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Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed:1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED?2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)?3. How valid is each triage scale in predicting hospitalization and hospital mortality?A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted.We found ED triage scales to be supported, at best, by limited and often insufficient evidence.The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

Objectives To assess the impact of population-based mammographic screening on breast cancer mortality in Europe, considering different methodologies and limitations of the data. Methods We conducted a systematic literature review of European trend studies (n ¼ 17), incidencebased mortality (IBM) studies (n ¼ 20) and case-control (CC) studies (n ¼ 8). Estimates of the reduction in breast cancer mortality for women invited versus not invited and/or for women screened versus not screened were obtained. The results of IBM studies and CC studies were each pooled using a random effects meta-analysis. Results Twelve of the 17 trend studies quantified the impact of population-based screening on breast cancer mortality. The estimated breast cancer mortality reductions ranged from 1% to 9% per year in studies reporting an annual percentage change, and from 28% to 36% in those comparing post-and prescreening periods. In the IBM studies, the pooled mortality reduction was 25% (relative risk [RR] 0.75, 95% confidence interval [CI] 0.69 -0.81) among invited women and 38% (RR 0.62, 95% CI 0.56 -0.69) among those actually screened. The corresponding pooled estimates from the CC studies were 31% (odds ratio [OR] 0.69, 95% CI 0.57 -0.83), and 48% (OR 0.52, 95% CI 0.42 -0.65) adjusted for self-selection. Conclusions Valid observational designs are those where sufficient longitudinal individual data are available, directly linking a woman's screening history to her cause of death. From such studies, the best 'European' estimate of breast cancer mortality reduction is 25 -31% for women invited for screening, and 38 -48% for women actually screened. Much of the current controversy on breast cancer screening is due to the use of inappropriate methodological approaches that are unable to capture the true effect of mammographic screening.

Abstract-Observational studies have shown inconsistent results for the association between blood pressure and cancer risk. We investigated the association in 7 cohorts from Norway, Austria, and Sweden. In total, 577799 adults with a mean age of 44 years were followed for, on average, 12 years. Incident cancers were 22184 in men and 14744 in women, and cancer deaths were 8724 and 4525, respectively. Cox regression was used to calculate hazard ratios of cancer per 10-mmHg increments of midblood pressure, which corresponded with 0.7 SDs and, for example, an increment of systolic/diastolic blood pressure of 130/80 to 142/88 mmHg. All of the models used age as the time scale and were adjusted for possible confounders, including body mass index and smoking status. In men, midblood pressure was positively related to total incident cancer (hazard ratio per 10 mmHg increment: 1.07 [95% CI: 1.04 -1.09]) and to cancer of the oropharynx, colon, rectum, lung, bladder, kidney, malignant melanoma, and nonmelanoma skin cancer. In women, midblood pressure was not related to total incident cancer but was positively related to cancer of the liver, pancreas, cervix, uterine corpus, and malignant melanoma. A positive association was also found for cancer mortality, with HRs per 10-mmHg increment of 1.12 (95% CI: 1.08 -1.15) for men and 1.06 (95% CI: 1.02-1.11) for women. These results suggest a small increased cancer risk overall in men with elevated blood pressure level and a higher risk for cancer death in men and women. ypertension accounts for Ϸ5% of the current global disease burden because of increasing longevity and prevalence of contributing factors, such as obesity, physical inactivity, and an unhealthy diet.1 Increasing age and metabolic aberrations related to obesity, for example, hyperglycemia and hypercholesterolemia, have been linked to increased risk of cancer, 2,3 and several lines of evidence also suggest a link between hypertension and cancer risk.4-8 However, there are only a few observational studies of the association between blood pressure (BP) and cancer incidence and mortality, which show inconsistent findings. 9,10In a meta-analysis based on 10 longitudinal studies of in total 47 119 participants, hypertension was related to a 23% increased risk of cancer mortality, 9 and in another study including 17 498 participants, BP was inversely associated with mortality from leukemia and pancreatic cancer but positively associated with mortality attributed to liver and rectal cancer. 11 The association between hypertension and incident cancer has also been found to differ by cancer site. 10These studies were hampered by small study size and/or lack of information on potential confounders, such as smoking habits and obesity. Moreover, assessment of BP on a single occasion entails a substantial random error attributed to measurement error and within-person variation of BP levels.12,13 Such inaccuracy of exposure assessment dilutes the association with outcome, that is, regression dilution bias. 12,14,15 Risk estimates ...

Background Rupture of the anterior cruciate ligament (ACL) may cause osteoarthrosis (OA) and functional impairment. We wanted to find out whether the degree of knee stability obtained after ACL reconstruction correlates with radiographic and clinical outcome.Patients and methods We examined 63 patients 2 and 5-9 years after anterior cruciate ligament (ACL) reconstruction. Knee stability was assessed 2 years after surgery by recording AP laxity using radiostereometric technique (RSA) and by performing the pivot shift test. Degeneration of the knee joint was evaluated with bone scintigraphy, and radiographically. Functional outcome was assessed with Lysholm score, Tegner activity scale and with the one-leg hop test.Results Radiographic signs of osteoarthrosis at the most recent follow-up (5-9 years) did not correlate with knee stability. Patients with positive pivot shift test 2 years after surgery showed increased scintigraphic activity of the subchondral bone at the most recent follow-up, and inferior subjective functional outcome 2 years after surgery. Knees having had meniscus resections had more often OA. Radiographical signs of OA were associated with higher scintigraphic uptake in the operated knee relative to the contralateral knee.Interpretation The ability to obliterate the pivoting by ACL reconstruction appears to be more important than normalizing the AP laxity in order to prevent later OA.

BackgroundOvercrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments.MethodsA systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group.ResultsThe interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient.ConclusionsIntroducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

Tanja Stocks and colleagues carry out an analysis of six European cohorts and confirm that abnormal glucose metabolism is linked with increased risk of cancer overall and at specific sites.

Background: Few studies have assessed the metabolic syndrome (MetS) as an entity in relation to breast cancer risk, and results have been inconsistent. We aimed to examine the association between MetS factors (individually and combined) and risk of breast cancer incidence and mortality.Methods: Two hundred ninety thousand women from Austria, Norway, and Sweden were enrolled during 1974-2005, with measurements of height, weight, blood pressure, and levels of glucose, cholesterol, and triglycerides. Relative risks (RR) of breast cancer were estimated using Cox proportional hazards regression for each MetS factor in quintiles and for standardized levels (z-scores) and for a composite z-score for the MetS.Results: There were 4,862 incident cases of breast cancer and 633 deaths from breast cancer identified. In women below age 50, there was a decreased risk of incident cancer for the MetS (per 1-unit increment of z-score; RR, 0.83; 95% confidence interval, 0.76-0.90) as well as for the individual factors (except for glucose). The lowest risks were seen among the heaviest women. In women above age 60, there was an increased risk of breast cancer mortality for the MetS (RR, 1.23; 95% confidence interval, 1.04-1.45) and for blood pressure and glucose. The strongest association with mortality was seen for increased glucose concentrations.Conclusions: The MetS was associated with a decreased risk of incident breast cancer in women below age 50 with high body mass index, and with an increased risk of breast cancer mortality in women above 60.Impact: Lifestyle interventions as recommended for cardiovascular disease prevention may be of value to prevent breast cancer mortality in postmenopausal women. Cancer Epidemiol Biomarkers Prev; 19(7); 1737-45.