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Background and importance

Crowded emergency departments (EDs) and long waiting times may lead to delayed care for acute conditions and increased mortality in patients leaving without being seen by a physician (LWBS).

Objectives

The aim of this study was to characterize patients LWBS from the ED at a Swedish university hospital and report their mortality.Design, setting, and participantsA cohort study was conducted. Data from electronic medical records of patients LWBS (exposure) were compared with those who stayed through completion of treatment. Data were gathered from 151 228 patients making 363 308 visits to the Uppsala University Hospital ED from 1 January 2010 to 30 June 2017.

Outcome measures and analysis

Short- and long-term mortality of patients LWBS were studied using Cox regression analysis. Sex, age, triage level, arrival mode, length of stay, presenting complaint, crowding, and time of day were assessed as regards effect on the probability of LWBS and as covariates in the mortality analysis.

Results

In our dataset, 9058 patient visits to the ED (2.5% of all ED visits) ended in LWBS. These patients were younger than average and had lower triage levels. No significant difference was found between males and females. The highest rates were seen in patients presenting with a psychiatric disorder (12.8%), victims of physical assault (11.7%), or alcohol/drug withdrawal (9.9%). The likelihood of LWBS was highest in the evening and lowest in the early morning. Short-term mortality at 28 days was not significantly affected by LWBS, but a 34% lower long-term mortality risk was seen for patients LWBS (hazard ratio 0.66, 95% confidence interval 0.45-0.95, P = 0.028) in median follow-up of 3.5 years.

Conclusion

Patients LWBS were younger, had lower triage levels, and more frequently presented with psychiatric or substance use-related complaints. They had lower short- and long-term mortality compared with those who completed treatment. This observation does not imply a causal relationship but highlights differences in patient characteristics.

Akutsjukvård från Ö till Ä är en omfattande kursbok och handbok som stödjer arbete på akutmottagningar med evidensbaserade algoritmer och praktiska riktlinjer för akuta tillstånd.

Boken är skriven av Caroline Hård af Segerstad och Susann J. Järhult och publicerades första gången 2017. Den är på svenska och omfattar 530 sidor med djupgående information om akutsjukvård, riktad till läkarstudenter samt läkare på AT- och ST-nivå som arbetar på akutmottagning. Den är utformad för att fungera som en praktisk vägledning i den nya basspecialiteten akutsjukvård. 

Boken är uppdelad i två huvuddelar:

Del 1: Följer algoritmen ÖABCDE (Överblick, Airway, Breathing, Circulation, Disability, Exposure), som guidar läsaren genom undersökning, akuta åtgärder och diagnostisering av patienter oberoende av ålder, kön eller etnicitet. 

Del 2: Behandlar specifika områden som patientflöde, patientsäkerhet, gynekologi, obstetrik, psykiatri, smärtbehandling och vård av äldre patienter. 

Handbok – Prio 1

Till huvudboken finns en kompakt klinisk handbok, Prio 1, som fokuserar på de mest akuta och väsentliga åtgärderna för Prio 1-patienter. Handboken är fickvänlig och lätt att bära med under kliniskt arbete, vilket gör den praktisk för snabb referens på akutmottagningen.

Pedagogiskt syfte: Boken och handboken säljs ofta som paket och är utformade för att:

Stödja undervisning och kliniskt arbete på akutmottagningar

Ge evidensbaserade algoritmer för riskvärdering och behandling

Fungera som referens för både studenter och yrkesverksamma läkare

Akutsjukvård från Ö till Ä är en omfattande kursbok och handbok som stödjer arbete på akutmottagningar med evidensbaserade algoritmer och praktiska riktlinjer för akuta tillstånd.

Boken är skriven av Caroline Hård af Segerstad och Susann J. Järhult och publicerades första gången 2017. Den är på svenska och omfattar 530 sidor med djupgående information om akutsjukvård, riktad till läkarstudenter samt läkare på AT- och ST-nivå som arbetar på akutmottagning. Den är utformad för att fungera som en praktisk vägledning i den nya basspecialiteten akutsjukvård. 

Boken är uppdelad i två huvuddelar:

Del 1: Följer algoritmen ÖABCDE (Överblick, Airway, Breathing, Circulation, Disability, Exposure), som guidar läsaren genom undersökning, akuta åtgärder och diagnostisering av patienter oberoende av ålder, kön eller etnicitet. 

Del 2: Behandlar specifika områden som patientflöde, patientsäkerhet, gynekologi, obstetrik, psykiatri, smärtbehandling och vård av äldre patienter. 

Handbok – Prio 1

Till huvudboken finns en kompakt klinisk handbok, Prio 1, som fokuserar på de mest akuta och väsentliga åtgärderna för Prio 1-patienter. Handboken är fickvänlig och lätt att bära med under kliniskt arbete, vilket gör den praktisk för snabb referens på akutmottagningen.

Pedagogiskt syfte: Boken och handboken säljs ofta som paket och är utformade för att:

Stödja undervisning och kliniskt arbete på akutmottagningar

Ge evidensbaserade algoritmer för riskvärdering och behandling

Fungera som referens för både studenter och yrkesverksamma läkare

Purpose:

Intracerebral haemorrhage (ICH) is the most devastating form of stroke and a major cause of disability. Clinical trials of individual therapies have failed to definitively establish a specific beneficial treatment. However, clinical trials of introducing care bundles, with multiple therapies provided in parallel, appear to clearly reduce morbidity and mortality. Currently, not enough patients receive these interventions in the acute phase.

Methods:

We convened an expert group to discuss best practices in ICH and to develop recommendations for bundled care that can be delivered in all settings that treat acute ICH, with a focus on European healthcare systems.

Findings:

In this consensus paper, we argue for widespread implementation of formalised care bundles in ICH, including specific metrics for time to treatment and criteria for the consideration of neurosurgical therapy.

Discussion:

There is an extraordinary opportunity to improve clinical care and clinical outcomes in this devastating disease. Substantial evidence already exists for a range of therapies that can and should be implemented now.

The aim was to study discrimination, with a focus on gender and sexual harassment among medical students at Uppsala University in Sweden. A survey was sent via email to all registered medical students in the spring semester of 2020. Data were compared with two previous studies. Questions about gender and sexual harassment were the same as in the study conducted in 2002 and 2013. In addition, the 2020 survey included a question about other grounds of discrimination. Forty percent, that is, 453 out of 1,130 medical students, participated. The proportion of students reporting gender-based discrimination during the preclinical semesters was similar for females and males. During the clinical semesters, significantly more females than males reported gender discrimination (41% vs. 21.5%, p = 0.005) and sexual harassment (22% vs. 5%, p = 0.001). Physicians were the most commonly reported perpetrator. Reports about not being respected had increased from 2% to 20% between 2013 and 2020 among female clinical students. The prevalence of those who experienced several sexually harassing behaviors increased for the female and male clinical students and the female preclinical students. Receiving an unwelcome touch increased from 1% to 7% for the female clinical students. Discrimination due to ethnicity was reported by 36% of the students born in a country other than Sweden compared to 3% of those born in Sweden. Our findings confirm that experiences of different forms of discrimination exist in this medical school, and females and minorities are particularly affected.

Background: Asthma is a common chronic disease presenting with airway symptoms such as wheezing, chest tightness and attacks of breathlessness. Underdiagnosis of asthma is common and correlates to negative outcomes such as a lower quality of life and reduced work capacity. Purpose: This study aims to identify factors for not being diagnosed with asthma if presenting with asthma symptoms. Patients and Methods: A questionnaire was sent to 45,000 subjects (age 16-74 years) in Sweden. Subjects who reported both wheeze and breathlessness and wheeze when not having a cold were defined as having asthma-related symptoms. Data on demographics, educational level, smoking, physical activity, comorbidities, symptoms and asthma were collected. Logistic regression was used to identify risk factors for not being diagnosed with asthma. Results: Of the 25,391 who responded to the survey, 6.2% reported asthma-related symptoms. Of these, 946 had been diagnosed with asthma previously, while 632 had not. Independent risk factors for not being diagnosed with asthma were higher age (OR (95% CI) (2.17 (1.39-3.40))), male sex (1.46 (1.17-1.81)), current smoking (2.92 (2.22-3.84)), low level of education (1.43 (1.01-2.01)), low physical activity (1.36 (1.06-1.74)), and hypertension (1.50 (1.06-2.12)). Conclusion: Men, smokers, older subjects, and those with low educational level or low physical activity are less likely to be diagnosed with asthma despite presenting asthma-related symptoms.

WHAT WE FOUND:Length of stay and time to surgery were significantly reduced after implementation of this admission pathway. Readmission rate was not adversely affected by this change. The protocol also significantly reduced the number of unnecessary body computed tomography imaging studies obtained in this patient population.

CONFOUNDING FACTORS/REAL-LIFE IMPLICATIONS:The results of this study should be interpreted with their retrospective nature in mind. Further, analysis of this admission pathway did not take into consideration patient perspective or cost implications. Finally, the authors recognize that the resources for such an operational shift may only be found in large, tertiary, referral centers.

Optimized specialized care for patients with new single brain masses promotes improved health care outcomes. It may also predictively reduce health care costs and improve patient satisfaction. More research is needed in this field. Limitations to our study included the inherent limitations of a retrospective pre-post design that can make it difficult to separate the effect of a specific intervention from other factors that change over time. In addition, assessment of patient satisfaction, use of diagnostic tests beyond body imaging, and advanced cost analysis could have strengthened this study. Lastly, it should be noted that the applicability of our approach may be limited to major tertiary centers with enough resources to implement such a pathway.

Purpose:To reduce care variation and improve the management of patients with newly identified single brain masses and no history of cancer, we implemented a dedicated admission protocol.

Methods:We reviewed records of 206 patients who presented to our emergency department between January 2010 and May 2016 with a new single brain mass but no history of cancer. Patients admitted before the protocol implementation were designated the pre-implementation group (PRE), and those admitted after implementation were designated the post-implementation group (POST).

Results:Ninety-six patients were in the PRE group and 110 in the POST group. Length of stay for POST patients was significantly shorter than for PRE patients (6 v 7 days, respectively; P = .042), and this effect was more robust after excluding the 66 patients who were discharged to rehabilitation, skilled nursing, or hospice facilities (5 v 7 days, respectively; P = .001). Additional comparison of POST with PRE patients showed that time to surgery was significantly reduced (2.7 v 3.5 days, respectively; P = .006) and that computed tomography scans of the chest, abdomen, and pelvis were reduced (12% v 47%, respectively; P < .001). No difference was found in the 30-day readmission rates. For patients with GBM, there also was no significant difference in time to initiation of chemoradiation or in median overall survival.

Conclusion:Implementation of a specialized admission pathway for patients with a new single brain mass decreased average length of hospital stay and time to surgery and reduced unnecessary diagnostic imaging tests in patients with primary brain tumors.

Introduction: Our goal was to assess whether use of a standardized clinical protocol improves efficiency for patients who present to the emergency department (ED) with symptoms of transient ischemic attack (TIA).

Methods: We performed a structured, retrospective, cohort study at a large, urban, tertiary care academic center. In July 2012 this hospital implemented a standardized protocol for patients with suspected TIA. The protocol selected high-risk patients for admission and low/intermediate-risk patients to an ED observation unit for workup. Recommended workup included brain imaging, vascular imaging, cardiac monitoring, and observation. Patients were included if clinical providers determined the need for workup for TIA. We included consecutive patients presenting during a six-month period prior to protocol implementation, and those presenting between 6-12 months after implementation. Outcomes included ED length of stay (LOS), hospital LOS, use of neuroimaging, and 90-day risk of stroke or TIA.

Results: From 01/2012 to 06/2012, 130 patients were evaluated for TIA symptoms in the ED, and from 01/2013 to 06/2013, 150 patients. The final diagnosis was TIA or stroke in 45% before vs. 41% after (p=0.18). Following the intervention, the inpatient admission rate decreased from 62% to 24% (p<0.001), median ED LOS decreased by 1.2 hours (5.7 to 4.9 hours, p=0.027), and median total hospital LOS from 29.4 hours to 23.1 hours (p=0.019). The proportion of patients receiving head computed tomography (CT) went from 68% to 58% (p=0.087); brain magnetic resonance (MR) imaging from 83% to 88%, (p=0.44) neck CT angiography from 32% to 22% (p=0.039); and neck MR angiography from 61% to 72% (p=0.046). Ninety-day stroke or recurrent TIA among those with final diagnosis of TIA was 3% for both periods.

Conclusion: Implementation of a TIA protocol significantly reduced ED LOS and total hospital LOS.

Cardiovascular risk factors and carotid atherosclerosis relate to blood flow velocity in the brachial artery during induced hyperaemia. This relation proved to be particularly strong when using the hyperaemic systolic to diastolic blood flow velocity (SDFV) ratio. In this study, we further investigated this ratio in relation to the left ventricular (LV) geometry in a cross-sectional analysis. In the Prospective Investigation of the Vasculature in Uppsala Seniors study, 1016 seventy-year-olds participated. Blood flow velocity during hyperaemia of the brachial artery by Doppler was analysed. Echocardiography was performed, allowing analysis of LV geometry, categorised into four different groups: normal, concentric remodelling, concentric and eccentric hypertrophy. The SDFV ratio increased in subjects with concentric LV-remodelling (P 0.006) or LV-hypertrophy (P=0.001), but not in those with eccentric hypertrophy (P=0.12) when compared with the group with normal LV geometry. These associations remained significant after adjustment for gender, blood pressure, blood glucose, body mass index and antihypertensive treatment. The SDFV ratio in the brachial artery was related to concentric geometry of the LV in an elderly population sample, suggesting this new hemodynamic variable as a marker of increased afterload. Future studies have to determine if the SDFV ratio is a powerful predictor of future CV events, in addition to LV geometry.

Background

Systolic to diastolic blood flow velocity (SDFV) ratio in the Brachial artery recently proved to be related to cardiovascular risk and Carotid atherosclerosis. We hypothesized that the SDFV ratio was related to established markers of vascular function and global atherosclerosis. 

Methods

Established markers of endothelial function in forearm resistance vessels, flow-mediated vasodilation and arterial stiffness were assessed in the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study including 1016 individuals aged 70. Whole body magnetic resonance angiography was performed in a random 306 of the participants. Atherosclerotic lesions were summarized in a total atherosclerotic score (TAS). Before and during hyperemia of the Brachial artery, systolic and diastolic blood flow velocities were measured by Doppler.

Results

The SDFV ratio was positively related to endothelium-independent vasodilatation, while inverse relations to flow-mediated dilation, common carotid artery distensibility and the stroke volume to pulse pressure ratio were found. Endothelium-dependent vasodilatation and total peripheral resistance index were not significantly related to the SDFV ratio.

The SDFV ratio (p=0.015) and the blood flow increase during hyperemia (p= 0.020) were both significantly related to TAS after gender adjustment. When adjusted for the Framingham risk score, both the SDFV ratio (p= 0.057) and blood flow increase (p= 0.078) lost somewhat in significance.

Conclusion

The SDFV ratio was related to established markers of both vasodilation and arterial compliance, and to global atherosclerosis. Future larger studies have to evaluate if the SDFV ratio is related to global atherosclerosis independently of traditional risk factors.