Examining capillary ketone testing in hospitalised patients: indications and outcomes.

Elevated blood ketone levels (ketosis) in inpatients with diabetes can herald diabetic ketoacidosis (DKA). However, ketosis can also occur in individuals without diabetes in certain settings. It is unclear what proportion of inpatients with ketosis are in DKA and which patients are at the highest risk of DKA. This study determined that many ketone tests are performed in individuals at low risk of DKA, and a ß-hydroxybutyrate <1.0 mmol/L had a low incidence of DKA and less need for escalation in their management.

Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration.

BACKGROUND: Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof. OBJECTIVES: This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration. METHODS: This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation. RESULTS: From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001). CONCLUSION: Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.

Direct oral anticoagulants in frail older adults: a geriatric perspective.

Direct oral anticoagulants (DOACs) have changed the paradigm of anticoagulation management, improving patient convenience as well as possibly reducing the incidence of spontaneous intracranial hemorrhage. However, concerns remain with these agents because of the lack of monitoring capacity and availability of readily accessible specific antidotes. This is particularly pertinent in the older population, specifically the frail older adults who have multiple comorbidities, higher risk of falls, and increased bleeding risk. This group has not been specifically studied in the DOAC randomized controlled trials and, hence, extrapolation of these data into this population should be done cautiously. We provide a review of the use of DOACs in the older frail population from both hematological and geriatric perspectives, as well as propose an algorithm for how these agents may be used in this frail population.

Secondary clonal cytogenetic abnormalities following successful treatment of acute promyelocytic leukemia.

To identify patients who developed secondary clonal cytogenetic aberrations (CCA) following therapy for acute promyelocytic leukemia (APL), we retrospectively analyzed cytogenetic results from 123 patients diagnosed with APL between 1995 and 2007, who had ongoing cytogenetic analysis undertaken in our laboratory. During follow-up for APL we identified 12 patients (9.8%) who developed CCA, not detected at diagnosis of APL and unrelated to their original APL karyotype. All patients had received all-trans retinoic acid (ATRA) and chemotherapy and were in complete remission for APL when secondary CCA were identified. The median latency period between diagnosis of APL and emergence of secondary CCA was 27.5 months (range: 2-54 months). To date, four patients with CCA have been diagnosed with therapy-related myelodysplastic syndrome (t-MDS)/acute myeloid leukemia (t-AML), giving a median t-MDS/AML free survival of 78 months, with follow-up ranging between 20 and 136 months from APL diagnosis. Three patients have died: two patients died of t-AML and another developed relapsed APL with persistence of his secondary clone but no diagnosis of t-MDS/AML and died from transplant-related complications. Two patients are alive with t-MDS. Seven patients with CCA are alive with no morphological evidence of MDS at the time of their last known follow-up; thus median survival has not been reached. The appearance of these abnormalities in the absence of morphological evidence of MDS in the majority of patients is unusual, and highlights the importance of continued cytogenetic follow-up in these patients. Am. J. Hematol., 2009. (c) 2009 Wiley-Liss, Inc.

Chronic norovirus infection in a patient with a past history of Burkitt lymphoma.

The noroviruses are a leading cause of gastroenteritis worldwide. Although the illness is normally mild and self-limiting, there is a growing literature documenting the chronic excretion of norovirus in the immunocompromised. The aim of the current study was to examine the molecular features of chronic norovirus excretion in an immunocompromised patient with a past history of Burkitt lymphoma. During the 241 day course of the study from December 2013 to August 2014, seven faecal specimens were collected from the patient, tested for norovirus by RT-PCR and further analysed in the open reading frame (ORF) 1 and ORF 2 regions. All seven specimens were positive for norovirus by RT-PCR. Molecular sequencing in the polymerase (ORF 1) and capsid (ORF 2) regions indicated that the norovirus could be classified as GII.4 (2006b)/GII.4 (unknown). No significant mutation was found in the ORF 1 or ORF 2 regions analysed over the period of the study. The current report appears to be the first to document chronic norovirus excretion in a patient with a past history of Burkitt lymphoma. It is also the first to indicate long term norovirus excretion in a given individual need not involve major genetic change in key regions of the genome.