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Purpose Fifteen years ago, a European survey demonstrated widespread adoption of early clinical exposure (ECE) programmes but little emphasis in the curricula of medical schools. We now repeat the survey in light of the ample emerging data suggesting multiple positive outcomes of ECE. Methods Online cross-sectional survey in European medical schools conducted by the EURACT Basic Medical Education Committee in 2021. Descriptive quantitative analyses and a thematic analysis approach were used. Results Eighy-nine (48%) medical schools in 30 European countries responded. ECE was used in 65 (73%) of the medical schools, and 88% of ECE programmes took place in primary care. The median total time spent on the ECE programme was 5 days. Teaching methods covered unstructured learning opportunities such as observation or shadowing doctors, as well as work-based learning whilst seeing real patients or reflecting on own encounters. Learning goals included knowledge, skills, and attitudes. More than half of the respondents expressed barriers to implementing or expanding ECE. Conclusions Compared to the previous survey, there was no significant change in the adoption or curricular emphasis of ECE programmes. Institutional attitudes towards certain disciplines and a lack of willingness to experiment with new teaching methods may be partially responsible.

Background Treating patients with acute poisoning by substances of abuse in a primary care emergency clinic has previously been shown to be a safe strategy. We conducted an economic evaluation of this strategy compared to hospital treatment, which is the usual strategy. Methods Assuming equal health outcomes, we conducted a cost-minimization analysis. We constructed a representative opioid overdose patient based on a cohort of 359 patients treated for opioid overdose at the Oslo Accident and Emergency Outpatient Clinic (OAEOC) from 1.10.2011 to 30.9.2012. Using a health care system perspective, we estimated the expected resources used on the representative patient in primary care based on data from the observed OAEOC cohort and on information from key informants at the OAEOC. A likely course of treatment of the same patient in a hospital setting was established from information from key informants on provider procedures at Drammen Hospital, as were estimates of hospital use of resources. We calculated expected costs for both settings. Given that the treatments usually last for less than one day, we used undiscounted cost values. Results The estimated per patient cost in primary care was 121 EUR (2018 EUR 1.00 = NOK 9.5962), comprising 97 EUR on personnel costs and 24 EUR on treatment costs. In the hospital setting, the corresponding cost was 612 EUR, comprising 186 EUR on personnel costs, 183 EUR on treatment costs, and 243 EUR associated with intensive care unit admission. The point estimate of the cost difference per patient was 491 EUR, with a low-difference scenario estimated at 264 EUR and a high-difference scenario at 771 EUR. Conclusions Compared to hospital treatment, treating patients with opioid overdose in a primary care setting costs substantially less. Our findings are probably generalizable to poisoning with other substances of abuse. Implementing elements of the OAEOC procedure in primary care emergency clinics and in hospital emergency departments could improve the use of health care resources.

Patients who use recreational drugs frequently co-ingest ethanol, which is considered a central nervous system (CNS) depressant. The clinical relevance of this in acute toxicity involving other CNS depressants is not well described.To assess the clinical impact of ethanol co-use in patients presenting to the emergency department (ED) with acute toxicity involving the use of CNS depressant drugs.A retrospective multicentre study using data from the Euro-DEN Plus database from January 2014 to December 2019.Comparison of epidemiologic and clinical characteristics, ED and hospital management of patients with CNS depressant intoxication with or without ethanol co-use.Although 7644 (17.5%) of the 43 633 presentations were included, ethanol was co-ingested in 3811 (49.9%). In total 53.3% required medical treatment, 14 patients died. Patients with ethanol co-use more frequently presented with a Glasgow Coma Scale (GCS) ≤8 (34.1% vs. 22.4%; P 0.001), vomiting (8.1% vs. 4.6%; P 0.001), anxiety (12 % vs. 6.4%; P 0.001), agitation/aggression (22% vs. 14.7%; P 0.001), seizures (3.8% vs. 2.4%; P 0.001) and hypotension (7.5% vs. 4.6%; P 0.001). They more often required ambulance transport (85.5% vs. 76.5%; P 0.001), medical treatment (57.3% vs. 48.0%; P 0.001), hospitalization (27.7% vs. 18.9%; P 0.001), and admission to intensive care (12.2% vs. 4.0%; P 0.001). Subgroup analysis showed that GCS ≤8 was particularly common in patients who combined ethanol with opioids or gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL).Co-use of ethanol with CNS-depressant drugs appears to increase the risk of adverse effects and is associated with a higher need for medical treatment, especially when ethanol is combined with opioids or GHB/GBL.

ObjectivesWe estimate the prevalence of sexually transmitted infection (STI) among patients after sexual assault, assess the possible value of azithromycin prophylaxis, and identify risk factors for assault-related STI and for not presenting at follow-up.DesignProspective observational cohort study.SettingSexual assault centre in Oslo, Norway.Participants645 patients, 602 (93.3%) women and 43 (6.7%) men, attending the centre from May 2017 to July 2019.Outcome measuresMicrobiological testing at the primary examination and at follow-up consultations after 2, 5 and 12 weeks. Estimated relative risk for assault-related STI and for not presenting at follow-up.ResultsAt primary examination, the prevalence of genital chlamydia was 8.4%,Mycoplasma genitalium6.4% and gonorrhoea 0.6%. In addition, the prevalence of bacterial STI diagnosed at follow-up and possibly from the assault was 3.0% in total: 2.5% forM. genitalium,1.4% for genital chlamydia and 0.2% for gonorrhoea. This prevalence did not change when azithromycin was no longer recommended from January 2018. There were no new cases of hepatitis B, hepatitis C, HIV or syphilis. We found no specific risk factors for assault-related STI. Patients with previous contact with child welfare service less often presented to follow-up (relative risk (RR) 2.0 (95% CI 1.1 to 3.5)), as did patients with a history of sex work (RR 3.6 (1.2 to 11.0)) or substance abuse (RR 1.7 (1.1 to 2.7)).ConclusionsMost bacterial STIs were diagnosed at the primary examination, hence not influenced by prophylaxis. There was no increase in bacterial STI diagnosed at follow-up when azithromycin prophylaxis was not routinely recommended, supporting a strategy of starting treatment only when infection is diagnosed or when the patient is considered at high risk. Sex work, substance abuse and previous contact with child welfare services were associated with not presenting to follow-up.Trial registration numberClinicalTrials.gov Registry (NCT03132389).

Objective Since 2017, an increasing number of opioid overdoses in Oslo, Norway, has been categorized as involving unspecified opioids, as noted in the patient records by the doctor treating the patient. In this study we compare the characteristics of overdoses involving unspecified opioids, long-acting opioids, and heroin. Data on patients presenting with opioid overdose was retrospectively collected from 1 October 2013 to 31 December 2019 at the Oslo Accident and Emergency Outpatient Clinic. Results Among 2381 included cases, 459 (19.3%) involved unspecified opioids, 134 (5.6%) long-acting opioids, and 1788 (75.1%) heroin. Overdoses involving unspecified opioids needed longer observation, median 5 h 29 min vs. 4 h 54 min (long-acting opioids) and 4 h 49 min (heroin) (p

Seizures are a recognized and potentially serious complication of recreational drug use. This study examined a large international data set of presentations to Emergency Departments with acute recreational drug toxicity, the European Drug Emergencies Plus (Euro-DEN Plus) Network, to compare presentations with and without seizures and estimate incidence and associated drugs. Amongst 23,947 presentations between January 2014 and December 2017, there were 1013 (4.2%) with reported seizures. Clinical and demographic features were similar between individuals who had a seizure and those who did not, although rates of coma, cardiac arrest, intubation, intensive care admission, and death were significantly higher in those with seizures. There was a significant association between specific drugs and a higher seizure incidence, including fentanyl (odds ratio 2.63, 95% confidence interval 1.20-5.80), and synthetic cannabinoids (OR 2.90, 95% CI 2.19-3.84). Other drugs were associated with a lower seizure incidence, including heroin (OR 0.46, 95% CI 0.35-0.61), clonazepam (OR 0.22, 95% CI 0.06-0.91), and cannabis (OR 0.65, 95% CI 0.50-0.86). This substantiates observations that the synthetic cannabinoids as a group of novel psychoactive substances are clinically different in consequence of intoxication than cannabis, and that individuals who suffer a seizure in the context of recreational drug intoxication are likely to have worse outcomes overall. Utilising this information of what substances have a greater risk of seizures, could provide tailored harm reduction and education strategies to users to reduce the risk of seizures and their associated complications.

Poisonings by substances of abuse are potentially dangerous and indicate risky substance use behaviour. To be prepared to handle patients with poisonings by substances of abuse, we need updated knowledge about the kinds of substances we can be expected to encounter. Most substance use-related poisonings in Oslo are treated at the OAEOC, and we describe the poisonings observed there in the period 2014-2018.We included all patients treated for poisoning by substances of abuse at the OAEOC in the years 2014-18, with the exception of lone ethanol poisonings. For 2018, these were also included. The patients were identified retrospectively by a review of the patient registration lists in the clinic's electronic records system. The diagnosis of the substances involved was based on the clinical assessment made by the doctor responsible for treatment.In the period 2014-18, altogether 8 116 cases of poisoning by a substance of abuse were treated at OAEOC, lone ethanol poisonings not included. The most frequently occurring intoxicants were heroin (3 237 cases), benzodiazepines (2 196), amphetamine/methamphetamine (1 827), cannabis (1 081), gamma-hydroxybutyrate (GHB) (904), cocaine (569) and unspecified opioids (546). There was an increasing trend in number of cases per year for central stimulants, cannabis and GHB, and a decreasing one for benzodiazepines. The number of heroin poisonings fell until 2017, but rose again in 2018. In 2018 there were 4 021 poisonings by substances of abuse, of which 2 022 were lone ethanol poisonings.The number of poisonings increased for most substances in 2014-18, but fell for heroin and benzodiazepines.

BACKGROUND Poisonings by substances of abuse are potentially dangerous and indicate risky substance use behaviour. To be prepared to handle patients with poisonings by substances of abuse, we need updated knowledge about the kinds of substances we can be expected to encounter. Most substance use-related poisonings in Oslo are treated at the OAEOC, and we describe the poisonings observed there in the period 2014-2018. MATERIAL AND METHOD We included all patients treated for poisoning by substances of abuse at the OAEOC in the years 2014-18, with the exception of lone ethanol poisonings. For 2018, these were also included. The patients were identified retrospectively by a review of the patient registration lists in the clinic's electronic records system. The diagnosis of the substances involved was based on the clinical assessment made by the doctor responsible for treatment. RESULTS In the period 2014-18, altogether 8 116 cases of poisoning by a substance of abuse were treated at OAEOC, lone ethanol poisonings not included. The most frequently occurring intoxicants were heroin (3 237 cases), benzodiazepines (2 196), amphetamine/methamphetamine (1 827), cannabis (1 081), gamma-hydroxybutyrate (GHB) (904), cocaine (569) and unspecified opioids (546). There was an increasing trend in number of cases per year for central stimulants, cannabis and GHB, and a decreasing one for benzodiazepines. The number of heroin poisonings fell until 2017, but rose again in 2018. In 2018 there were 4 021 poisonings by substances of abuse, of which 2 022 were lone ethanol poisonings. INTERPRETATION The number of poisonings increased for most substances in 2014-18, but fell for heroin and benzodiazepines.

International audience; Objective: To analyse the relative percentage of acute recreational drug toxicity emergency department (ED) presentations involving the main drug groups according to age and sex and investigate different patterns based on sex and age strata.Methods: We analysed all patients with acute recreational drug toxicity included by the Euro-DEN Plus dataset (22 EDs in 14 European countries) between October 2013 and December 2016 (39 months). Drugs were grouped as: opioids, cocaine, cannabis, amphetamines, gamma-hydroxybutyrate (GHB), hallucinogens, new psychoactive substances (NPS), benzodiazepines and ketamine. Descriptive data by age and sex are presented and compared among age/sex categories and among drug families.Results: Of 17,371 patients were included during the 39-month period, 17,198 (99.0%) had taken at least one of the investigated drugs (median age: 31 years; 23.9% female; ethanol co-ingestion recorded in 41.5%, unknown in 31.2%; multiple drug use in 37.9%). Opioids (in 31.4% of patients) and amphetamines (23.3%) were the most frequently involved and hallucinogens (1.9%) and ketamine (1.7%) the least. Overall, female patients were younger than males, both in the whole cohort (median age 29 vs. 32 years; p < 0.001) and in all drug groups except benzodiazepines (median age 36 vs. 36 years; p = 0.83). The relative proportion of each drug group was different at every age strata and some patterns could be clearly described: cannabis, NPS and hallucinogens were the most common in patients

Background Patients presenting with acute chest pain outside of hospitals represent a diagnostic challenge. Purpose We aimed to validate whether a single high-sensitivity cardiac troponin T (hs-cTnT) safely can rule out acute myocardial infarction (AMI) in a primary care emergency setting. In addition, we aimed to investigate if the hs-HEART (History, Electrocardiogram (ECG), Age, Risk factors, and hs-Troponin) score would add valuable diagnostic information. Methods This is a secondary analysis from a prospective diagnostic study, including 1711 patients with acute non-specific chest pain presenting to a primary care emergency clinic from November 2016 to October 2018. The European Society of Cardiology (ESC) 0/1-hour algorithm triages patients towards direct rule-out if the 0-hour hs-cTnT is below 5 ng/L, combined with a normal ECG and a 3-hour symptom duration. The hs-HEART score (0–10 points) was calculated retrospectively, and a score ≤3 points was considered low-risk. In addition, a modified hs-HEART score, with more comparable hs-cTnT cut-off values, was applied. The primary endpoint was AMI during the index episode; the secondary the 90-day incidence of AMI (including index) and all-cause death. Results Among 1711 patients, 61 (3.6%) had an AMI, and 525 (30.7%) were assigned towards direct rule-out. With no AMIs in this group, the rule-out safety was high (negative predictive value (NPV) and sensitivity 100%). The hs-HEART score triaged more patients (n=966) as low-risk, but missed six AMIs (NPV 99.4% and sensitivity 90.2%). The modified hs-HEART score (n=707, AMI=3) increased the low-risk sensitivity to 95.1%. The 90-day incidence of AMI and all-cause death in the direct rule-out, low-risk hs-HEART, and modified hs-HEART group, were 0.0%, 0.7%, and 0.4%, respectively. Conclusions The ESC direct rule-out approach, with a single hs-cTnT below 5 ng/L, combined with a normal ECG, and a 3-hour symptom duration, is superior to the two hs-HEART scores in ruling out AMI in a primary care emergency setting. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The Norwegian Research Fund for General Practice

Many patients with gamma-hydroxybutyrate (GHB) poisoning are treated at the emergency primary health care (AE clinic) level in Oslo. We describe the clinical picture of GHB poisoning and compare hospitalised patients with patients who were discharged from the main AE clinic in Oslo.We registered retrospectively all patients with the clinical diagnosis GHB poisoning at the Oslo Accident and Emergency Outpatient Clinic from 1 October 2013 to 30 September 2015. We only included cases where GHB was taken as an intoxicant.We found 329 cases of GHB poisoning in the period. The median age was 30 years (interquartile range 25-36 years, range 15-56 years), and 228 (69 %) of the cases were men. GHB was taken as the only intoxicant in 128 cases (39 %), combined with alcohol in 96 (29 %) and with amphetamine in 65 (20 %). Reduced level of consciousness was observed in 218 cases (69 %), coma (Glasgow Coma Scale score ≤ 7) in 43 (14 %) and agitation in 117 (36 %). Compared with patients who were discharged from the AE clinic, the 159 hospitalised patients (48 % of the total number) were more often comatose (23 % vs 5 %, p0.001) and agitated (43 % vs 28 %, p = 0.008). The median observation time at the AE clinic prior to hospitalisation was 42 minutes (interquartile range 26 min - 1 h 23 min, range 2 min - 20 h 10 min) vs 3 h 1 min (interquartile range 1 h 32 min - 4 h 42 min, range 14 min - 15 h 37 min) for those who were discharged from the AE clinic (p0.001).Half of the patients with GHB poisoning were only treated at AE clinic level. Many of those who were hospitalised had severe symptoms that quickly called for hospitalisation.

Benzodiazepines are also used as intoxicants. This can be dangerous, particularly in multi-substance abuse. We describe cases of acute poisoning related to substance abuse of benzodiazepines in patients at the main AE clinic in Oslo.We included all patients treated for substance abuse poisoning with benzodiazepines and/or z-hypnotics at the Oslo Accident and Emergency Outpatient Clinic from 1 October 2013 to 30 September 2015. The patients were found through a retrospective review of the AE clinic's registers. Data were taken from patient records. Diagnosis of the toxic agent was based on the attending doctor's recorded clinical evaluation.Of 1 037 cases, 787 (76 %) were men. The median age was 36 (interquartile range 28-46, range 14-78). Clonazepam (Rivotril) was the most frequently occurring drug, with 575 cases (55 %), followed by diazepam (Stesolid, Valium, Vival) 158 (15 %), alprazolam (Xanor) 125 (12 %) and oxazepam (Sobril) 94 (9 %). Zopiclone (Imovane, Zopitin) and zolpidem (Stilnoct) occurred rarely, in 25 (2 %) and 11 (1 %) cases, respectively. Benzodiazepines were combined with other intoxicants in 936 (90 %) cases, most frequently heroin 484 (47 %), ethanol 321 (31 %) and amphetamine 199 (19 %).In substance abuse poisoning, benzodiazepines were very often combined with other intoxicants, most frequently opioids, ethanol and/or amphetamine.

ObjectiveThe European Society of Cardiology 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) has demonstrated high rule-out safety in large hospital validation cohorts. We aimed to validate the algorithm in a primary care setting, where patients have a lower pretest probability for acute coronary syndrome.MethodsThis prospective, observational, diagnostic study included patients with acute non-specific chest pain admitted to a primary care emergency clinic in Oslo, Norway, from November 2016 to October 2018. hs-cTnT was measured after 0, 1 and 4 hours. The primary outcome measure was the diagnostic performance of the 0/1-hour algorithm, the 90-day incidence of AMI or all-cause death the secondary.ResultsAmong 1711 included patients, 61 (3.6%) were diagnosed with AMI. By applying the algorithm, 1311 (76.6%) patients were assigned to the rule-out group. The negative predictive value was 99.9% (95% CI 99.5% to 100.0%), the sensitivity and specificity 98.4% (91.2–100.0) and 79.4% (77.4–81.3), respectively. Sixty-six (3.9%) patients were triaged towards rule-in, where 45 were diagnosed with AMI. The corresponding positive predictive value was 68.2% (58.3–76.7), sensitivity 73.8% (60.9–84.2), and specificity 98.7% (98.1–99.2). Among 334 (19.5%) patients assigned to the observation group in need of further tests, 15 patients had an AMI. The following 90 days, five new patients experienced an AMI and nine patients died, with a low incidence in the rule-out group (0.3%).ConclusionThe 0/1-hour algorithm for hs-cTnT seems safe, efficient and applicable for an accelerated assessment of patients with non-specific chest pain in a primary care emergency setting.Trial registration numberNCT02983123.

BACKGROUND Many patients with gamma-hydroxybutyrate (GHB) poisoning are treated at the emergency primary health care (A&E clinic) level in Oslo. We describe the clinical picture of GHB poisoning and compare hospitalised patients with patients who were discharged from the main A&E clinic in Oslo. MATERIAL AND METHOD We registered retrospectively all patients with the clinical diagnosis GHB poisoning at the Oslo Accident and Emergency Outpatient Clinic from 1 October 2013 to 30 September 2015. We only included cases where GHB was taken as an intoxicant. RESULTS We found 329 cases of GHB poisoning in the period. The median age was 30 years (interquartile range 25-36 years, range 15-56 years), and 228 (69 %) of the cases were men. GHB was taken as the only intoxicant in 128 cases (39 %), combined with alcohol in 96 (29 %) and with amphetamine in 65 (20 %). Reduced level of consciousness was observed in 218 cases (69 %), coma (Glasgow Coma Scale score ≤ 7) in 43 (14 %) and agitation in 117 (36 %). Compared with patients who were discharged from the A&E clinic, the 159 hospitalised patients (48 % of the total number) were more often comatose (23 % vs 5 %, p < 0.001) and agitated (43 % vs 28 %, p = 0.008). The median observation time at the A&E clinic prior to hospitalisation was 42 minutes (interquartile range 26 min - 1 h 23 min, range 2 min - 20 h 10 min) vs 3 h 1 min (interquartile range 1 h 32 min - 4 h 42 min, range 14 min - 15 h 37 min) for those who were discharged from the A&E clinic (p < 0.001). INTERPRETATION Half of the patients with GHB poisoning were only treated at A&E clinic level. Many of those who were hospitalised had severe symptoms that quickly called for hospitalisation.

Background Benzodiazepines are also used as intoxicants. This can be dangerous, particularly in multi-substance abuse. We describe cases of acute poisoning related to substance abuse of benzodiazepines in patients at the main A&E clinic in Oslo. Material and method We included all patients treated for substance abuse poisoning with benzodiazepines and/or z-hypnotics at the Oslo Accident and Emergency Outpatient Clinic from 1 October 2013 to 30 September 2015. The patients were found through a retrospective review of the A&E clinic's registers. Data were taken from patient records. Diagnosis of the toxic agent was based on the attending doctor's recorded clinical evaluation. Results Of 1 037 cases, 787 (76 %) were men. The median age was 36 (interquartile range 28-46, range 14-78). Clonazepam (Rivotril) was the most frequently occurring drug, with 575 cases (55 %), followed by diazepam (Stesolid, Valium, Vival) 158 (15 %), alprazolam (Xanor) 125 (12 %) and oxazepam (Sobril) 94 (9 %). Zopiclone (Imovane, Zopitin) and zolpidem (Stilnoct) occurred rarely, in 25 (2 %) and 11 (1 %) cases, respectively. Benzodiazepines were combined with other intoxicants in 936 (90 %) cases, most frequently heroin 484 (47 %), ethanol 321 (31 %) and amphetamine 199 (19 %). Interpretation In substance abuse poisoning, benzodiazepines were very often combined with other intoxicants, most frequently opioids, ethanol and/or amphetamine.

Background Recreational use of prescription drugs is widespread. We describe acute poisonings related to the recreational use of prescription drugs. Methods Retrospective observational study. We retrospectively registered all patients presenting from October 2013 through March 2015 at a primary care emergency outpatient clinic in Oslo, Norway, with an acute poisoning related to recreational drug use. We registered demographic data, toxic agents taken, clinical course and treatment. From this data set we extracted the 819/2218 (36.9%) cases involving one or more prescription drugs. Results Among the 819 included cases, 190 (23.2%) were female. Median age was 37 years. The drugs most commonly involved were benzodiazepines in 696 (85.0%) cases, methadone in 60 (7.3%), buprenorphine in 53 (6.5%), other opioids in 56 (6.8%), zopiclone/zolpidem in 26 (3.2%), and methylphenidate in 11 (1.3%). Prescription drugs were combined with other toxic agents in 659 (80.5%) cases; heroin in 351 (42.9%), ethanol in 232 (28.3%), amphetamine in 141 (17.2%), cannabis in 70 (8.5%), gamma-hydroxybutyrate (GHB) in 34 (4.2%), cocaine in 29 (3.5%), and other illegal drugs in 46 (5.6%). The patient was given naloxone in 133 (16.2%) cases, sedation in 15 (1.8%), and flumazenil in 3 (0.4%). In 157 (19.2%) cases, the patient was sent on to hospital. Conclusions One in three acute poisonings related to recreational drug use involved prescription drugs. Benzodiazepines were by far the most common class of drugs. Prescription drugs had mostly been taken in combination with illegal drugs or ethanol.

Background The majority of patients with chest pain in Norway initially present to the primary health care system, which serves to triage them to the specialist health care services including hospitals. In some emergency primary care institutions, patients who are not hospitalised directly undergo further diagnostic testing to rule out acute myocardial infarction (AMI). Purpose Several studies have shown the advantage of using high-sensitivity assays for fast interpretation of cardiac troponins. The majority of these studies included patient populations from hospital emergency departments. In contrast, we aimed to investigate whether the 1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) is safe and useful for implementation in a primary care emergency setting where the patients have a much lower pre-test probability for an acute coronary syndrome. Methods In this prospective cohort study, we included 1672 patients with acute non-specific chest pain from November 2016 to October 2018 at a primary care emergency outpatient clinic in Norway. Serial hs-cTnT samples were analysed after 0, 1 and 4 hours on the Cobas 8000 e602 analyzer. We divided the results into one of three groups (rule-out, rule-in, or further observation), according to the 0/1-hour algorithm for hs-cTn from the current ESC guidelines on non-ST-elevation myocardial infarction. In the rule-out group, the 0/1-hour results were compared to the standard 4-hour hs-cTnT. Final hospital diagnoses were collected as a gold standard for the patients in the rule-in group. Results A total of 44 (2.6%) of 1672 patients were diagnosed with AMI. By applying the algorithm, 1274 (76.2%) patients were assigned to the rule-out group. One of the rule-out patients had a significant increase in hs-cTnT in the 4-hour sample. This results in a sensitivity for AMI of 97.7% (95% confidence interval [CI] 88.0–99.9) and negative predictive value of 99.9% (95% CI 99.6–100.0). There were 50 (3.0%) patients in the rule-in group, amongst whom 35 had a verified AMI. This gives a specificity for AMI of 99.1% (95% CI 98.5–99.5) and a positive predictive value at 70.0% (95% CI 55.4–82.1). Among the 348 (20.8%) patients assigned to further observation, eight patients had an AMI. The 15 rule-in patients who did not have an AMI, had other acute illnesses that required further diagnostic work-up at the hospital. Conclusions With a negative predictive value at 99.9%, the 1-hour algorithm for hs-cTnT seems safe and applicable for a faster assessment of patients with non-specific chest pain in a primary care emergency setting. Prehospital implementation of this algorithm may reduce the need for hospitalisation of these patients and hence may probably lower the costs. ClinicalTrial.gov identifier: NCT02983123 Acknowledgement/Funding Norwegian Research Fund for General Practice, The Norwegian Physicians' Association Fund for Quality Improvement and Patient Safety

Ethanol intake can increase the sedative effects of gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL), although the real clinical impact is unknown. We studied the clinical impact of the co-ingestion of ethanol in patients presenting to the Emergency Department (ED) with acute toxicity related to GHB/GBL use.We performed a secondary analysis of the Euro-DEN Plus Registry (14 countries, 22 EDs) which includes 17,371 consecutive patients presenting to the ED with acute recreational drug toxicity over 39 consecutive months (October 2013 - December 2016). We compared the epidemiological and clinical characteristics and ED management of patients identified as presenting with acute toxicity related to lone GHB/GBL (Group A) or GHB/GBL combined with ethanol (Group B) without other concomitant drugs.A total of 609 patients were included (age 32 (8) years; 116 women (19%); Group A: 183 patients and Group B: 426). The most common features were reduction in consciousness (defined as Glasgow Coma Score13 points: 56.1%) and agitation/aggressiveness (33.6%). Those with ethanol co-ingestion were younger patients (Group A/B: 31.5/33.1 years, p = 0.029) and ethanol co-ingestion was associated with a lower frequency of bradycardia (23.5%/15.7%, p = 0.027) and more frequent arrival at the ED by ambulance (68.3/86.6%; p 0.001), reduction in consciousness (58.9%/49.1%; p = 0.031), need for treatment in the ED (49.2%/60.4%; p = 0.011), use of sedatives (20.1%/12.8%; p = 0.034), admission to critical care units (22.4%/55.3%; p 0.001), and longer hospital stay (stay longer than 6 h: 16.9%/28.4%; p = 0.003).Co-ingestion of ethanol increases the adverse effects of patients intoxicated by GHB/GBL, leading to greater depression of consciousness, need for treatment, admission to the ICU and longer hospital stay.

Background Female drug users report poorer physical and mental health than male drug users. We describe female and male patients treated for acute recreational drug toxicity, and look for gender differences in clinical state, treatment, and toxic agents taken. Methods Retrospective case series from a primary care emergency outpatient clinic and a hospital emergency department in Oslo, Norway. All patients treated for acute recreational drug toxicity from October 2013 through March 2015 were included, except patients with lone alcohol intoxication. Patients were grouped according to whether they had taken opioids or not, as a proxy differentiation between heavy drug users and party drug users. Data from the two clinical settings were analysed separately. Results In total, 2495 cases were included, 567 (22.7%) were women. Female patients were younger than males, median 31 vs 34 years (p

Following the bomb attack on the government quarter on 22 July 2011, many of the injured were treated at the accident and emergency department in Oslo.The patients (n=79) were sent a questionnaire ten months after their treatment and again after three years. A total of 42 patients responded on one or both occasions. Post-traumatic stress reactions were measured using PTSD-RI (University of California at Los Angeles PTSD Reaction Index). Symptoms of anxiety and depression were measured with the aid of HSCL-8 (Hopkins Symptom Checklist). Physical symptoms were surveyed using twelve questions. Satisfaction with follow-up was measured with eight questions on a five-point scale.After ten months, the average score for PTSD-RI was 1.4 (95 % CI 1.0-1.7), and 31 % of the responses were at a clinical PTSD level. After three years, the average score was 1.3 (95 % CI 0.9-1.7), and 25 % were at a clinical PTSD level. Symptom score for anxiety and depression after ten months was 0.9 (95 % CI 0.6-1.2) and after three years 0.8 (95 % CI 0.5-1.2). The most frequent physical symptom was headache. The satisfaction with follow-up varied somewhat but was generally good.Several patients who received treatment for injuries at the accident and emergency department in Oslo had mental symptoms for a long period following the terror attack. The patients were satisfied with the follow-up, which was mainly provided by the primary healthcare service.

Background Following the bomb attack on the government quarter on 22 July 2011, many of the injured were treated at the accident and emergency department in Oslo. Material and method The patients (n=79) were sent a questionnaire ten months after their treatment and again after three years. A total of 42 patients responded on one or both occasions. Post-traumatic stress reactions were measured using PTSD-RI (University of California at Los Angeles PTSD Reaction Index). Symptoms of anxiety and depression were measured with the aid of HSCL-8 (Hopkins Symptom Checklist). Physical symptoms were surveyed using twelve questions. Satisfaction with follow-up was measured with eight questions on a five-point scale. Results After ten months, the average score for PTSD-RI was 1.4 (95 % CI 1.0-1.7), and 31 % of the responses were at a clinical PTSD level. After three years, the average score was 1.3 (95 % CI 0.9-1.7), and 25 % were at a clinical PTSD level. Symptom score for anxiety and depression after ten months was 0.9 (95 % CI 0.6-1.2) and after three years 0.8 (95 % CI 0.5-1.2). The most frequent physical symptom was headache. The satisfaction with follow-up varied somewhat but was generally good. Interpretation Several patients who received treatment for injuries at the accident and emergency department in Oslo had mental symptoms for a long period following the terror attack. The patients were satisfied with the follow-up, which was mainly provided by the primary healthcare service.

Aims: Despite the excess mortality and morbidity associated with acute poisoning by substances of abuse, follow-up is frequently not organised. We assessed morbidity, including repeated poisoning, and follow-up after acute poisoning by substances of abuse through charting contacts with health services. We also charted short-term mortality. Methods: Patients 12 years and older treated for acute poisoning by substances of abuse at a primary care emergency outpatient clinic in Oslo, Norway, were included consecutively from October 2011 through September 2012. We retrieved information from national registers on fatalities, hospital admissions, and contacts at outpatient specialist health services and with general practitioners (GPs), during the 90 days following a poisoning episode. Results: We included 1731 patients treated for 2343 poisoning episodes. During the 90 days following the poisoning, 31% of the patients were treated at somatic hospitals, 9% admitted to psychiatric hospitals, 37% in treatment at outpatient psychiatric/addiction specialist health services, 55% saw their GP, while 34% had no follow-up. The short-term mortality rate was 2.0%, eight times higher than expected. Increasing age, suicidal intention, opioid poisoning, and severe mental illness were associated with increased risk of death. Increasing age, male gender, opioid poisoning, and severe mental illness were associated with repeated poisoning. Patients with increased risk of repeated poisoning were more likely to be in follow-up at outpatient specialist psychiatric/addiction services and in contact with their GP. Conclusions: Follow-up measures seem targeted to those most in need, though one out of three had none. The mortality rate calls for concern.

Objective We have previously found that 9% of patients treated for acute poisoning by substances of abuse in a primary care emergency outpatient setting presented with a new poisoning within a week. We now identify factors associated with rapidly repeated acute poisoning by substances of abuse. Results In 169/1952 (9%) cases of acute poisoning by substances of abuse included consecutively from October 2011 through September 2012 at a primary care emergency outpatient clinic in Oslo, Norway, the patient re-presented within a week with a new poisoning. Homeless patients were more likely to re-present, adjusted odds ratio (AOR) 2.0 (95% confidence interval (CI) 1.3–3.2, p = 0.003), as were self-discharging patients, AOR 1.7 (95% CI 1.2–2.4, p = 0.007), and patients with an opioid as main toxic agent, AOR 1.5 (95% CI 1.0–2.3, p = 0.028). There was no statistically significant association between rapid re-presentation and severe mental illness or suicidal intention.