Impact of Constipation on Health Outcomes in Medically Hospitalized Patients: A Prospective Study on Laxative Use and Health Care Outcomes.

Background and Objectives: Constipation affects health-related quality of life and increases hospital visits. We conducted this prospective cohort study to assess laxative use, health outcomes of constipation in medically hospitalized patients, and related health outcomes. Materials and Methods: A prospective single-center study included all adult patients admitted under the General Internal Medicine Unit from 1 February 2022, to 31 August 2022. Constipation was defined using the Constipation Assessment Scale (CAS). Patients were assessed for 28 days during their hospital stay and up to 90 days post-discharge. Result: Among the included patients, 62.45% experienced constipation, which was associated with poor health outcomes including delirium (p = 0.048), intensive care admission (p < 0.01), cardiopulmonary arrest (p < 0.01), inpatient mortality (p < 0.01), longer hospital stay (p < 0.01), 90-day mortality (p < 0.01), and 90-day hospital readmission (p < 0.01). Laxative treatment was administered to only 33.93% of patients with constipation and was more commonly used among older patients (p < 0.01), those with high CAS scores (p < 0.01), longer hospital stays (p < 0.01), and critically ill patients (intensive care admission) (p = 0.01), as well as those who had cardiopulmonary arrest (p < 0.01) and high inpatient mortality (p < 0.01). Conclusions: This study identified several associations between constipation and poor health outcomes and highlighted the underutilization of laxatives in treating constipation. It is vital to interpret our results with caution. Therefore, we believe that a randomized controlled trial will help enhance our understanding of the interaction between constipation, laxative use, and poor health outcomes.

Prevalence of hyponatremia among medically hospitalized patients and associated outcomes: a retrospective cohort study.

BACKGROUND: Hyponatremia is a common electrolyte disturbance among hospitalized patients and is linked to increased mortality as well as poor outcomes. OBJECTIVES: Study the prevalence of hyponatremia among medically admitted patients and the outcomes associated with hyponatremia. DESIGN: Retrospective cohort. SETTING: Medical ward at tertiary hospital setting. PATIENTS AND METHODS: The study included adult (≥18 years) hospitalized patients in general medical wards. Three readings of serum sodium level were taken (initial sodium level, nadir during admission, and before discharge). SAMPLE SIZE AND BASIS: The sample size of 350 was determined based on a presumed 35% incidence of hyponatremia among hospitalized patients, with a 5% error margin. MAIN OUTCOME MEASURES: The prevalence of hyponatremia among medically hospitalized patients and association with health outcomes including length of hospital stay, inpatient mortality, 90-days readmission and 1-year mortality. RESULTS: In this study, 736 patients met the inclusion criteria. Of these, 377 (51.2%) had hyponatremia on admission, increasing to 562 (76.35%) during hospitalization. Mild hyponatremia was observed in 49.6% (n=365), moderate in 13.6% (n=100), and severe in 13.2% (n=97). Severe hyponatremia patients were significantly older (P<.01), predominantly female (P=.014), and had lower serum magnesium and albumin levels (P<.01). Hypertension, ischemic heart disease, heart failure, and diabetes were more prevalent in severe hyponatremia cases (P<.01, P<.01, P=.045, P<.01, respectively). Hospital stays were significantly shorter for patients with normal sodium levels (P<.01). Patients with severe hyponatremia had a shorter time for first hospital readmission (HR=0.80, P<.01 [95% CI; 0.69-0.94]). CONCLUSION: Hyponatremia was prevalent among medically hospitalized patients and more common among old patients, women, and patients with comorbidities. Hyponatremia was associated with increased length of stay in hospital and increased risk of 90-day re-admission. LIMITATIONS: Single-centre design and retrospective nature.

Prevalence, clinical characteristics, and health outcomes of dysmagnesemia measured by ionized and total body concentrations among medically hospitalized patients.

Ionized Mg (iMg) may offer a more reliable indicator of Mg status during acute illness than total Mg (tMg) concentrations. This study aimed to determine the prevalence of dysmagnesemia and their relationship using iMg and tMg. The clinical and biochemical characteristics as well as health outcomes and their association with iMg and tMg were also assessed. A prospective study including all eligible adult patients (≥18 years) who were hospitalized in the General Internal Medicine unit at Sultan Qaboos University Hospital (SQUH) for 3.5 months in 2023. The iMg and tMg concentrations were collected on all at the admission. In total 500 patients were included (females 49.2%) with a median age of 64.5 years (IQR: 48-77). The prevalence of hypomagnesemia and hypermagnesemia by iMg concentrations was 3.4% and 26.6%, respectively, while by tMg concentrations 13.2% and 11.0%, respectively. The agreement between both measurements was strong (r=0.665, p<0.01). An increased tMg concentration was independently associated with high dependency units' admission (adjusted odds ratio (aOR): 4.34, 95%CI: 1.24-15.06, p=0.02) and cardiac arrest (aOR: 14.64, 95%CI: 3.04-70.57, p<0.01), and 6-month all-cause mortality (aOR: 11.44, 95%CI: 2.46-53.17, p<0.01). During follow-up hypermagnesemia using tMg had a higher mortality compared to other groups (hazard ratio (HR): 1.82, 95%CI: 1.11-3.01, p=0.02) while no significant findings were demonstrated using iMg concentrations. iMg and tMg concentrations had a strong correlation that might be supporting the potential use of point-of-care devices. Multivariant regression analysis showed that hypermagnesemia by tMg was associated with adverse outcomes. However, the generalizability of the study findings should be taken with caution and the difference in the associations with outcomes highlight the importance of further research to examine the complex associations and impacts of dysmagnesemia in various clinical settings.

LUDT-ADHF trial: Lung ultrasound-guided diuretic therapy for hospitalized patients with acute decompensated heart failure: An open-label clinical trial.

Background Acute Decompensated Heart Failure (ADHF) constitutes a major reason for hospital admissions and significantly contributes to increased morbidity and mortality. Limited research indicates that lung ultrasound (LUS) may enhance the care for patients with ADHF. Objectives The purpose of this study was to evaluate the impact of LUS-guided diuretic therapy on reducing length of hospital stay (LOS) and 90-day readmissions among patients with ADHF. Methods This open-label, non-randomized clinical trial included patients with ADHF managed with diuretics based on LUS findings of B-lines and pleural effusion (LUS group) compared to those receiving standard care (control group). The primary outcome was LOS during the index admission, and secondary outcomes included 90-day ADHF readmissions, all-cause readmissions, and safety parameters like acute kidney injury, hypokalemia, and hypotension. Results The study included a total of 77 patients, segregated into two groups: control and LUS. The median age of the patients was 68 years, with women slightly outnumbering men (53.25%, n=41). The most prevalent comorbidities were hypertension (88.31%, n=68), diabetes mellitus (59.74%, n=46), and chronic kidney disease (66.23%, n=51). The LUS group had a shorter LOS, though not statistically significant (4 vs five days, p= 0.175). Patients in the LUS group had significantly fewer 90-day ADHF readmissions compared to the control group (10.53% vs. 35.9%; p<0.01). Survival analysis demonstrated that the LUS group had a longer time to 90-day ADHF readmissions, with a hazard ratio (HR) of 0.24 (95% CI: 0.08-0.75, p=0.014). For 90-day all-cause readmissions, the LUS group also showed a longer time to readmission compared to controls, with an HR of 0.45 (95% CI: 0.200-1.005, p=0.046). For other safety measures, there was no significant difference in the incidence of adverse events, including acute kidney injury, hypokalaemia, or hypotension, between the LUS and control groups. Conclusion LUS might reduce in-hospital mortality and readmissions among adults with acute decompensated HF. However, further double-blinded randomized clinical trials are needed to confirm these preliminary results.

Prevalence of Non-Alcoholic Fatty Liver Disease and Its Impact on Fibrosis Risk in Inactive Chronic Hepatitis B Patients: Insights from a Cross-Sectional Study.

Background: Chronic hepatitis B (CHB) and non-alcoholic fatty liver disease (NAFLD) are significant causes of chronic liver disease, potentially leading to liver cirrhosis and hepatocellular carcinoma. Moreover, the coexistence of CHB and NAFLD is increasingly common, although the relationship between NAFLD and inactive CHB infection remains poorly understood. Objectives: This study aimed to investigate the prevalence of NAFLD among patients with inactive CHB, identify risk factors for NAFLD, and determine predictors of significant fibrosis in these patients. Methods: This single-center cross-sectional study targeted patients with inactive CHB at Sultan Qaboos University Hospital from January 2010 to November 2021. Results: A total of 425 patients with inactive CHB were identified, of which 53.1% were male and 62.6% were aged 40-60 years. The prevalence of NAFLD was 47.8%. Various independent factors were associated with NAFLD, including type 2 diabetes mellitus, elevated low-density lipoprotein levels, high hemoglobin levels, low platelet counts, and normal alpha-fetoprotein levels. Significant associations were noted between NAFLD and significant fibrosis, with 10.5% of CHB patients with NAFLD exhibiting significant fibrosis compared to 1.4% of those without NAFLD. Other significant parameters included male gender, increased age, high alanine transaminase levels, elevated hemoglobin, and decreased platelet levels. Conclusions: The high prevalence of NAFLD in patients with inactive CHB and its associations with increased fibrosis and cirrhosis risk underscore the need for comprehensive management strategies for these patients.

Clinical outcomes in patients hospitalised with dysmagnesemia in the Northern Territory of Australia: a retrospective, longitudinal data-linkage study.

INTRODUCTION: Magnesium is an essential cation, and dysmagnesaemia is linked to many poor outcomes. This study aimed to assess the prevalence of dysmagnesaemia and associated health outcomes among hospitalised patients. METHODS: This register-based study collected demographic and laboratory data of hospitalised patients from five publicly funded hospitals in the Northern Territory, Australia, between 2008 and 2017. Patients were stratified into five groups based on their initial serum magnesium level at admission and followed up to death or 31 December 2017. RESULTS: A total of 22 293 patients were admitted during the study period. Dysmagnesaemia was present in 31.75% of hospitalised patients, with hypomagnesaemia being more common (29.62%) than hypermagnesaemia (2.13%). Hypomagnesaemia was more prevalent (43.13%) among the Australian First Nations Peoples. All levels of hypomagnesaemia were associated with a longer median length of hospital stay (p<0.001). Also, all levels of hypermagnesaemia were associated with a longer median stay in intensive care units (p<0.001). Patients with severe hypermagnesaemia had increased mortality compared to patients with severe hypomagnesaemia (56.0% v 38.0.0%, p<0.0001). Mortality was increased in both hypomagnesaemia (hazard ratio 1.86, 95% confidence intervaI 1.74-1.99, p<0.001) and hypermagnesaemia (1.78, 1.48-2.19, p<0.001) compared to normomagnesaemia. CONCLUSION: Dysmagnesaemia was prevalent among hospitalised patients and associated with increased mortality.

Prevalence of Dysmagnesemia among Patients with Diabetes Mellitus and the Associated Health Outcomes: A Cross-Sectional Study.

Introduction: Magnesium is a vital intracellular cation crucial for over 320 enzymatic reactions related to energy metabolism, musculoskeletal function, and nucleic acid synthesis and plays a pivotal role in human physiology. This study aimed to explore the prevalence of dysmagnesemia in patients with diabetes mellitus and evaluate its correlations with glycemic control, medication use, and diabetic complications. Methods: A cross-sectional study was conducted at Sultan Qaboos University Hospital, including 316 patients aged 18 years or older with diabetes mellitus. Data included demographics, medical history, medications, and biochemical parameters. Serum total magnesium concentrations were measured, and dysmagnesemia was defined as magnesium ≤ 0.69 mmol/L for hypomagnesemia and ≥1.01 mmol/L for hypermagnesemia. Results: The prevalence of hypomagnesemia in patients with diabetes was 17.1% (95% CI: 13.3-21.7%), and hypermagnesemia was 4.1% (95% CI: 2.4-7.0%). Females were significantly overrepresented in the hypomagnesemia group, while the hypermagnesemia group showed a higher prevalence of hypertension, retinopathy, an increased albumin/creatinine ratio, chronic kidney disease (CKD), elevated creatinine levels, and a lower adjusted calcium concentration. The multinominal logistic regression exhibited that the female sex and higher serum-adjusted calcium were independent risk factors of hypomagnesemia. In contrast, the presence of hypertension, higher levels of albumin/creatinine ratio, and stage 5 CKD were independent risk factors of hypermagnesemia. Conclusions: Hypomagnesemia was common among patients with diabetes mellitus; however, hypermagnesemia was associated with microvascular complications.

A Machine Learning-Based Mortality Prediction Model for Patients with Chronic Hepatitis C Infection: An Exploratory Study.

Background: Chronic hepatitis C (HCV) infection presents global health challenges with significant morbidity and mortality implications. Successfully treating patients with cirrhosis may lead to mortality rates comparable to the general population. This study aims to utilize machine learning techniques to create predictive mortality models for individuals with chronic HCV infections. Methods: Data from chronic HCV patients at Sultan Qaboos University Hospital (2009-2017) underwent analysis. Data pre-processing handled missing values and scaled features using Python via Anaconda. Model training involved SelectKBest feature selection and algorithms such as logistic regression, random forest, gradient boosting, and SVM. The evaluation included diverse metrics, with 5-fold cross-validation, ensuring consistent performance assessment. Results: A cohort of 702 patients meeting the eligibility criteria, predominantly male, with a median age of 47, was analyzed across a follow-up period of 97.4 months. Survival probabilities at 12, 36, and 120 months were 90.0%, 84.0%, and 73.0%, respectively. Ten key features selected for mortality prediction included hemoglobin levels, alanine aminotransferase, comorbidities, HCV genotype, coinfections, follow-up duration, and treatment response. Machine learning models, including the logistic regression, random forest, gradient boosting, and support vector machine models, showed high discriminatory power, with logistic regression consistently achieving an AUC value of 0.929. Factors associated with increased mortality risk included cardiovascular diseases, coinfections, and failure to achieve a SVR, while lower ALT levels and specific HCV genotypes were linked to better survival outcomes. Conclusions: This study presents the use of machine learning models to predict mortality in chronic HCV patients, providing crucial insights for risk assessment and tailored treatments. Further validation and refinement of these models are essential to enhance their clinical utility, optimize patient care, and improve outcomes for individuals with chronic HCV infections.

Baclofen Toxicity in a Dialysis-Dependent Patient: A Case Report.

Baclofen toxicity is a significant concern, particularly in patients with advanced chronic kidney disease. We present a case of a 74-year-old female who developed depressed consciousness after receiving 20 mg of baclofen for back pain control. A presumptive diagnosis of baclofen toxicity was made, and the patient underwent continuous hemodialysis sessions, leading to neurological recovery within two days. This case highlights the risk of baclofen toxicity in dialysis-dependent patients with advanced chronic kidney disease, emphasizing the importance of vigilance and alternative treatment options in this population.

Incidence of Dysmagnesemia among Medically Hospitalized Patients and Associated Clinical Characteristics: A Prospective Cohort Study.

Background: Magnesium (Mg) disorders are common among hospitalized patients and are linked to poor health outcomes. We aimed to determine the incidence of dysmagnesemia among medically hospitalized patients and to identify factors that are associated with dysmagnesemia. Methods: A prospective cohort study was conducted at Sultan Qaboos University Hospital (SQUH) from April 1st, 2022, to October 31st, 2022, and involved hospitalized adult patients (≥18 years) under the care of the general internal medicine unit. The patients' serum total magnesium (Mg) concentrations were categorized as hypomagnesemia (≤0.69 mmol/L), hypermagnesemia (≥1.01 mmol/L), or dysmagnesemia, which encompassed either hypomagnesemia or hypermagnesemia. Results: Of the 304 patients evaluated, dysmagnesemia was observed in 22.0%, which comprised of 17.4% with hypomagnesemia and 4.6% with hypermagnesemia. Statistically significant associations were identified between hypermagnesemia and chronic kidney disease (CKD) (p = 0.05) and elevated creatinine levels (p < 0.01) and lower estimated glomerular filtration rate (eGFR) (p < 0.01). Hypomagnesemia was linked to lower ionized calcium (p = 0.03) and admission due to infectious diseases (p = 0.02). However, ordered regression analysis did not find any significant associations with the different magnesium groups. Conclusion: Dysmagnesemia was prevalent among hospitalized patients and was associated with different factors; however, ordered regression analysis did not find any association with the different magnesium group, probably due to the limited number of included individuals.

Clinical Characteristics, Etiology, and Prognostic Scores in Patients with Acute Decompensated Liver Cirrhosis.

BACKGROUND: Chronic liver disease and cirrhosis contribute significantly to global mortality, with limited improvements despite medical advancements. This study aims to evaluate acute decompensation of liver cirrhosis characteristics, etiology, and survival outcomes in Oman. In addition, we examined the accuracy of prognostic scores in predicting mortality at 28 and 90 days. METHODS: We conducted a retrospective analysis of 173 adult patients with acute decompensation of liver cirrhosis at Sultan Qaboos University Hospital in Oman. We collected demographic, clinical, and biochemical data, including etiology, prognostic scores (CTP, MELD-Na, CLIF-C), and health outcomes. RESULTS: Alcohol (29.5%), hepatitis C (27.75%), and hepatitis B (26.74%) were the predominant causes of liver cirrhosis in our cohort. Hepatic encephalopathy, mechanical ventilation, and admission to the intensive care unit were strongly associated with an increased mortality rate. The 1-year readmission rate stood at 42.2%. Liver transplantation was performed in 4.1% of cases. The overall mortality rate was approximately 40% during the follow-up period, and the cumulative 28-days and 90-days mortality rates were 20.8% and 25.4%, respectively. Prognostic scores (CTP, MELD-Na, CLIF-C) effectively predicted 28- and 90-day mortality, with CLIF-C demonstrating superior performance (AUROC 0.8694 ± 0.0302 for 28-day mortality and AUROC 0.8382 ± 0.0359 for 90-day mortality). CONCLUSION: Alcohol and viral hepatitis are the leading causes of liver cirrhosis in our study. Hepatic encephalopathy is a significant predictor of poor outcomes. Prognostic scores (CTP, MELD-Na, CLIF-C) have valuable predictive abilities for short-term mortality. These findings highlight the importance of public strategies to reduce alcohol consumption and the need for the comprehensive management of liver cirrhosis in Oman. Early diagnosis and intervention can improve clinical outcomes and support the establishment of a national organ transplantation program to address the healthcare challenge effectively.

The Stability of Analytes of Ionized Magnesium Concentration and Its Reference Range in Healthy Volunteers.

This study aimed to determine the stability of refrigerated analytes of iMg concentration at different time intervals and to establish iMg reference range in a cohort of healthy Omani volunteers (≥18 years). The concentrations of iMg were measured using the direct ion-selective electrode technique. Pearson's and Lin's concordance correlation coefficients along with the Bland-Altman plot were used to assess the levels of agreement between iMg concentrations of fresh and refrigerated blood samples at different time intervals. The study included 167 volunteers (51% females) with a median age of 21 (range: 20-25) years. The median, 2.5th, and 97.5th percentiles for fresh iMg reference ranges were 0.55, 0.47, and 0.68 mmol/L, respectively. The overall agreement between the fresh and refrigerated iMg concentrations was poor (rho-c = 0.51; p < 0.001). However, according to Altman's definition, iMg concentrations of the refrigerated samples for a period of ≤1 h had an excellent correlation with the fresh iMg concentrations (Lin's rho-c = 0.80), with a small average bias difference of 0.009 (95%CI; -0.025-0.043). A cut-off refrigeration period within ≤1 h at 2-8 °C can be considered an alternate time frame for the gold standard measurement (fresh or within 0.5 h).

Delirium and Its Association with Short- and Long-Term Health Outcomes in Medically Admitted Patients: A Prospective Study.

BACKGROUND: Delirium is highly prevalent among elderly hospitalized patients in various healthcare settings. This study aimed to assess the impact of delirium on short- and long-term health outcomes. METHODS: A prospective cohort included medically ill patients (≥65 years) admitted to a tertiary healthcare facility. Delirium was screened using the 3-Minute Diagnostic confusion assessment method (3D-CAM). RESULTS: During hospitalization, 53.8% (n = 153/284) had delirium. Patients with delirium had a longer length of hospital stay (LOS) (7 vs. 5 days; p < 0.01) compared to patients without delirium. Delirium caused a higher frequency of high-dependency unit (HDU) or intensive care unit (ICU) admission (p < 0.01) and an increased incidence of hospital-acquired complications, including infections (p = 0.03), pressure injuries (p = 0.01), and upper gastrointestinal bleeding (p < 0.01). Inpatient all-cause mortality was higher in patients with delirium than those without delirium (16.3% vs. 1.5%; p < 0.01). Patients with delirium had higher rates of 90-day all-cause mortality (25.4% vs. 8.4%; p < 0.01) and 1-year all-cause mortality (35.9% vs. 16%; p < 0.01) compared to patients without delirium. Patients with delirium exhibited shorter survival periods at 90 days and 1 year compared to patients without delirium with a hazard ratio (HR) = 3.41, 95% CI: 1.75-6.66, p < 0.01 and HR = 2.64, 95% CI: 1.59-4.37, p < 0.01, respectively. CONCLUSIONS: Delirium is associated with serious short-term and long-term clinical consequences. Early recognition, prevention, and targeted interventions addressing reversible risk factors are crucial. Further research is warranted to explore effective strategies for delirium management in general medical wards.

Hypermagnesemia in Clinical Practice.

Hypermagnesemia is a relatively uncommon but potentially life-threatening electrolyte disturbance characterized by elevated magnesium concentrations in the blood. Magnesium is a crucial mineral involved in various physiological functions, such as neuromuscular conduction, cardiac excitability, vasomotor tone, insulin metabolism, and muscular contraction. Hypomagnesemia is a prevalent electrolyte disturbance that can lead to several neuromuscular, cardiac, or nervous system disorders. Hypermagnesemia has been associated with adverse clinical outcomes, particularly in hospitalized patients. Prompt identification and management of hypermagnesemia are crucial to prevent complications, such as respiratory and cardiovascular negative outcomes, neuromuscular dysfunction, and coma. Preventing hypermagnesemia is crucial, particularly in high-risk populations, such as patients with impaired renal function or those receiving magnesium-containing medications or supplements. Clinical management of hypermagnesemia involves discontinuing magnesium-containing therapies, intravenous fluid therapy, or dialysis in severe cases. Furthermore, healthcare providers should monitor serum magnesium concentration in patients at risk of hypermagnesemia and promptly intervene if the concentration exceeds the normal range.

Prevalence, Recognition, and Risk Factors of Constipation among Medically Hospitalized Patients: A Cohort Prospective Study.

Background and Objective: Constipation is a prevalent gastrointestinal condition that has a substantial impact on individuals and healthcare systems. This condition adversely affects health-related quality of life and leads to escalated healthcare expenses due to an increase in office visits, referrals to specialists, and hospital admission. This study aimed to evaluate the prevalence, recognition, risk factors, and course of constipation among hospitalized patients in medical wards. Materials and Methods: A prospective study was conducted, including all adult patients admitted to the General Medicine Unit between 1 February 2022 and 31 August 2022. Constipation was identified using the Constipation Assessment Scale (CAS), and relevant factors were extracted from the patients' medical records. Results: Among the patients who met the inclusion criteria (n = 556), the prevalence of constipation was determined to be 55.6% (95% CI 52.8-58.4). Patients with constipation were found to be older (p < 0.01) and had higher frailty scores (p < 0.01). Logistic regression analysis revealed that heart failure (Odds ratio (OR) 2.1; 95% CI 1.2-3.7; p = 0.01), frailty score (OR 1.4; 95% CI 1.2-1.5; p < 0.01), and dihydropyridines calcium channel blockers (OR 1.8; 95% CI 1.2-2.8; p < 0.01) were independent risk factors for constipation. Furthermore, the medical team did not identify constipation in 217 patients (64.01%). Conclusions: Constipation is highly prevalent among medically hospitalized patients. To ensure timely recognition and treatment, it is essential to incorporate a daily constipation assessment scale into each patient's medical records.

Delirium in Medically Hospitalized Patients: Prevalence, Recognition and Risk Factors: A Prospective Cohort Study.

BACKGROUND: Delirium is a common neuropsychiatric syndrome in hospitalized elderly patients and is associated with poor clinical outcomes. We aimed to determine the prevalence, recognition, risk factors, and course of delirium among hospitalized elderly (65 years of age or older) patients at Sultan Qaboos University Hospital (SQUH). METHODS: A prospective cohort study included 327 elderly patients (65 years of age or older) admitted to the medical wards at SQUH. Patients were screened for delirium using the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM). Additionally, medical records were reviewed to identify possible associated factors. RESULTS: The prevalence of delirium was 55.4% (95% CI 49.9-60.7), and 35.4% of patients with delirium were not recognized by the treating team. Hypoactive delirium is the most common type of delirium. The logistic regression analyzes demonstrated that pre-existing cognitive impairment (OR = 4.0); poor functional status (OR = 1.9); the use of medications that are known to precipitate delirium (OR = 2.3); polypharmacy (OR = 5.7); urinary catheterization (OR = 2.2); dehydration (OR = 3.1); and electrolytes derangements (OR = 2.0) were independent risk factors for delirium. Furthermore, 56.9% of patients with delirium continued to have delirium upon discharge from the hospital. CONCLUSIONS: Delirium is common among elderly patients hospitalized in general medical wards. Implementing effective preventive strategies for delirium during the hospital stay, including early recognition using standard sensitive and specific screening tools (i.e., 3D-CAM) and developing geriatric wards, is crucial.

Inappropriate Hospital Stay of Patients Admitted Under Care of General Medicine Units: A retrospective study.

Objectives: This study aimed to assess the incidence of inappropriate hospital stay and to identify the reasons behind inappropriate hospitalisation. Methods: This retrospective cohort study included patients admitted in the General Internal Medicine Unit, Sultan Qaboos University Hospital, Muscat, Oman, from January to June 2020. The average length of hospital stay for all included patients was calculated. The appropriateness evaluation protocol technique was used to examine admissions that exceeded the average length of hospital stay; subsequently, the reasons for the inappropriate hospital stay were identified. Results: There were 855 admissions during the study period. In this cohort, 53.1% were male and the median age was 64 years (interquartile range [IQR]: 44-75 years). There was a total of 6,785.4 hospitalisation days and the average length of hospital stay was five days (IQR: 3-9 days). A total of 31.8% of admissions (n = 272) and 9.9% of hospitalisation days (n = 674 days) were classified as inappropriate. Delay in complementary tests (29.0%) and unavailability of extra hospital resources (21.7%) were identified as the most common reasons associated with inappropriate hospital stays. Old age was associated with increase in inappropriate hospital stay. Conclusion: A significant proportion of hospitalisation days were inappropriate due to hospital-related factors. Therefore, auditing hospital services and investing in home-based care are among the top strategies that are likely to improve early discharge and minimise inappropriate hospital bed occupancy.

Quality of death certification based on the documented underlying cause of death: A retrospective study.

BACKGROUND: The underlying cause of death (UCOD) documented in the death certificate is a cornerstone in the mortality data that has significant impact on national policies, health system, and socioeconomics. However, a wide range of inaccuracies have been reported worldwide and were linked to multiple factors, including sociodemographic development and lack of physician training. Hence, this study aimed to assess the quality of death certification by reviewing the reported UCOD in the death certificate and study the potential factors that might be associated with inaccuracies. METHODS: All in-patient deaths that occurred in the Sultan Qaboos University Hospital from January 2020 to 31 December 2020 were included in this retrospective study. The study investigators reviewed all death certifications that were recorded during the study period for the accuracy of the documented UCOD using a systemic framework recommended by the World Health Organization. RESULTS: The study included 384 mortality cases. The mean age at the time of death was 55.7 ± 27.1 years, and 209 (54.3%) cases were men. Approximately 80% (95% confidence interval: 84-76%) of the deceased patients had inaccurate data on the UCOD. Old age (58.1 ± 25.8 vs 46.5 ± 30.1, p < 0.001), death certification by doctor in training (70.8% vs 51.9%, p = 0.001), and admission under the Department of Medicine (68.5% vs 54.4%, p = 0.019) were more common in mortality cases with inaccurate data on the UCOD. Regression analysis confirmed that old age, male sex, and certification by doctor in training were independent predictors of inaccurate data on the UCOD. CONCLUSION: Inaccurate data on the UCOD is a prevalent issue in many healthcare settings, especially in the developing countries. Introduction of death certification training in the medical curriculum for medical doctors, implementation of periodic auditing, and provision of feedback are among the evidence-based approaches that are likely to improve the overall accuracy of mortality data.

Very long-chain acyl-CoA dehydrogenase deficiency and type I diabetes mellitus: Case report and management challenges.

BACKGROUND: Very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) is a rare autosomal recessive disorder of fatty acid metabolism. Its clinical presentation includes hypoketotic hypoglycemia and potentially life-threatening multiorgan dysfunction.Therefore, the cornerstone of management includes avoiding fasting, dietary modification, and monitoring for complications. The co-occurrence of type 1 diabetes mellitus (DM1) with VLCADD has not been described in the literature. CASE REPORT: A 14-year-old male with a known diagnosis of VLCADD presented with vomiting, epigastric pain, hyperglycemia, and high anion gap metabolic acidosis. He was diagnosed with DM1 and managed with insulin therapy while maintaining his high complex carbohydrate, low long-chain fatty acids diet with medium-chain triglyceride supplementation. The primary diagnosis (VLCADD) makes the management of DM1 in this patient challenging as hyperglycemia related to the lack of insulin puts the patient at risk of intracellular glucose depletion and hence increases the risk for major metabolic decompensation.Conversely, adjustment of the dose of insulin requires more attention to avoid hypoglycemia. Both situations represent increased risks compared to managing DM1 alone and need a patient-centred approach, with close follow-up by a multidisciplinary team. CONCLUSION: We present a novel case of DM1 in a patient with VLCADD. The case describes a general management approach and highlights the challenging aspects of managing a patient with two diseases with different potentially paradoxical life-threatening complications.

Novel Oral Anticoagulants in Patients With Atrial Fibrillation and Moderate to Severe Mitral Stenosis: A Systematic Review.

The use of novel oral anticoagulants (NOAC) in patients with moderate to severe mitral stenosis (MS) and atrial fibrillation (AF) is not recommended. We aimed to evaluate the efficacy and safety of NOAC usage compared to vitamin K antagonist (VKA) in patients with moderate to severe MS and AF. We conducted a systematic review to identify articles that compared warfarin to NOAC in patients with moderate to severe MS and AF. Only four studies (two observational studies and two trials) met our search criteria and reported a total of 7529 patients with MS and AF with MS and AF, 4138 of them treated with NOAC. In both observational studies, the severity of MS was not determined, and there was heterogeneity in MS etiology. Nevertheless, both studies showed a positive signal toward the efficacy and safety of NOAC compared to VKA in this population. A randomized pilot trial (n=40) was done on patients with moderate to severe MS, and it showed further acceptable efficacy and safety for rivaroxaban use. However, a larger randomized controlled trial (n=4531) disclosed that VKA (warfarin) led to a significantly lower rate of a composite of cardiovascular events or mortality than rivaroxaban, without a higher rate of major bleeding but not fatal bleeding. Our systematic review provides exploratory information on NOAC safety and effectiveness in patients with MS; it also discourages using NOACs for patients with moderate to severe MS and supports the current treatment guidelines. However, more dedicated clinical trials evaluating the use of NOACs in moderate to severe MS are underway. They will categorically establish the safety profile and clinical effectiveness of NOAC in this high-risk population.