Age in addition to RETTS triage priority substantially improves 3-day mortality prediction in emergency department patients: a multi-center cohort study.

BACKGROUND: Previous studies have shown varying results on the validity of the rapid emergency triage and treatment system (RETTS), but have concluded that patient age is not adequately considered as a risk factor for short term mortality. Little is known about the RETTS system's performance between different chief complaints and on short term mortality. We therefore aimed to evaluate how well a model including both RETTS triage priority and patient age (TP and age model) predicts 3-day mortality compared to a univariate RETTS triage priority model (TP model). Secondarily, we aimed to evaluate the TP model compared to a univariate age model (age model) and whether these three models' predictive performance regarding 3-day mortality varies between patients with different chief complaints in an unsorted emergency department patient population. METHODS: This study was a prospective historic observational cohort study, using logistic regression on a cohort of patients seeking emergency department care in Stockholm during 2012-2016. Patient visits were stratified into the 10 chief complaint categories (CCC) with the highest number of deceased patients within 3 days of arrival, and to "other chief complaints". Patients with priority 1 were excluded. RESULTS: The studied cohort contained 1,690,981 visits by 788,046 different individuals. The TP and age model predicted 3-day mortality significantly and substantially better than both univariate models in the total population and in each studied CCC. The age model predicted 3-day mortality significantly and substantially better than the TP model in the total population and for all but three CCCs and was not inferior in any CCC. There were substantial differences between the studied CCCs in the predictive ability of each of the three models. CONCLUSIONS: Adding patient age to the RETTS triage priority system significantly and substantially improves 3-day mortality prediction compared to RETTS priority alone. Age alone is a non-inferior predictor of 3-day mortality compared to RETTS priority. The impact on 3-day mortality prediction of adding patient age to RETTS priority varies between CCCs but is substantial for all CCCs and for the total population. Including age as a variable in future revisions of RETTS could substantially improve patient safety.

Age is associated with increased mortality in the RETTS-A triage scale.

BACKGROUND: Triage is widely used in the emergency department (ED) in order to identify the patient's level of urgency and often based on the patient's chief complaint and vital signs. Age has been shown to be independently associated with short term mortality following an ED visit. However, the most commonly used ED triage tools do not include age as an independent core variable. The aim of this study was to investigate the relationship between age and 7- and 30-day mortality across the triage priority level groups according to Rapid Emergency Triage and Treatment System - Adult (RETTS-A), the most widely used triage tool in Sweden. METHODS: In this cohort, we included all adult patients visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015, n = 639,387. All patients were triaged according to the RETTS-A and subsequently separated into three age strata: 18-59, 60-79 and ≥ 80 years. Descriptive analyses and logistic regression was used. The primary outcome measures were 7- and 30-day mortality. RESULTS: We observed that age was associated with both 7 and 30-day mortality in each triage priority level group. Mortality was higher in older patients across all triage priority levels but the association with age was stronger in the lowest triage group (p-value for interaction = < 0.001). Comparing patients ≥80 years with patients 18-59 years, older patients had a 16 and 7 fold higher risk for 7 day mortality in the lowest and highest triage priority groups, respectively. The corresponding numbers for 30-d mortality were a 21- and 8-foldincreased risk, respectively. CONCLUSION: Compared to younger patients, patients above 60 years have an increased short term mortality across the RETTS-A triage priority level groups and this was most pronounced in the lowest triage level. The reason for our findings are unclear and data suggest a validation of RETTS-A in aged patients.

Diagnosing upper extremity deep vein thrombosis with non-contrast-enhanced Magnetic Resonance Direct Thrombus Imaging: A pilot study.

Diagnosing upper extremity deep vein thrombosis (UEDVT) can be challenging. Compression ultrasonography is often inconclusive because of overlying anatomic structures that hamper compressing veins. Contrast venography is invasive and has a risk of contrast allergy. Magnetic Resonance Direct Thrombus Imaging (MRDTI) and Three Dimensional Turbo Spin-echo Spectral Attenuated Inversion Recovery (3D TSE-SPAIR) are both non-contrast-enhanced Magnetic Resonance Imaging (MRI) sequences that can visualize a thrombus directly by the visualization of methemoglobin, which is formed in a fresh blood clot. MRDTI has been proven to be accurate in diagnosing deep venous thrombosis (DVT) of the leg. The primary aim of this pilot study was to test the feasibility of diagnosing UEDVT with these MRI techniques. MRDTI and 3D TSE-SPAIR were performed in 3 pilot patients who were already diagnosed with UEDVT by ultrasonography or contrast venography. In all patients, UEDVT diagnosis could be confirmed by MRDTI and 3D TSE-SPAIR in all vein segments. In conclusion, this study showed that non-contrast MRDTI and 3D TSE-SPAIR sequences may be feasible tests to diagnose UEDVT. However diagnostic accuracy and management studies have to be performed before these techniques can be routinely used in clinical practice.

The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory.

INTRODUCTION: The soluble fibrin monomer (sFM) assay, like the D-dimer (DDi) assay, has the potential to be used both as an aid in the diagnosis of disseminated intravascular coagulation (DIC) and as a thrombotic marker. It differs from DDi in that it is a much earlier produced fragment produced only by thrombin action on fibrinogen, whereas DDi is a much later produced fragment formed by plasmin cleavage of cross-linked fibrin. METHODS: In our study, we compared two commercially available automated sFM assays in the routine hospital setting using samples obtained from the general hospital ward and the emergency room. The results obtained with the two automated assays (Stago LIA sFM assays and the LPIA-Iatro SF assay) were compared with each other and with the results obtained using the routine semiquantitative hemagglutination assay. RESULTS: The study showed that both automated assays were comparable with each other. No patient sample previously classified as positive would be missed, but with the higher sensitivity in the automated tests, more samples are positive. CONCLUSION: In conclusion, we suggest that both automated tests are suitable for routine laboratory use. Both assays had the advantage over the hemagglutination assay in that previously frozen samples could be used, and the assays are easier and quicker to perform. The LIA sFM Stago has slightly better sensitivity but has a tendency to lower specificity than the Iatro SF test.

Treatment of malarial acute renal failure by hemodialysis.

We studied 112 patients with malarial acute renal failure (ARF) during the period 1991-1997 at Bangkok Hospital for Tropical Diseases (Mahidol University, Bangkok, Thailand). Hemodialysis was performed in 101 (90.2%) of these patients. The mean number of times the patients were hemodialyzed was 6.5 (range = 1-27). Ninety-three (83.0%) patients were oliguric and the remainder were nonoliguric. Patients who had oliguric renal failure required more hemodialyses and had more complications than the nonoliguric patients. The oliguric patients had an eight-fold higher risk of requiring six or more hemodialyses (95% confidence interval = 1.2-53.9, P = 0.0008). The overall mortality rate was 10.7% (12 of 112). Eleven of the patients who died were jaundiced and eight of them had cerebral malaria with a Glasgow Coma Score < or = 8. We conclude that hemodialysis is a useful treatment for oliguric and nonoliguric ARF from severe malaria, particularly when initiated early in the course of the illness.

Structural features of an arabinan fragment isolated from the water-soluble fraction of dehulled rapeseed.

A water-soluble polysaccharide fraction was prepared from dehulled rapeseed meal (winter rapeseed variety Casino). Further purification yielded two major fractions having a high content of arabinose and galactose residues, with Ara/Gal ratios of 5.4 (G1) and 1.8 (G2). The Ara/Gal ratio of the high molecular weight fraction G1 was stable over the whole gel filtration peak, indicating that the arabinose and galactose residues are part of the same polysaccharide. The high molecular weight fraction G1 was studied further by methylation analysis and several NMR techniques. Structural studies showed G1 to consist mainly of arabian fragments, which have terminal alpha-L-arabinofuranosyl groups with anomeric carbons bound (1-->5) (A) or (1-->2) (B), and 2,5-substituted arabinosyl residues with anomeric carbons bound (1-->5) (D) or (1-->2) (C) to adjacent arabinosyl residues. The A:B:C:D ratios were 2:1:1:1 according to results from NMR and methylation analysis.

Total dietary fiber determined as neutral sugar residues, uronic acid residues, and Klason lignin (the Uppsala method): collaborative study.

A joint AOAC/American Association of Cereal Chemists (AACC) collaborative study was conducted to determine by the Uppsala method the dietary fiber content and its composition in various foods. The method includes preparation of a residue by treatment with thermostable alpha-amylase and amyloglucosidase and then ethanol precipitation of solubilized dietary fiber components while leaving low-molecular weight carbohydrates in solution. After acid hydrolysis of residue, neutral polysaccharide residues are determined as alditol acetates by gas-liquid chromatography, uronic acid residues are determined by colorimetry, and ash-free acid-insoluble residue (Klason lignin) is determined gravimetrically. Total dietary fiber, including enzyme-resistant starch, is calculated as the sum of nonstarch polysaccharide residues and Klason lignin. Nine laboratories completed the study, analyzing in duplicate 8 unknown dried products that included 4 cereal products, green peas, potato fiber, carrots, and apples. Total dietary fiber contents of products tested ranged from 4.6 to 84.3%, with an average RSDR value of 8.4% (range, 4.8-11.1%). Total neutral polysaccharide residues ranged from 3.8 to 64.1%, with an average RSDR value of 7.5% (range, 5.4-10.5%). Individual neutral sugars (rhamnose, arabinose, xylose, mannose, galactose, and glucose) and uronic acid residues present at more than 1% generally had good RSDR values (3.3-22.8%), whereas, as expected for Klason lignin, only the wheat bran sample with a high content (16%) had an excellent RSDR value (5.0%). The gas chromatographic-colorimetric-gravimetric method (Uppsala method) for determination of total dietary fiber (as neutral sugar residues, uronic acid residues, and Klason lignin) has been adopted first action by AOAC INTERNATIONAL.

Effects of rye bran, oat bran and soya-bean fibre on bile composition, gallstone formation, gall-bladder morphology and serum cholesterol in Syrian golden hamsters (Mesocricetus auratus).

The effects of rye bran, oat bran and soya-bean fibre on serum lipids, bile composition and gallstone formation were studied in male Syrian golden hamsters (Mesocricetus auratus). The control groups received fibre-free stone-provoking (O1 diet) or non-stone-provoking (O2 diet) diets. The serum cholesterol levels were lower for all groups fed on the diets supplemented with the dietary fibre sources compared with the control groups. The total content of bile acids in bile was higher in groups given rye-bran diets compared with the corresponding controls. The proportion of cholic acid was higher and that of chenodeoxycholic and lithocholic acid lower in the groups given rye-bran-, oat-bran- or soya-bean-fibre-supplemented diets, compared with the corresponding controls. The secondary:primary bile acid ratio was lower in the group given the rye-bran-supplemented O1 diet. The lithocholic:deoxycholic acid ratio was lower in the groups given rye-bran-, oat-bran- or soya-bean-fibre-supplemented diets than in the corresponding controls. A lower frequency of gallstones was observed only for the group receiving the rye-bran-supplemented O1 diet while the lithogenic index was lower in the groups given the rye-bran-supplemented O2 diet. A decreased epithelial volume density of the gall-bladder and an increased smooth muscular volume density were observed in animals given oat-bran- and rye-bran-supplemented O1 diets, whereas for the soya-bean-fibre-supplemented O1 diet, only the smooth muscular volume density was increased.

Enzymatic/chemical analysis of dietary fiber.

The Uppsala methodology for rapid analysis and characterization of total dietary fiber, defined as the sum of dietary fiber polysaccharides (DFP) and Klason lignin, was studied. A sugar- and starch-free residue was prepared by treatment with a thermostable amylase and amyloglucosidase. Neutral DFP residues were quantified by gas chromatography as alditol acetates after acid hydrolysis of this residue, and the acid-insoluble fraction, Klason lignin, was determined gravimetrically. Uronic acid residues were quantified by decarboxylation of the original sample. The efficacy of the Uppsala methodology was tested with foods varying in fiber content and composition, including heat-treated samples. The present method allowed the analysis of up to 40 samples per week. It had good repeatability and coefficients of variation of 3-5% for the main fiber components. Fiber contents determined with the method were higher than those determined with a similar method that excludes Klason lignin and starch resistant to amylases but soluble in dimethyl sulfoxide and lower than those determined with an enzymatic/gravimetric method. Important aspects of fiber analysis, like enzyme purity and the recovery of soluble fiber on ethanol precipitation, also were investigated.

Effects of oat and rye fractions on biliary and faecal bile acid profiles in Syrian golden hamsters (Mesocricetus auratus).

The effects of bran and starchy endosperm fractions of oat and rye on faecal weight and on biliary and faecal bile acids were studied in Syrian golden hamsters (Mesocricetus auratus). The animals fed on diets supplemented with steam-flaked oat bran, oat bran or rye bran had higher wet and dry weights of faeces compared with the animals fed on the fibre-free or low-fibre endosperm diets. A higher mean percentage of biliary cholic acid and a lower mean percentage of chenodeoxycholic and lithocholic (LCA) acids was observed in the bran-supplemented dietary groups. Animals fed on the bran-supplemented diets had increased daily faecal excretion of both total saponifiable and total free bile acids compared with the animals fed on fibre-free or endosperm-supplemented diets. The mean percentage of total saponifiable bile acids in the faeces was higher, and that of free bile acids lower in the animals fed on bran-supplemented diets. A significantly lower concentration of faecal free LCA was observed in the animals fed on the rye-bran diet. Both bran and endosperm diets reduced the faecal LCA:deoxycholic acid compared with the fibre-free diet, but the bran diets had a more pronounced effect than endosperm diets.

Dietary effects of barley fibre, wheat bran and rye bran on bile composition and gallstone formation in hamsters.

The effects of brewer's spent grain (BSG), wheat bran and rye bran on bile composition, gallstone formation and serum cholesterol were studied in Syrian golden hamsters. The frequency of gallstone formation in the animals fed diets supplemented with low (10%) and high (20%) concentrations of BSG or wheat bran was significantly lower than that of the animals fed a stone-provoking, fibre-free diet. The ratios of secondary to primary bile acids were lower in the animals fed the diets supplemented with a high dose of BSG, wheat bran and rye bran than in the controls. The ratio of LCA to DCA was reduced only in the animals fed the diet supplemented with rye bran as compared with controls. No significant changes in bile and serum cholesterol levels were observed in the experiment.

The influence of barley fibre on bile composition, gallstone formation, serum cholesterol and intestinal morphology in hamsters.

Frequency of gallstones, concentration of bile acids and cholesterol in bile, concentration of cholesterol in serum, and structure of the small intestinal mucosa were analyzed in male Syrian Golden hamsters fed a stone provoking fibre-free diet with or without supplementation of brewer's spent grain (BSG), a concentrated barley fibre source from the by-product of brewing. A significantly lower frequency of gallstones was found in the animals with 10% BSG dietary supplementation. Addition of 30% BSG after an initial 6-week period with a fibre-free, stone provoking diet seemed to dissolve previously formed gallstones. Total bile acid concentration was higher in bile from animals given a diet supplemented with 10% BSG. In addition, the cholesterol concentration in both serum and bile was lower in the 30% BSG supplemented group. Structurally, a 10% BSG supplementation decreased ileal epithelium height whereas a high supplementation (30%) of BSG induced a decrease in epithelial height both of jejunal and ileal mucosa. The results show that BSG has significant effects on the metabolism of bile acids and cholesterol as well as on the morphology of the small intestinal mucosa.

Cesium-137 body burdens in Norwegian Lapps, 1965-1983.

Results of measurements of the whole-body contents of 137Cs during the period 1965-1983 in Lapps from the Kautokeino area in Norway are reported with measurements of 137Cs in reindeer meat during the period 1966-1983. By using available data on 137Cs in precipitation for the period 1950-1980, transfer coefficients from 137Cs in precipitation to reindeer meat have been assessed. A correlation between the 137Cs content in reindeer meat and the 137Cs content in Lapp reindeer breeders has been established. The average whole-body committed dose equivalent, H50, to the reindeer breeders from internally deposited 137Cs from intakes up to year 2000 was assessed to 13 mSv with a peak value of 30 mSv. In comparison, the corresponding committed dose equivalent to the Norwegian population from internally deposited 137Cs has been estimated to be about 1 mSv. The higher intake of 137Cs by reindeer breeders is due to the lichen-reindeer-man exposure pathway.

Absorbable sutures (Dexon and Vicryl) in the corneolimbal incision. Used in lens implantation surgery.

In 115 consecutive cataract extractions with implantation of artificial lens a clinical evaluation of absorbable sutures--polyglactin (910) (Vicryl 7-0) and polyglycolic acid (Dexon 8-0)--in corneolimbal incision has been performed. The corneolimbal wounds were closed by continuous suture technique with one double loop knot at the 12 o'clock and 5-6 loops on each side of the 12 o'clock knot. The suture had disappeared after 8 weeks in 95% of the eyes. Two months after operation the visual acuity, the power of corneal astigmatism and astigmatic orientation remained unchanged in both the Vicryl and the Dexon sutured group. This provided effectuation of early full prescription of glasses. Most complications in this material were suture independent and appeared during the early postoperative period. In only one eye inadequate wound closure was noticed. Shallow anterior chamber and hypotonia of short duration occurred in 5 eyes. Four of these patients developed corneal dystrophy. In the Vicryl sutured group suture reactions took place in 87% of the eyes. With dexon suture no such reaction appeared. The use of absorbable sutures in corneolimbal incision technique implies several surgical advantages and is seemingly safe.