Reduced kidney function at presentation in unselected acute emergency medical admissions: incidence, outcome and associated factors.

We sought to assess the impact of renal impairment on acute medical admissions and to identify potential contributory factors to admissions involving renal impairment at presentation. In a prospective cohort study, 29.5% of all acute medical emergency admissions had an eGFR <60ml/min/1.73m2 at presentation. Of these, 19.9% had definite chronic kidney disease and 8.4% had definite acute kidney injury. Detailed analysis of a random subset of patients with an eGFR <60ml/min/1.73m2 at presentation demonstrated that the major reasons for admission included falls, dehydration and fluid overload. 46% were on diuretics and 53% were on an ACEI or ARB or both. Gastrointestinal disturbance and recent medication changes were common and diuretic use persisted even with diarrhoea or vomiting.

SAMBA18 Report - A National Audit of Acute Medical Care in the UK.

SAMBA18 took place on Thursday 28th June 2018 with follow up data at 7 days. Acute medical teams from 127 Acute Medical Units (AMUs) across the UK collected data relating to operational performance, clinical quality indicators and standards from NHS Improvement. Data was collected from 6114 patients.

Antibiotic prescribing for the older adult: beliefs and practices in primary care.

BACKGROUND: Older adults suffer high morbidity and mortality following serious infections, and hospital admissions with these conditions are increasingly common. Antibiotic prescribing in the older adult population, especially in long-term care facilities, has been argued to be inappropriately high. In order to develop the evidence base and provide support to GPs in achieving antimicrobial stewardship in older adults it is important to understand their attitudes and beliefs toward antibiotic prescribing in this population. OBJECTIVES: To understand the attitudes and beliefs held by GPs regarding antibiotic prescribing in older adults. METHODS: Semi-structured qualitative interviews were conducted with 28 GPs working in the UK. Data analysis followed a modified framework approach. RESULTS: GPs described antibiotic prescribing in older adults as differing from prescribing in other age groups in a number of ways, including prescribing broad-spectrum, longer and earlier antibiotics in this population. There were also rationales for situations where antibiotics were prescribed despite there being no clear diagnosis of infection. Trials of antibiotics were used both as diagnostic aids and in an attempt to avoid admission. The risks of antibiotics were understood, but in some cases restrictions on antibiotic use were thought to hamper optimal management of infection in this age group. CONCLUSIONS: Diagnosing serious infections in older adults is challenging and antibiotic prescribing practices reflect this challenge, but also reflect an absence of clear guidance or evidence. Research that can fill the gaps in the evidence base is required in order to support GPs with their critical antimicrobial stewardship role in this population.

What is the evidence base for ambulatory care for acute medical illness?

Acute ambulatory care is a critical component of the emergency care pathway with national policy support and a dedicated NHS Improvement network. The evidence base for treating acute medical illness outside hospital is a diverse mix of randomised and observational studies with varying inclusion criteria, prognostic stratification, interventions and healthcare setting which limits synthesis of all available evidence and translation to the UK context. There is little consensus on the level of risk for home-based treatment for acute medical illness. Selection tools for referral to acute ambulatory care have been developed but there is limited evidence for their use. There are still research questions concerning optimal staffing, referral mechanisms, point of care diagnostic portfolio and tools for shared decision making.

Increase in antibiotic prescriptions in out-of-hours primary care in contrast to in-hours primary care prescriptions: service evaluation in a population of 600 000 patients.

OBJECTIVES: The objective of this study was to describe the frequency and nature of antibiotic prescriptions issued by a primary care out-of-hours (OOH) service and compare time trends in prescriptions between OOH and in-hours primary care. METHODS: We performed a retrospective audit of 496 931 patient contacts with the Oxfordshire OOH primary care service. Comparison of time trends in antibiotic prescriptions from OOH primary care and in-hours primary care for the same population was made using multiple linear regression models fitted to the monthly data for OOH prescriptions, OOH contacts and in-hours prescriptions between September 2010 and August 2014. RESULTS: Compared with the overall population contacting the OOH service, younger age, female sex and patients who were less deprived were independently correlated with an increased chance of a contact resulting in prescription of antibiotics. The majority of antibiotics were prescribed to patients contacting the service at weekends. Despite a reduction in patient contacts with the OOH service [an estimated decrease of 486.5 monthly contacts each year (95% CI -676.3 to -296.8), 5.0% of the average monthly contacts], antibiotic prescriptions from this service rose during the study period [increase of 37.1 monthly prescriptions each year (95% CI 10.6-63.7), 2.5% of the average monthly prescriptions]. A matching increase was not seen for in-hours antibiotic prescriptions; the difference between the year trends was significant (Z test, P = 0.002). CONCLUSIONS: We have demonstrated trends in prescribing that could represent a partial displacement of antibiotic prescribing from in-hours to OOH primary care. The possibility that the trends we describe are evident nationally should be explored.

Optimal insulin regimens in type 2 diabetes mellitus: systematic review and meta-analyses.

AIMS/HYPOTHESIS: We compared the effect of biphasic, basal or prandial insulin regimens on glucose control, clinical outcomes and adverse events in people with type 2 diabetes. METHODS: We searched the Cochrane Library, MEDLINE, EMBASE and major American and European conference abstracts for randomised controlled trials up to October 2008. A systematic review and meta-analyses were performed. RESULTS: Twenty-two trials that randomised 4,379 patients were included. Seven trials reported both starting insulin dose and titration schedules. Hypoglycaemia definitions and glucose targets varied. Meta-analyses were performed pooling data from insulin-naive patients. Greater HbA(1c) reductions were seen with biphasic and prandial insulin, compared with basal insulin, of 0.45% (95% CI 0.19-0.70, p = 0.0006) and 0.45% (95% CI 0.16-0.73, p = 0.002), respectively, but with lesser reductions of fasting glucose of 0.93 mmol/l (95% CI 0.21-1.65, p = 0.01) and 2.20 mmol/l (95% CI 1.70-2.70, p < 0.00001), respectively. Larger insulin doses at study end were reported in biphasic and prandial arms compared with basal arms. No studies found differences in major hypoglycaemic events, but minor hypoglycaemic events for prandial and biphasic insulin were inconsistently reported as either higher than or equivalent to basal insulin. Greater weight gain was seen with prandial compared with basal insulin (1.86 kg, 95% CI 0.80-2.92, p = 0.0006). CONCLUSIONS/INTERPRETATION: Greater HbA(1c) reduction may be obtained in type 2 diabetes when insulin is initiated using biphasic or prandial insulin rather than a basal regimen, but with an unquantified risk of hypoglycaemia. Studies with longer follow-up are required to determine the clinical relevance of this finding.

Initial management of suspected transient cerebral ischaemia and stroke in primary care: implications of recent research.

Strategies are required to reduce the personal, societal and healthcare burden caused by cerebrovascular disease. Urgent medical intervention after transient ischaemic attack (TIA) can prevent recurrent stroke, and modern healthcare has to respond rapidly to the patient with TIA. The primary care practitioner contributes to stroke prevention by rapidly and accurately diagnosing TIA and arranging urgent specialist assessment. Diagnosis of TIA in primary care is difficult, as transient symptoms are common. Stroke-screening tools are available, but there is no evidence base for diagnostic support tools for TIA in primary care. The ABCD2 scoring system identifies patients after TIA at high early risk, and secondary care assessment within 24 h is reserved for patients with a high predicted risk. General practitioners are advised to give aspirin at the time of diagnosis, although prescribing a full range of vascular risk-reducing therapies may be appropriate. Specialist assessment confirms the diagnosis, usually with cerebral imaging (preferably MRI to detect cerebral injury), and carotid ultrasound will detect patients suitable for endarterectomy. Patients with suspected stroke should be urgently transferred to the nearest stroke centre, for assessment and investigation before potential thrombolysis, which may be effective within a longer timeframe than current practice. Primary care follow-up is essential to ensure adherence to evidence-based therapies. Dual combinations of antiplatelet agents (aspirin and dipyridamole) and antihypertensive agents (ACE inhibitors and thiazides) as well as high-dose statins have proven benefit. For patients in atrial fibrillation, even if very elderly, anticoagulation has a net benefit in preventing stroke.