patients developed clinical complications. CONCLUSION: TBFs are common injuries in patients with head trauma. More than one third of these fractures may be missed by clinical diagnosis alone. Although the clinical importance of the missed TBF is debatable, 12% of our patients developed complications. Therefore, to rule out these lesions, routine cranial helical CT scan should be recommended in all patients presenting with head trauma, independent of clinical findings and GCS score.     

A 5‐year follow up of patients discharged with non‐specific abdominal pain: out of sight,out of mind?

Background/Aim: Acute non‐specific abdominal pain (NSAP) is prevalent in 6–25% of the general population and is a common cause of admission to the emergency department (ED). Despite involvement of substantial financial and human resources, there are few data on long‐term outcome after initial diagnosis. The aim of this study was to evaluate long‐term outcome of patients initially admitted with NSAP to an ED. Methods: The study involves a 5‐year follow‐up analysis of prospectively collected data on 104 patients admitted to our ED in 2003 with NSAP. Primary end‐point was clinical outcome 5 years after initial ED admission. Predictive risk factors were assessed using a multivariate regression model. Results: 29 patients (28%) had recurring NSAP 5 years after initial ED admission, 76% of these patients received (multiple) diagnostic examinations and 13% eventually required diagnostic (or therapeutic) surgery. Although approximately half of patients with recurring NSAP eventually received a definite diagnosis, 30% still suffered from recurrent abdominal pain. Using regression analysis, no single factor in our dataset could be identified as a predictor for NSAP persistence. Conclusion: The long‐term impact for patients initially admitted to our ED with acute NSAP is significant – 28% of patients continue to suffer from recurring NSAP after 5 years. NSAP therefore remains, despite more advanced diagnostic tools, a true and, as yet, unsolved problem.