Assessment and treatment of the acutely ill patient have improved by introducing systematic assessment and accelerated protocols for specific patient groups. Triage systems are widely used, but few studies have investigated the ability of the triage systems in predicting outcome in the unselected acute population. The aim of this study was to quantify the association between the main component of the Hillerød Acute Process Triage (HAPT) system and the outcome measures; Admission to Intensive Care Unit (ICU) and in-hospital mortality, and to identify the vital signs, scored and categorized at admission, that are most strongly associated with the outcome measures.
The HAPT system is a minor modification of the Swedish Adaptive Process Triage (ADAPT) and ranks patients into five level colour-coded triage categories. Each patient is assigned a triage category for the two main descriptors; vital signs, T(vitals), and presenting complaint, T(complaint). The more urgent of the two determines the final triage category, T(final). We retrieved 6279 unique adult patients admitted through the Emergency Department (ED) from the Acute Admission Database. We performed regression analysis to evaluate the association between the covariates and the outcome measures.
The covariates, T(vitals), T(complaint) and T(final) were all significantly associated with ICU admission and in-hospital mortality, the odds increasing with the urgency of the triage category. The vital signs best predicting in-hospital mortality were saturation of peripheral oxygen (SpO(2)), respiratory rate (RR), systolic blood pressure (BP) and Glasgow Coma Score (GCS). Not only the type, but also the number of abnormal vital signs, were predictive for adverse outcome. The presenting complaints associated with the highest in-hospital mortality were 'dyspnoea' (11.5%) and 'altered level of consciousness' (10.6%). More than half of the patients had a T(complaint) more urgent than T(vitals), the opposite was true in just 6% of the patients.
The HAPT system is valid in terms of predicting in-hospital mortality and ICU admission in the adult acute population. Abnormal vital signs are strongly associated with adverse outcome, while including the presenting complaint in the triage model may result in over-triage.
Aclarubicin plus cytosine arabinoside versus daunorubicin plus cytosine arabinoside in previously untreated patients with acute myeloid leukemia: a Danish national phase III trial. The Danish Society of Hematology Study Group on AML, Denmark.
A regimen of aclarubicin (ACR) of 75 mg/m2 daily for 3 days plus a continuous intravenous infusion of cytosine arabinoside (ara-C) of 100 mg/m2 per day for 7 days was compared with daunorubicin (DNR) 45 mg/m2/day for 3 days plus ara-C for 7 days as first-line chemotherapy of de novo acute myeloid leukemia (AML) in a randomized, nationwide Danish study. A total of 180 patients aged between 17 and 65 years were entered onto the protocol. Patients who achieved complete remission (CR) were given five courses of intensive consolidation therapy consisting of two courses of high dose ara-C, two courses of amsacrine plus etoposide, and one course of DNR plus ara-C. Of 174 evaluable patients, 99 achieved CR. The rate of CR was significantly higher on ACR plus ara-C than on DNR plus ara-C [66% versus 50% (p = 0.043)] and decreased significantly with increasing age. The hematological toxicity was identical for the two regimens. A total of 83 patients entered consolidation therapy. At 4 years, 37% of patients with CR following ACR were still in remission compared with 33% following DNR (p = 0.48), and the total survival at 4 years was 29% versus 20% (p = 0.26). The duration of remission and total survival both decreased with increasing age. ACR plus ara-C seem at least as good or better than DNR plus ara-C as first-line chemotherapy of AML.
BACKGROUND AND PURPOSE: Stroke represents a major economic challenge to society. The direct cost of stroke is largely determined by the duration of hospital stay, but internationally applicable estimates of the direct cost of acute stroke care and rehabilitation on cost-efficient stroke units are not available. Information regarding social and medical factors influencing the length of hospital stay (LOHS) and thereby cost is needed to direct cost-reducing efforts. METHODS: We determined the direct cost of stroke in the prospective, consecutive, and community-based stroke population of the Copenhagen Stroke Study by measuring the total LOHS in the 1197 acute stroke patients included in the study. All patients had all their acute care and rehabilitation on a dedicated stroke unit. Neurological impairment was measured by the Scandinavian Stroke Scale. Local nonmedical factors affecting the LOHS, such as waiting time for discharge to a nursing home after completed rehabilitation, were accounted for in the analysis. The influence of social and medical factors on the LOHS was analyzed in a multiple linear regression model. RESULTS: The average LOHS was 27.1 days (SD, 44.1; range, 1 to 193), corresponding to a direct cost of $12.150 per patient including all acute care and rehabilitation. The LOHS increased with increasing stroke severity (6 days per 10-point increase in severity; P
We use the additive risk model of Aalen (Aalen, 1980) as a model for the rate of a counting process. Rather than specifying the intensity, that is the instantaneous probability of an event conditional on the entire history of the relevant covariates and counting processes, we present a model for the rate function, i.e., the instantaneous probability of an event conditional on only a selected set of covariates. When the rate function for the counting process is of Aalen form we show that the usual Aalen estimator can be used and gives almost unbiased estimates. The usual martingale based variance estimator is incorrect and an alternative estimator should be used. We also consider the semi-parametric version of the Aalen model as a rate model (McKeague and Sasieni, 1994) and show that the standard errors that are computed based on an assumption of intensities are incorrect and give a different estimator. Finally, we introduce and implement a test-statistic for the hypothesis of a time-constant effect in both the non-parametric and semi-parametric model. A small simulation study was performed to evaluate the performance of the new estimator of the standard error.
To determine the adherence to the national guidelines for start of highly active antiretroviral treatment (HAART) in HIV infected patients.
We used a Danish nationwide cohort of HIV infected patients to calculate the fraction of patients who in the period 1997-2006 started HAART according to the guidelines from The Danish Society of Infectious Diseases. We used Kaplan-Meier tables to estimate time from fulfilling the criteria for start of HAART to initiation of the treatment. Cox regression and logistic regression was used to identify risk factors for delayed initiation of treatment and chance of being included in clinical trials.
The study included 3223 patients, 74% of whom initiated HAART in the study period. Ninety-four% fulfilled the criteria for start of HAART, with minor differences over calendar periods. Ninety-four% initiated a recommended regimen or were included in a clinical trial. Intravenous drug use predicted initiation of a non-recommended regimen and delay in start of HAART, while non-Caucasians were less likely to be included in clinical trials.
In a Western world setting, the adherence to national guidelines for start of HAART can be high. We suggest that simplicity of the guidelines, centralization of treatment and involvement of local clinicians in the development of guidelines are of major importance for high adherence to treatment guidelines.
Cites: Stud Health Technol Inform. 2008;136:339-4418487754
OBJECTIVES. To investigate the relationship between gonadal function, insulin and psychosocial stress in middle-aged men. DESIGN. A population-based, cross-sectional, observational study. SETTING. Glostrup Hospital, Copenhagen, Denmark. SUBJECTS. Four hundred and thirty-nine males, all aged 51 years. MAIN VARIABLES. Body-mass index (BMI), waist-to-hip ratio (WHR), insulin, C-peptide, free testosterone, luteinizing hormone (LH), lipids, fibrinogen, lung function tests (FVC, FEV1, PEF), blood pressure, a self-administered questionnaire with questions on psychosocial variables, lifestyle and self-rated health. RESULTS. Free testosterone correlated inversely (P
The aims of the study were to evaluate if the front-door concentrations of benzene, toluene, and xylenes can be used to classify the personal exposures of Danish children and to identify factors that affect their personal exposure. Average concentrations were measured over 1 week with diffusive samplers, and the personal exposures of 98 children and the concentrations outside the front doors of their homes were measured simultaneously. Time and activity patterns were noted in diaries. The front-door concentrations were significantly higher in Copenhagen than in rural areas (all P
Analysis of the treatment effect on recurrent bleeding and death in patients with cirrhosis and esophageal varices: multistage competing-risks model compared to conventional methods. The Copenhagen Esophageal Varices Sclerotherapy Project.
Multiple recurrences of bleeding with high mortality in cirrhosis with esophageal varices have been inadequately analyzed in previous trials. We propose analysis by the multistage competing-risks model, specifying the effect on overall mortality as an effect on mortality during bleeding, rate of cessation of bleeding, mortality rate without bleeding, and rate of rebleeding.
The Copenhagen Esophageal Varices Project enrolled patients after first bleeding and randomized 94 to usual treatment and 93 to sclerotherapy as supplement. During 9-52 months of follow-up, rebleeding occurred in 49 and 42, and death in 68 and 60 patients, respectively. The proportional hazards regression model (Cox model) was used for reanalysis both by the multistage competing-risks model and by conventional analysis for overall mortality and rate of first rebleeding. In the multistage model, time zero was at entry to any new disease stage, of which the first four were analyzed - two bleeding stages and two bleeding-free stages.
The conventional analysis showed a reduction of overall mortality rate in the sclerotherapy group of borderline significance, but no effect on rate of rebleeding. The multistage model indicated that sclerotherapy reduced the rate of rebleeding late in the disease course, and particularly after the first rebleeding. Rate of cessation of bleeding and mortality rates during bleeding and without bleeding were not affected by sclerotherapy.
Conventional analysis may give misleading conclusions, which might be avoided by applying the multistage model. The effect of sclerotherapy on overall mortality may be ascribed entirely to the reduced rate of rebleeding.
In postmenopausal women, we investigated if the response in bone mineral density (BMD) was associated with the response in the atherogenic lipid profile during hormone replacement therapy.
We performed an exploratory, post-hoc analysis of data from a prospective double-blind placebo-controlled trial. Healthy postmenopausal women were randomised into five groups, each receiving different combinations of 17 beta-estradiol and gestodene or placebo. A total of 133 women completed the study. The study period was 3 years. The response in bone mass was expressed as the percentage change in BMD from baseline calculated by linear regression from semi-annual measurements. The change in lipid profile was evaluated as the average of three mid-cycle and end-cycle values in percentage from baseline in order to account for cyclic changes during sequential hormone therapy.
A significant correlation between the increase in BMD of the spine and hip and forearm with the decrease in serum low density lipoprotein (LDL) and cholesterol was found. Additionally, the decrease in atherogenic lipids correlated significantly with the response in biochemical bone markers for resorption and formation.
In conclusion, our study shows that it is the same women who have a favourable response in BMD as in the lipid-profile during hormone replacement therapy (HRT). The association is most likely driven by a common response in FSH to exogenous estradiol therapy. This indicates that common denominators for the response to HRT exist. Further studies are needed to explore and identify such predictors.