Multidimensional versus unidimensional pain scales for the assessment of analgesic requirement in the emergency department: a systematic review.

Pain is a multidimensional experience, potentially rendering unidimensional pain scales inappropriate for assessment. Prior research highlighted their inadequacy as reliable indicators of analgesic requirement. This systematic review aimed to compare multidimensional with unidimensional pain scales in assessing analgesic requirements in the emergency department (ED). Embase, Medline, CINAHL, and PubMed Central were searched to identify ED studies utilizing both unidimensional and multidimensional pain scales. Primary outcome was desire for analgesia. Secondary outcomes were amount of administered analgesia and patient satisfaction. Two independent reviewers screened, assessed quality, and extracted data of eligible studies. We assessed risk of bias with the ROBINS-I tool and provide a descriptive summary. Out of 845 publications, none met primary outcome criteria. Three studies analyzed secondary outcomes. One study compared the multidimensional Defense and Veterans Pain Rating Scale (DVPRS) to the unidimensional Numerical Rating Scale (NRS) for opioid administration. DVPRS identified more patients with moderate instead of severe pain compared to the NRS. Therefore, the DVPRS might lead to a potential reduction in opioid administration for individuals who do not require it. Two studies assessing patient satisfaction favored the short forms (SF) of the Brief Pain Inventory (BPI) and McGill Pain Questionnaire (MPQ) over the Visual Analogue Scale (VAS) and the NRS. Limited heterogenous literature suggests that in the ED, a multidimensional pain scale (DVPRS), may better discriminate moderate and severe pain compared to a unidimensional pain scale (NRS). This potentially impacts analgesia, particularly when analgesic interventions rely on pain scores. Patients might prefer multidimensional pain scales (BPI-SF, MPQ-SF) over NRS or VAS for assessing their pain experience.

Role of visceral fat on postoperative complications and relapse in patients with Crohn's disease after ileocecal resection: Is it overrated?

INTRODUCTION: The role of visceral fat in disease development, particularly in Crohn´s disease (CD), is significant. However, its preoperative prognostic value for postoperative complications and CD relapse after ileocecal resection (ICR) remains unknown. This study aims to assess the predictive potential of preoperatively measured visceral and subcutaneous fat in postoperative complications and CD recurrence using magnetic resonance imaging (MRI). The primary endpoint was postoperative anastomotic leakage of the ileocolonic anastomosis, with secondary endpoints evaluating postoperative complications according to the Clavien Dindo classification and CD recurrence at the anastomosis. METHODS: We conducted a retrospective analysis of 347 CD patients who underwent ICR at our tertiary referral center between 2010 and 2020. We included 223 patients with high-quality preoperative MRI scans, recording demographics, postoperative outcomes, and CD recurrence rates at the anastomosis. To assess adipose tissue distribution, we measured total fat area (TFA), visceral fat area (VFA), subcutaneous fat area (SFA), and abdominal circumference (AC) at the lumbar 3 (L3) level using MRI cross-sectional images. Ratios of these values were calculated. RESULTS: None of the radiological variables showed an association with anastomotic leakage (TFA p = 0.932, VFA p = 0.982, SFA p = 0.951, SFA/TFA p = 0.422, VFA/TFA p = 0.422), postoperative complications, or CD recurrence (TFA p = 0.264, VFA p = 0.916, SFA p = 0.103, SFA/TFA p = 0.059, VFA/TFA p = 0.059). CONCLUSIONS: Radiological visceral obesity variables were associated with postoperative outcomes or clinical recurrence in CD patients undergoing ICR. Preoperative measurement of visceral fat measurement is not specific for predicting postoperative complications or CD relapse.

Can acutely ill patients predict their outcomes? A scoping review.

INTRODUCTION: The full impact of an acute illness on subsequent health is seldom explicitly discussed with patients. Patients' estimates of their likely prognosis have been explored in chronic care settings and can contribute to the improvement of clinical outcomes and patient satisfaction. This scoping review aimed to identify studies of acutely ill patients' estimates of their outcomes and potential benefits for their care. METHODS: A search was conducted in PubMed, Embase, Web of Science and Google Scholar, using terms related to prognostication and acute care. After removal of duplicates, all articles were assessed for relevance by six investigator pairs; disagreements were resolved by a third investigator. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Our search identified 3265 articles, of which 10 were included. The methods of assessing self-prognostication were very heterogeneous. Patients seem to be able to predict their need for hospital admission in certain settings, but not their length of stay. The severity of their symptoms and the burden of their disease are often overestimated or underestimated by patients. Patients with severe health conditions and their relatives tend to be overoptimistic about the likely outcome. CONCLUSION: The understanding of acutely ill patients of their likely outcomes and benefits of treatment has not been adequately studied and is a major knowledge gap. Limited published literature suggests patients may be able to predict their need for hospital admission. Illness perception may influence help-seeking behaviour, speed of recovery and subsequent quality of life. Knowledge of patients' self-prognosis may enhance communication between patients and their physicians, which improves patient-centred care.

Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review.

BACKGROUND: Frailty is a common condition present in older Emergency Department (ED) patients that is associated with poor health outcomes. The Clinical Frailty Scale (CFS) is a tool that measures frailty on a scale from 1 (very fit) to 9 (terminally ill). The goal of this scoping review was to describe current use of the CFS in emergency medicine and to identify gaps in research. METHODS: We performed a systemic literature search to identify original research that used the CFS in emergency medicine. Several databases were searched from January 2005 to July 2021. Two independent reviewers completed screening, full text review and data abstraction, with a focus on study characteristics, CFS assessment (evaluators, timing and purpose), study outcomes and statistical methods. RESULTS: A total of 4818 unique citations were identified; 34 studies were included in the final analysis. Among them, 76% were published after 2018, mainly in Europe or North America (79%). Only two assessed CFS in the pre-hospital setting. The nine-point scale was used in 74% of the studies, and patient consent was required in 69% of them. The main reason to use CFS was as a main exposure (44%), a potential predictor (15%) or an outcome (15%). The most frequently studied outcomes were mortality and hospital admission. CONCLUSION: The use of CFS in emergency medicine research is drastically increasing. However, the reporting is not optimal and should be more standardized. Studies evaluating the impact of frailty assessment in the ED are needed. REGISTRATION: https://doi.org/10.17605/OSF.IO/W2F8N.

Insights Into Adolescents' Substance Use in a Low-Middle-Income Country During the COVID-19 Pandemic.

Introduction: The COVID-19 pandemic and its lockdown have been a significant life event for many individuals, particularly adolescents. The immense psychological pressure could drive risky behavior, e.g., substance use, while lockdown might lead to decreased use. This study aimed to observe the change in substance use among adolescents in Indonesia and the moderating variables to consumption during the COVID-19 lockdown period. Methods: This study utilized an online survey from April 28, 2020 to June 30, 2020. The hyperlink was disseminated to school administrators and parenting groups through social media and direct messages. A total of 2,932 adolescents (17.4 ± 2.24 and 78.7% females) submitted valid responses. The survey was comprised of a sociodemographic section, substance use details, and psychometric sections, including the Alcohol Use Disorders Identification Test (AUDIT), Cigarette Dependence Scale 12 (CDS-12), Pittsburgh Sleep Quality Index (PSQI), and Strength and Difficulties Questionnaire (SDQ). Results: Overall, adolescent alcohol use during the pandemic was 5.1%, cigarette smoking was 3.1%, and drug consumption was 0.4%. Over half (53.4%) of alcohol drinkers reported increased drinking, and 33.1% had harmful or dependence-like drinking behavior; in contrast, 44.4% of adolescent smokers disclosed reduced cigarette consumption. Around 37.8% of the drug users indicated increased use. During the pandemic, adolescent alcohol use was associated with higher education [adjusted odds ratio (AOR) = 2.67, 95% confidence interval (CI) 1.02-4.86, p = 0.04], higher AUDIT scores (AOR = 1.33, 95% CI 1.25-1.42, p < 0.001), and very low prosocial behavior (AOR = 2.46, 95% CI 1.52-3.88, p < 0.001). Cigarette smoking was correlated with male sex (AOR = 9.56, 95% CI 5.64-16.62, p < 0.001), age (AOR = 1.40, 95% CI 1.14-1.75, p < 0.001), and higher CDS score (AOR = 1.17, 95% CI 1.13-1.20, p < 0.001). Conclusions: Rates of adolescent substance use were significant, with sizeable proportions reporting higher usage. This appeared to occur predominantly in specific demographics and those with a lower protective psychosocial attribute, i.e., prosocial behavior, during the lockdown. These findings should urge the strengthening of adolescent addiction care during and after the pandemic.

Implications of COVID-19 and Lockdown on Internet Addiction Among Adolescents: Data From a Developing Country.

Introduction: Physical distancing policy during coronavirus disease 2019 (COVID-19) pandemic requires adolescents to spend most of their time at home, thus increasing Internet use duration. Limited social interaction with their peers may lead to loneliness and an increased risk of mental health among adolescents. This study aimed to assess the prevalence of Internet addiction (IA) among adolescents and analyze the influence of psychosocial factors toward the heightened risk of IA during the COVID-19 pandemic. Methods: An online survey comprising sociodemographic questionnaire, Internet Addiction Diagnostic Questionnaire (KDAI), Strengths and Difficulties Questionnaire (SDQ), and Pittsburgh Sleep Quality Index (PSQI) was distributed. Overall, a total of 2,932 adolescents (mean age, 17.38 ± 2.24 years old; female, 78.7%), originating from 33 of 34 provinces in Indonesia, completed the survey. Results: The point prevalence of IA among Indonesian adolescents during the COVID-19 outbreak was 19.3%. Increased Internet use duration, internalization, externalization, low prosocial behavior, and sleep disturbances were found as risk factors of IA, either directly or as mediating variables. Physical distancing, large-scale social restriction (PSBB), and health status were not correlated to IA. Discussion: Physical distancing was not established as a risk of IA. This could be due to other psychological factors such as internalization, externalization, prosocial, and sleep problems that had correlations to IA occurrence among adolescents in the COVID-19 pandemic. Sleep impairment might have resulted from the emotional and behavioral issues and directly contributed to IA development. Conclusion: The present study found the prevalence of IA among Indonesian adolescents to be higher than the adult during the COVID-19 pandemic. Several psychological measures were indicated to increase the risk of IA, while physical distancing did not elevate the risk. Thus, remote schooling is preferable in Indonesia along with proper parental supervision to minimize Internet use for entertainment purposes.

Anxiety and Its Associated Factors During the Initial Phase of the COVID-19 Pandemic in Indonesia.

Introduction: Coronavirus disease 2019 (COVID-19) is caused by a novel coronavirus which has not been identified previously in humans. The disease leads to respiratory problems, systemic disorders, and death. To stop the virus transmission, physical distancing was strongly implemented, including working and school from home (WFH & SFH). The limitation altered daily routines and needs advanced to adapt. Many have felt uncomfortable and this could have triggered anxiety symptoms. This study aimed to evaluate the proportion of significant anxiety symptoms and its association with COVID-19-related situations in an Indonesian context during the initial months of the pandemic. Methods: An online community survey was distributed through social media and communication platforms, mainly WhatsApp, targeting people >18 years old in Indonesia. Anxiety symptoms were assessed using Generalized Anxiety Disorder-7 (Indonesian Version). Demographical data and information on social situation related to the COVID-19 pandemic were collected. The proportion of clinically significant anxiety symptoms was calculated and the association with demographic and social factors was assessed using chi square test (χ2) and logistic regression for multivariate analysis. Results: Out of 1215 subjects that completed the survey, 20.2% (n = 245) exhibited significant anxiety symptoms. Several factors, such as age (AOR = 0.933 CI 95% = 0.907-0.96), sex (AOR = 1.612 CI 95% = 1.097-2.369), medical workers (AOR = 0.209 CI 95% = 0.061-0.721), suspected case of COVID-19 (AOR = 1.786 CI 95% = 1.001-3.186), satisfaction level of family support (AOR = 3.052 CI 95% = 1.883-4.946), and satisfaction level of co-workers (AOR = 2.523 CI 95% = 1.395-4.562), were associated with anxiety. Conclusion: One out of five Indonesian people could have suffered from anxiety during the COVID-19 pandemic. The riskiest group being young females, people who had suspected cases of COVID-19, and those with less satisfying social support. Nevertheless, health workers were found to have a lesser risk of developing anxiety. Accessible information and healthcare, social connection, supportive environment, and mental health surveillance are important to prevent bigger psychiatric problems post-pandemic.

Emergency department management of older people living with frailty: a guide for emergency practitioners.

Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.

Internet addiction in adolescents: Development and validation of Internet Addiction Diagnostic Questionnaire (KDAI).

Internet addiction (IA) is an emerging behavioral problem that constitutes a major health threat to vulnerable populations, including adolescents. However, there is a paucity of IA screening tools specifically designed for adolescents, especially in Indonesia. Therefore, the current study developed and validated the IA Diagnostic Questionnaire (KDAI) in adolescents while acknowledging local cultural influences. The KDAI was conceived through extensive literature reviews, expert discussions based on Delphi methods, a face validity study, focus group discussion (N = 31) for initial reliability testing, and a recruited pilot study (N = 385) and main study (N = 643) for exploratory and confirmatory factor analyses, respectively. The multi-sample analyses demonstrated that the KDAI model with the best fit and reliability comprised a seven-factor structure, including withdrawal, loss of control, increase of priority, negative consequences, mood modification, salience, and impairment. These factors were scrutinized against domains of IA Test, and concurrent validity was ascertained. Subsequently, a receiver operating characteristic curve and area under the curve determined a cutoff score of 108 to discern adolescents with IA. Taken together, the KDAI displayed excellent psychometric indices and sensitivity as a screening tool for IA in adolescents.

Alcohol- and Cigarette-Use Related Behaviors During Quarantine and Physical Distancing Amid COVID-19 in Indonesia.

Background: In light of the coronavirus disease 2019 (COVID-19) pandemic, Indonesia implemented large-scale social restrictions (pembatasan sosial berskala besar/PSBB) to combat the spread of COVID-19, which might influence addictive behaviors. The current study aimed to explore the fluctuation of substance use during the pandemic and association of physical distancing and related factors toward consumption of alcohol and cigarettes. Method: An online survey was conducted from April 28 to June 1, 2020. Data regarding sociodemographic information, physical distancing profile, alcohol and cigarette usages, Alcohol Use Disorders Identification Test (AUDIT), Cigarette Dependence Scale (CDS), Symptom Checklist-90, and Pittsburg Sleep Quality Index (PSQI) were collected. A total of 4,584 respondents from all 34 provinces in Indonesia completed the survey. Data were summarized descriptively and analyzed using chi-square, ANOVA, and multinomial regression on SPSS 23.0 for Windows. Results: This study found that during the COVID-19 pandemic in Indonesia alcohol consumption was 9.50% and daily cigarette smoking was 20.3%. Around 44.5% and 47.6% of respondents reported stable alcohol consumption and cigarette consumption, respectively. The mean AUDIT score was 3.52 ± 4.66 and the mean CDS score was 24.73 ± 8.86. Physical distancing was not correlated to any substance use changes. Increased alcohol consumption was negatively correlated with being unmarried and positively correlated with a higher PSQI score. Decreased alcohol use positively correlated with living in PSBB-implementing provinces and higher AUDIT scores when compared to stable alcohol drinking. Increased cigarette smoking was positively correlated with being male, unmarried, and higher CDS scores. Reduced cigarette smoking was negatively correlated with living in provinces implementing PSBB, higher CDS scores, and phobic anxiety, hostility, and psychoticism subscales of SCL-90. Discussion and Conclusion: The prevalence of alcohol and cigarette consumption changes showed a similar trend with other available studies in other countries. This study established that substance use was mainly sustained with a smaller proportion of respondents amplifying their substance usages. The changes were correlated with PSBB policy but not the practice of physical distancing. Psychiatry and addiction services in Indonesia should be strengthened to cope with the increased burden of psychological distress. Future studies should conduct more comparisons to determine whether the overall rising intensity of consumption was maintained post-pandemic and delineate acute psychopathologies' effects on substance use.

Accuracy of plain radiography in detecting fractures in older individuals after low-energy falls: current evidence.

BACKGROUND: Older individuals sustaining low-energy falls (LEF) and presenting to the emergency department (ED) demand straightforward diagnostic measures for injury detection. Plain radiography (XR) series for diagnosis of fall-related injuries are standard of care, but frequently subsequent CT examination is required for diagnostic assurance. A systematic database search of diagnostic accuracy of XR for detection of fractures in older LEF patients was performed. METHODS: We searched PubMed, Embase, Cochrane Library, WHO International Clinical Trial Platform, and Clinical trials.gov databases from inception to January 2020 for studies including older patients (≥65 years) with LEF and obtaining CT examination and XR of the skeleton in an ED setting. RESULTS: From 8944 references screened, 11 studies met the criteria for inclusion. Performance of XR for detection of fractures of the pelvic ring and hip was analyzed in nine studies, two studies investigated XR performance to detect rib fractures, and two studies compared diagnostic accuracy of thoracolumbar spine XR. Sensitivity estimates ranged from 10% to 58% and specificity estimates from 55% to 100%. Clinical and statistical heterogeneity was significant among included studies, with an overall considerable risk of bias. DISCUSSION: High-quality evidence on accurate imaging strategies in older patients with LEF is lacking to date. XR is missing a reasonable amount of fractures of the pelvic ring, rib cage, and thoracic and lumbar spine. However, the utility of first-line CT imaging and the benefit of diagnosing every fracture is unknown, demanding high-quality prospective trials considering patient-oriented outcome as well.

The Impact of Physical Distancing and Associated Factors Towards Internet Addiction Among Adults in Indonesia During COVID-19 Pandemic: A Nationwide Web-Based Study.

INTRODUCTION: Physical distancing has encouraged the public to utilize the Internet for virtually all daily activities during the COVID-19 pandemic. This study aimed to assess the impact of COVID-19 on Internet addiction (IA) prevalence and analyzed the correlated factors during quarantine and pandemic. METHODS: An online survey was generated, comprising of a sociodemographic section, Internet Addiction Diagnostic Questionnaire (KDAI), Symptoms Checklist-90, and Pittsburgh Sleep Quality Index. The hyperlink was disseminated through social media, companies, and universities. Overall, 4,734 adults, (mean age 31.84 ± 7.73 years old and 55.2% males) representing all 34 provinces of Indonesia, gave valid responses. RESULTS: Point prevalence of IA during the COVID-19 pandemic was 14.4% in Indonesian adults. Online duration increased by 52% compared to before the pandemic. Physical distancing was not established as a risk of IA. Increased daily online duration, specific motivations, types of application, and having confirmed/suspected COVID-19 cases within the household were predictive of IA. All subscales of SCL-90 and PSQI were higher in the group with positive/suspect cases of COVID-19 within households and were correlated to higher scores of IA. DISCUSSION: Physical distancing alone was not associated with an increased risk of IA. The prevalence of IA during COVID-19 was higher than the previously proposed rate among Indonesian adults, which might be related to digital activities associated with COVID-19 and the popularity of virtual socializing. Furthermore, psychopathologies and sleep disruptions were related to IA occurrences and especially prevalent in groups with proximity to COVID-19. Fear of COVID-19 contraction and rampant misinformation of COVID-19 probably contributed to these factors, which potentially harbor long-term consequences. CONCLUSION: The current study demonstrated a high point prevalence of IA and identified several preventable factors predictive of IA during home-quarantine and COVID-19, especially in adults with confirmed/suspected COVID-19 cases within the household. However, physical distancing did not increase the odds of IA. Public health agencies should maintain physical distancing advisory while providing adaptive psychiatric education and service.

Prescription drug misuse in adolescents and young adults: an emerging issue as a health problem.

INTRODUCTION: In recent years, prescription drug misuse has become a common issue among adolescents and young adults in many countries, with, for example, a lifetime prevalence of 12% among individuals aged 12-17 in 2017 in United States. PURPOSE OF REVIEW: To summarize recently published studies about prescription drug misuse among adolescent and young adults. RECENT FINDINGS: Prescription drug misuse has many definitions, one being any medication taken in a way other than prescribed, whether related to dosage or manner of usage. Among adolescents, it has a relationship with illicit drug use, decline in academic performance, future delinquency, and mental problems. Individual predisposing factors include identity crisis and role confusion, and there are also environmental influences. Preventive approaches include the use of monitoring systems. Management involves initial assessment and treatment, which largely focuses on behavioural interventions. SUMMARY: Further understanding of risk and protective factors, co-occurring issues, and treatment can help prevent and reduce the prevalence of prescription drug misuse. Collaboration among government, clinicians, and patients is urged to combat this growing issue.

Sustained plasma hepcidin suppression and iron elevation by Anticalin-derived hepcidin antagonist in cynomolgus monkey.

BACKGROUND AND PURPOSE: Anaemia of chronic disease (ACD) has been linked to iron-restricted erythropoiesis imposed by high circulating levels of hepcidin, a 25 amino acid hepatocyte-derived peptide that controls systemic iron homeostasis. Here, we report the engineering of the human lipocalin-derived, small protein-based anticalin PRS-080 hepcidin antagonist with high affinity and selectivity. EXPERIMENTAL APPROACH: Anticalin- and hepcidin-specific pharmacokinetic (PK)/pharmacodynamic modelling (PD) was used to design and select the suitable drug candidate based on t1/2 extension and duration of hepcidin suppression. The development of a novel free hepcidin assay enabled accurate analysis of bioactive hepcidin suppression and elucidation of the observed plasma iron levels after PRS-080-PEG30 administration in vivo. KEY RESULTS: PRS-080 had a hepcidin-binding affinity of 0.07 nM and, after coupling to 30 kD PEG (PRS-080-PEG30), a t1/2 of 43 h in cynomolgus monkeys. Dose-dependent iron mobilization and hepcidin suppression were observed after a single i.v. dose of PRS-080-PEG30 in cynomolgus monkeys. Importantly, in these animals, suppression of free hepcidin and subsequent plasma iron elevation were sustained during repeated s.c. dosing. After repeated dosing and followed by a treatment-free interval, all iron parameters returned to pre-dose values. CONCLUSIONS AND IMPLICATIONS: In conclusion, we developed a dose-dependent and safe approach for the direct suppression of hepcidin, resulting in prolonged iron mobilization to alleviate iron-restricted erythropoiesis that can address the root cause of ACD. PRS-080-PEG30 is currently in early clinical development.

Risk of adverse outcome in patients referred by emergency medical services in Switzerland.

AIMS OF THE STUDY: Comparison of outcomes between different emergency medical services (EMS) is difficult and lacking in Switzerland. Therefore, knowledge about the inherent risks of EMS-referred patients is important. Targeted interventions may benefit these patients by optimising resource allocation. We therefore aimed to study outcomes in EMS-referred patients presenting to a Swiss emergency department (ED). METHODS: Prospective observational study in all patients presenting to the ED of Basel University Hospital. Mode of referral was recorded (EMS or other). Univariate and multivariate linear, Poisson and logistic regression models were used. Crude and age/gender adjusted associations between mode of referral and outcomes were calculated. Outcomes were shown for admission, length of stay (LOS), in-hospital, and 1-year mortality. RESULTS: Of 5634 patients presenting in the inclusion period, 4703 were screened, 4544 were included and 4287 were followed up for 365 days. Associations between EMS referral and several adverse outcomes were found and expressed as odds ratios (ORs) and geometric mean ratios (GMRs): hospital admission (OR 3.8, 95% CI 3.2-4.5; p <0.001), intensive care unit (ICU) admission (OR 4.2, 95% CI 3.2-5.5, p <0.001), ED-LOS (GMR 1.2, 95% CI 1.1-1.2; p <0.001), in-hospital mortality (OR 6.4, 95% CI 2.9-15.6; p <0.001) and 1-year mortality (OR 2.3, 95% CI 1.7-3.0; p <0.001). CONCLUSION: Patients referred by EMS have higher odds of admission to hospital and ICU, a longer ED LOS, and higher short- and long-term mortalities than the general ED population.

[Emergency Triage. An Overview]. / Bedeutung der Triage in der klinischen Notfallmedizin.

In emergency departments, patients present with different severities of diseases and traumatic injuries. However, patients with severe and life-threatening conditions compete for the same resources such as personal and structure. As a general rule, each patient should receive immediate diagnostic and treatment, independent of his or her severity of disease or traumatic injury. However, an unexpected number of patients presenting to the emergency department at the same time may exceed available resources. Thus, waiting times will occur and management of patients may be impeded. As a consequence, patients with diseases or traumatic injuries with a need for time-critical management, have to be detected at the time of presentation. After categorization, patients have to be prioritized and guided to the correct place of treatment ("triage"). Starting in Australia and the United States, nurse-driven triage systems have been introduced in the emergency departments. Aim of triage is to correctly identify at increased risk of death and guide them to rapid and correct treatment. In Germany, two five-level triage systems have been introduced: Manchester Triage System (MTS) and Emergency Severity Index (ESI). We give an overview of these risk assessment tools and discuss pros and cons. In addition, new options such as "team triage" and a combination with "Early Warning Scores" are reported. In summary, nurse-driven triage is an instrument to improve patient safety in emergency medicine. A structured and systematic triage of patients using validated triage assessment tools are recommended from national and international societies of emergency medicine. Therefore, nurse-driven triage is also a must in Germany.

Adrenomedullin for Risk Stratification of Emergency Patients With Nonspecific Complaints: An Interventional Multicenter Pilot Study.

Patients with nonspecific complaints (NSC) presenting to the emergency department (ED) are at risk of life-threatening conditions. New stress biomarkers such as the midregional portion of adrenomedullin (MR-proADM) promise to support decision-making. This study tested the following hypotheses: biomarker-assisted disposition of patients with NSC will not increase mortality. Second, discharge from the ED will increase if clinical risk assessment is combined with low MR-proADM levels. Third, inappropriate disposition to a lower level of care will decrease, if clinical assessment is combined with high MR-proADM levels, and fourth that this algorithm is feasible in the ED setting. Prospective, multicenter, randomized, controlled interventional feasibility study with a 30-day follow-up, including patients with NSC. Patients were randomly assigned to either the standard group (decision-making solely based on clinical assessment) or the Novum group (biomarker-assisted). Regarding disposition, patients were assigned to 1 of 3 risk classes: high-risk (admission to hospital), intermediate risk (community geriatric hospital), and low-risk patients (discharge). In the Novum group, in addition to clinical risk assessment, the information of the MR-proADM level was used. Unless there were overruling criteria, patients were transferred or discharged according to the risk assessment. Primary endpoint was 30-day mortality. Secondary endpoints were comparisons of patient disposition and related mortality rates, ED, and hospital length of stay and readmission. The final study cohort consisted of 398 patients (210 in the Standard group and 188 in the Novum group). Overruling, that is, disposition not according to the result of the proposed algorithm occurred in 51 cases. Baseline characteristics between Standard and Novum groups were similar. The mortality rate in the Novum group was 4.3%, as compared to the Standard group mortality of 6.2%, which was not significantly different (intention-to treat analysis). This was confirmed by the perprotocol analysis as well as by sensitivity analysis. For the secondary endpoints, no significant differences were detected. Biomarker-assisted disposition is safe in patients with NSC. Discharge rates did not increase. Feasibility could only partly be shown due to an unexpectedly high overruling rate. Inappropriate disposition to lower levels of care did not change. ClinicalTrials. gov Identifier: NCT00920491.

Discharge Communication in Patients Presenting to the Emergency Department With Chest Pain: Defining the Ideal Content.

In an emergency department (ED), discharge communication represents a crucial step in medical care. In theory, it fosters patient satisfaction and adherence to medication, reduces anxiety, and ultimately promotes better outcomes. In practice, little is known about the extent to which patients receiving discharge information understand their medical condition and are able to memorize and retrieve instructions. Even less is known about the ideal content of these instructions. Focusing on patients with chest pain, we systematically assessed physicians' and patients' informational preferences and created a memory aid to support both the provision of information (physicians) and its retrieval (patients). In an iterative process, physicians of different specialties (N = 47) first chose which of 81 items to include in an ED discharge communication for patients with acute chest pain. A condensed list of 34 items was then presented to 51 such patients to gauge patients' preferences. Patients' and physicians' ratings of importance converged in 32 of the 34 items. Finally, three experts grouped the 34 items into five categories: (1) information on diagnosis; (2) follow-up suggestions; (3) advice on self-care; (4) red flags; and (5) complete treatment, from which we generated the mnemonic acronym "InFARcT." Defining and structuring the content of discharge information seems especially important for ED physicians and patients, as stress and time constraints jeopardize effective communication in this context. Chest pain accounts for up to 10% of all patient presentations in emergency departments (EDs) (Konkelberg & Esterman, 2003). The majority of these patients will usually be discharged within hours, after exclusion of serious conditions such as myocardial infarction (Goodacre et al., 2011). A comprehensive workup of low- to intermediate-risk patients is not feasible in the ED (Reichlin et al., 2009). Yet many of these patients go on to suffer from repeated episodes of chest pain, associated with anxiety and uncertainty about diagnosis and outcome (Jones & Mountain, 2009). Effective discharge communication, empowering patients to understand and memorize medical information, should therefore be an integral part of patient care. It is a likely contributor to better outcomes (Bishop, Barlow, Hartley, & William, 1997; Kessels, 2003), higher patient satisfaction (Kessels, 2003), better adherence to medication (Cameron, 1996; Kessels, 2003), more adequate disease management, and reduced anxiety (Galloway et al., 1997; Mossman, Boudioni, & Slevin, 1999).