Esbjerg, Denmark
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Pareek M.,Sydvestjysk Sygehus Esbjerg | Haidl F.,Sygehus Lillebaelt Vejle | Folkestad L.,Sydvestjysk Sygehus Esbjerg | Brabrand M.,Sydvestjysk Sygehus Esbjerg
European Journal of Emergency Medicine | Year: 2014

Objective: The objective of this pilot study was to evaluate whether the use of predefined biochemical profiles as an alternative to individually ordered blood tests by the treating physicians resulted in fewer tests or a lower total cost. Patients and Methods: This was a randomized-controlled trial of 191 adult patients admitted to a medical admission unit. Upon admission, the patients were randomized to have their blood tests determined by either using a predefined profile (used routinely and designed by the department head) or ordered individually by the treating physician. All patients were initially assessed by junior physicians. We compared the number of tests, estimated total cost, and length of stay. Data are presented as median (interquartile range). Differences were compared using the Wilcoxon rank-sum test and Fishers' exact test. Results: Ninety-two patients were men, median age 65 years. Patients randomized to the use of the predefined profile had median 17 (14-22) blood tests drawn and patients randomized to physician discretion had median 17 (12-21) tests drawn (P=0.3). The median total cost of tests in the profile group was 618 DKK (493-803) and the cost in the physician group was 564 DKK (434-812) (P=0.19). Length of stay in the profile group was a median of 4 days (2-6 days) and 2 days (2-6 days) in the physician group (P=0.08). Conclusion: The use of a predefined blood test panel did not significantly affect the number of tests, total cost, or length of stay for acutely admitted medical patients compared with tests ordered at the discretion of the treating physician. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Lauridsen M.M.,Sydvestjysk Sygehus Esbjerg | Frojk J.,Sydvestjysk Sygehus Esbjerg | de Muckadell O.B.S.,University of Southern Denmark | Vilstrup H.,Aarhus University Hospital
Metabolic Brain Disease | Year: 2014

The continuous reaction times (CRT) method describes arousal functions. Reaction time instability in a patient with liver disease indicates covert hepatic encephalopathy (cHE). The effects of sleep deprivation are unknown although cirrhosis patients frequently suffer from sleep disorders. The aim of this study was to determine if sleep deprivation influences the CRT test. Eighteen cirrhosis patients and 27 healthy persons were tested when rested and after one night's sleep deprivation. The patients filled out validated sleep quality questionnaires. Seven patients (38 %) had unstable reaction times (a CRTindex < 1.9) compatible with cHE. In these patients, the wakefulness improved or normalized their reaction speed and CRTindex (p = 0.01). There was no change in the other patients' reaction speed or stability. Seven patients (38 %) reported poor sleep that was not related to their CRT tests before or after the sleep deprivation. In the healthy participants, the sleep deprivation slowed their reaction times by 11 % (p < 0.0001) and in 7 persons (25 %) destabilized them. The acute sleep deprivation normalized or improved the reaction time stability of the patients with a CRTindex below 1.9 and had no effect in the patients with a CRTindex above 1.9. There was no relation between reported sleep quality and reaction time results. Thus, in cirrhosis patients, sleep disturbances do not lead to 'falsely' slowed and unstable reaction times. In contrast, the acute sleep deprivation slowed and destabilized the reaction times of the healthy participants. This may have negative consequences for decision-making. © 2014 Springer Science+Business Media New York.

PubMed | Sydvestjysk Sygehus Esbjerg and Center for Eating Disorder
Type: | Journal: BMJ case reports | Year: 2016

We present the case of a woman aged 48years, diagnosed with anorexia nervosa (AN) at the age of 12. She was admitted to a highly specialised eating disorder facility with distended abdomen, muscular atrophy, ulcerative dermatitis, electrolyte derangements and low serum albumin. Her weight was 53.1kg, corresponding to a body mass index (BMI) of 17.9kg/m

Straede M.,Sydvestjysk Sygehus Esbjerg | Brabrand M.,Sydvestjysk Sygehus Esbjerg | Brabrand M.,University of Southern Denmark
PLoS ONE | Year: 2014

Background: Clinical scores can be of aid to predict early mortality after admission to a medical admission unit. A developed scoring system needs to be externally validated to minimise the risk of the discriminatory power and calibration to be falsely elevated. We performed the present study with the objective of validating the Simple Clinical Score (SCS) and the HOTEL score, two existing risk stratification systems that predict mortality for medical patients based solely on clinical information, but not only vital signs. Methods: Pre-planned prospective observational cohort study. Setting: Danish 460-bed regional teaching hospital. Findings: We included 3046 consecutive patients from 2 October 2008 until 19 February 2009. 26 (0.9%) died within one calendar day and 196 (6.4%) died within 30 days. We calculated SCS for 1080 patients. We found an AUROC of 0.960 (95% confidence interval [CI], 0.932 to 0.988) for 24-hours mortality and 0.826 (95% CI, 0.774-0.879) for 30-day mortality, and goodness-of-fit test, χ2 = 2.68 (10 degrees of freedom), P = 0.998 and χ2 = 4.00, P = 0.947, respectively. We included 1470 patients when calculating the HOTEL score. Discriminatory power (AUROC) was 0.931 (95% CI, 0.901-0.962) for 24-hours mortality and goodness-of-fit test, χ2 = 5.56 (10 degrees of freedom), P = 0.234. Conclusion: We find that both the SCS and HOTEL scores showed an excellent to outstanding ability in identifying patients at high risk of dying with good or acceptable precision. © 2014 Stræde, Brabrand.

Mondrup F.,Sydvestjysk Sygehus Esbjerg | Brabrand M.,Sydvestjysk Sygehus Esbjerg | Folkestad L.,Sydvestjysk Sygehus Esbjerg | Oxlund J.,Sydvestjysk Sygehus Esbjerg | And 4 more authors.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Year: 2011

Background: Interruption in chest compressions during cardiopulmonary resuscitation can be characterized as no flow ratio (NFR) and the importance of minimizing these pauses in chest compression has been highlighted recently. Further, documentation of resuscitation performance has been reported to be insufficient and there is a lack of identification of important issues where future efforts might be beneficial. By implementing in situ simulation we created a model to evaluate resuscitation performance. The aims of the study were to evaluate the feasibility of the applied method, and to examine differences in the resuscitation performance between the first responders and the cardiac arrest team.Methods: A prospective observational study of 16 unannounced simulated cardiopulmonary arrest scenarios was conducted. The participants of the study involved all health care personel on duty who responded to a cardiac arrest. We measured NFR and time to detection of initial rhythm on defibrillator and performed a comparison between the first responders and the cardiac arrest team.Results: Data from 13 out of 16 simulations was used to evaluate the ability of generating resuscitation performance data in simulated cardiac arrest. The defibrillator arrived after median 214 seconds (180-254) and detected initial rhythm after median 311 seconds (283-349). A significant difference in no flow ratio (NFR) was observed between the first responders, median NFR 38% (32-46), and the resuscitation teams, median NFR 25% (19-29), p < 0.001. The difference was significant even after adjusting for pulse and rhythm check and shock delivery.Conclusion: The main finding of this study was a significant difference between the first responders and the cardiac arrest team with the latter performing more adequate cardiopulmonary resuscitation with regards to NFR. Future research should focus on the educational potential for in-situ simulation in terms of improving skills of hospital staff and patient outcome. © 2011 Mondrup et al; licensee BioMed Central Ltd.

Brabrand M.,Sydvestjysk Sygehus Esbjerg | Hosbond S.,University of Southern Denmark | Folkestad L.,Sydvestjysk Sygehus Esbjerg
European Journal of Emergency Medicine | Year: 2011

Objectives The interobserver variability of capillary refill time (CRT) has been questioned. Earlier studies of interobserver variability of CRT have been on a large number of patients but with few observers. The objective of our study was to investigate how a large group of nurses and nurse assistants would grade CRT. Methods We recorded a video of the index finger of six medical patients and these were shown to nurses and nurse assistants. They were asked to record the CRT and whether they found this value to be normal. The data were analyzed using the Fleiss Kappa Coefficient Analysis and graded according to the Landis and Koch correlation. Correlation between the exact numbers was evaluated using interclass correlation. Results Nine nurse assistants and 37 nurses participated. The patients were aged between 44 and 87 years. All but one patient had a systolic blood pressure reading above 130 mmHg. All had arterial blood oxygen saturation above 92% and all but one had normal body temperature. The j value for normality was 0.56. The interclass correlation of measurement of CRT was 0.62. Conclusion This is the largest interobserver study of CRT when looking at the number of observers. We found an only moderate agreement for the exact value of CRT and a moderate agreement for normality. We believe that CRT should be used with caution in clinical practice. European Journal of Emergency Medicine 18:46-49 © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Brabrand M.,Sydvestjysk Sygehus Esbjerg | Knudsen T.,Sydvestjysk Sygehus Esbjerg | Hallas J.,University of Southern Denmark
BMC Health Services Research | Year: 2011

Background: To examine the prognostic significance of fulfilling at least one of the Appropriateness Evaluation Protocol (AEP) criteria. Methods. Prospective observational cohort study at medical admission units at a regional teaching hospital in Denmark. 3,050 consecutively admitted patients were included, median age 66 (IQR: 50-77), 48% female. We assessed the fulfilment of the AEP criteria and mortality data, length of stay, readmissions and co-morbidity. We analyzed the association between day of admission and time of day and compared the opinion of the admitting doctors and nurses on the relevancy of admission. Results: 61.9% of the patients fulfilled the AEP criteria. Patients fulfilling were older (p < 0.001), had a higher in-hospital mortality (p < 0.001), a higher 30-days mortality (p < 0.001), a longer length of stay (p < 0.001), more readmissions within 30 days (p < 0.001) and higher co-morbidity (p < 0.001). There were no association between day of admission and fulfilment of AEP criteria, but significantly fewer patients fulfilled the AEP criteria in the morning hours (p < 0.05). The nurses found 79.1% of the admissions relevant with a sensitivity of 84.8% and a specificity of 30.1% with a Kappa of 0.16. The doctors found 76.2% of the admissions relevant with a sensitivity of 86.4% and a specificity of 40.9% and a Kappa of 0.29. Conclusions: Fulfilment of the AEP criteria adequately reflect increased morbidity and mortality of acutely admitted medical patients. © 2011 Brabrand et al; licensee BioMed Central Ltd.

Brabrand M.,Sydvestjysk Sygehus Esbjerg | Knudsen T.,Sydvestjysk Sygehus Esbjerg | Hallas J.,University of Southern Denmark
BMJ Open | Year: 2013

Objectives: Risk assessment is an important part of emergency patient care. Risk assessment tools based on biochemical data have the advantage that calculation can be automated and results can be easily provided. However, to be used clinically, existing tools have to be validated by independent researchers. This study involved an independent external validation of four risk stratification systems predicting death that rely primarily on biochemical variables. Design: Prospective observational study. Setting: The medical admission unit at a regional teaching hospital in Denmark. Participants: Of 5894 adult (age 15 or above) acutely admitted medical patients, 205 (3.5%) died during admission and 46 died (0.8%) within one calendar day. Interventions: None. Main outcome measures: The main outcome measure was the ability to identify patients at an increased risk of dying (discriminatory power) as area under the receiver-operating characteristic curve (AUROC) and the accuracy of the predicted probability (calibration) using the Hosmer-Lemeshow goodness-offit test. The endpoint was all-cause mortality, defined in accordance with the original manuscripts. Results: Using the original coefficients, all four systems were excellent at identifying patients at increased risk (discriminatory power, AUROC ?0.80). The accuracy was poor (we could assess calibration for two systems, which failed). After recalculation of the coefficients, two systems had improved discriminatory power and two remained unchanged. Calibration failed for one system in the validation cohort. Conclusions: Four biochemical risk stratification systems can risk-stratify the acutely admitted medical patients for mortality with excellent discriminatory power. We could improve the models for use in our setting by recalculating the risk coefficient for the chosen variables.

Folkestad L.,Sydvestjysk Sygehus Esbjerg | Brabrand M.,Sydvestjysk Sygehus Esbjerg | Hallas P.,Sydvestjysk Sygehus Esbjerg
Ugeskrift for Laeger | Year: 2010

INTRODUCTION: It is being debated whether medical staff working at the emergency departments with acute admission services dealing with medical patients have the required professional competence level. It has not previously been documented which doctors see the acute admissions initially at emergency departments, nor how often these patients are debated with an attending doctor. MATERIAL AND METHODS: Questionnaire survey performed January-April 2008, in which medical interns on call at Danish public hospitals completed an online questionnaire. The questions regarded: admissions and follow-up of patients with clinical deterioration at the wards. RESULTS: A total of 88 interns with an average of 2.8 months of experience were included in the survey. Sixty percent of the interns answered that they initially dealt with acute admissions. During the day, patients with clinical deterioration are the responsibility of the physicians doing their rounds at the ward. During evening and night hours, 80% of interns say that patients with clinical deterioration are their responsibility. Fifty four percent of participants care for medical patients as they initially arrive at the emergency room. The interns consult the attending doctors in 6-10% (median interval) of the cases, there is no significant correlation between the experience of physicians and the frequency with which the intern consults with the attending physicians (p = 0,07). Sixty four percent of the physicians had not received any training in emergency medicine. CONCLUSION: Interns with a few months of experience are frequently the first physicians that acute patients see at the Danish internal medicine wards. There is little supervision on how to handle these patients. There is no correlation between the level of experience and the frequency of asking for help from a senior colleague.

Blichfeldt-Lauridsen L.,Sydvestjysk Sygehus Esbjerg | Hansen B.D.,Sydvestjysk Sygehus Esbjerg
Acta Anaesthesiologica Scandinavica | Year: 2012

Myasthenia gravis (MG) is a disease affecting the nicotinic acetylcholine receptor of the post-synaptic membrane of the neuromuscular junction, causing muscle fatigue and weakness. The myasthenic patient can be a challenge to anesthesiologists, and the post-surgical risk of respiratory failure has always been a matter of concern. The incidence and prevalence of MG have been increasing for decades and the disease is underdiagnosed. This makes it important for the anesthesiologist to be aware of possible signs of the disease and to be properly updated on the optimal perioperative anesthesiological management of the myasthenic patient. The review is based on electronic searches on PubMed and a review of the references of the articles. The following keywords were used: myasthenia gravis AND neuromuscular blocking agents, myasthenia gravis AND sevoflurane, myasthenia gravis AND epidural, myasthenia gravis AND neuromuscular blockade reversal and myasthenia gravis AND pyridostigmine. The articles included were from reviews and clinical trials written in English. MG patients can easily be anesthetized without need for post-surgery mechanical ventilation whether it is general anesthesia or peripheral nerve block. Volatile anesthesia or the use of an epidural for the patient makes it possible to avoid the use of neuromuscular blocking agents, and when used, it should be in smaller doses and the patient should be carefully monitored. This review shows that with thorough pre-operative evaluation, continuing the daily pyridostigmine and careful monitoring the MG patient can be managed safely. © 2011 The Authors Acta Anaesthesiologica Scandinavica.

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