Preemptive anticoagulation of pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is a life-threatening disease where preemptive anticoagulation is recommended by guidelines for patients with intermediate to high pretest risk of PE. AIMS: The primary objective of our study was to describe the use of preemptive anticoagulation from the emergency department (ED) or inpatient wards stratified by risk assessment score. METHODS: We performed a retrospective observational cohort study of consecutive patients undergoing computed tomography pulmonary angiography (CTPA) for investigation of PE. Patients were classified as either ED patients or hospital ward patients based on where the CTPA was requested. The pretest risk of PE was calculated using the Revised Geneva Score (RGS) and patients were divided into low and intermediate to high risk. RESULTS: A total of 392 consecutive patients who underwent CTPA at Monash Health were reviewed. There were 108 (27.6%) patients who were categorised as low risk (RGS 0-3) and 284 (72.4%) categorised as intermediate to high risk (RGS >3). There were 29 (7.4%) patients overall who received preemptive anticoagulation. Diagnostic yield of CTPA in the ED was low, with only four of 144 (2.8%) CTPA scans positive for PE. The yield of CTPA was higher in ward patients, with 63 of 248 (25.4%) being diagnostic of PE. CONCLUSIONS: The use of preemptive anticoagulation for suspected PE was uncommon and was not influenced by the pretest probability of PE as determined by a validated clinical prediction tool. This may reflect concerns regarding haemorrhagic complications without any clear evidence of benefit. Diagnostic yield of CTPA performed in the ED was low.

Are our patients becoming more complex? Trends in comorbidity and functional dependence in General Medicine 2011-2019.

BACKGROUND: Anecdotally, patients don't seem to be more unwell than they were 10 years ago, yet they still seem more 'complex'. AIMS: The aim of this study was to use an objective measure to assess the trend in complexity of general medicine patients over a 9-year period. METHODS: Complexity was pragmatically defined as a composite of comorbidity plus dependence/frailty. We selected 100 consecutive patients discharged from General Medicine at Monash Medical Centre (a tertiary hospital in Melbourne, Australia) in the month of April of each year from 2011 to 2019. For each patient, we retrospectively calculated their burden of comorbidity and their degree of dependency/frailty. Comorbidity was measured using the Charlson Comorbidity Index (CCI), and dependence/frailty was assessed using the Katz Index of Independence in Activities of Daily Living (Katz ADL) and the Braden Scale (BS). The BS is a pressure injury risk assessment tool. Additional demographic data were collected, including length of stay, admission and discharge residence, 30-day readmission rate and inpatient mortality. RESULTS: There was no statistically significant change in the CCI or the Katz ADL. The median BS did however significantly decrease from 19 in 2011 to 16 in 2019 (P = 0.006), reflecting an increased risk of pressure injuries. CONCLUSIONS: Despite a stable level of comorbidity, our finding of a decreasing BS score may suggest that patients are becoming more dependent. This increase in dependency rather than a change in chronic disease burden may be the cause of apparent increasing patient complexity.

Anticholinergic burden and poor oral health are associated with frailty in geriatric patients undergoing inpatient rehabilitation: A cross-sectional study.

BACKGROUND: Poor oral health is known to be associated with frailty in geriatric populations. Recent exposure to anticholinergic medications is responsible for features of poor oral health. Anticholinergic medications pose a cumulative risk for frailty. METHODS: We studied 115 geriatric inpatients (aged >65 years and recruited over a 3-month period from October to December 2017). Patients who were severely agitated, cognitively impaired, from a non-English speaking background and with severe sensory impairment were excluded. Frailty and oral health were assessed using the Reported Edmonton Frailty Scale and the Oral Health Assessment Test, respectively. Exposure to anticholinergic medications was assessed using the Anticholinergic Burden Scale. RESULTS: The mean age was 80 (range from 66 to 101). Only 44 patients (38.3%) were not exposed to any anticholinergic medication. Nearly two-thirds of patients were taking anticholinergic medications, with 25% classified as having a high anticholinergic burden (ACB ≥ 4). Approximately one-third of severely frail patients were exposed to a high anticholinergic burden. Patients with a high anticholinergic burden were more than twice as likely to have severe frailty (OR 2.21; 95% confidence interval 1.05-4.6). Poor oral health was associated with frailty (OR 1.24; 95% CI 1.02-1.49). CONCLUSION: High anticholinergic burden was found to be a risk marker for severe frailty independent of its effect on oral health. Poor oral health was associated with all levels of frailty. This study highlights a need for a review of medications with anticholinergic properties in older patients. Further research should be directed at whether deprescribing could prevent poor oral health or slow the progression of frailty.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider.

BACKGROUND: Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management. AIM: To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF. METHODS: The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality. RESULTS: New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059). CONCLUSION: Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

Frailty, oral health and nutrition in geriatrics inpatients: A cross-sectional study.

BACKGROUND: Poor nutritional status is a risk factor for the development of frailty. Likewise, oral health is independently associated with nutrition. The potential association between oral health and frailty in hospitalised elderly adults has, however, not previously been investigated. OBJECTIVE: To investigate the relationship between oral health and frailty in hospitalised elderly adults and to identify the predictors of frailty. METHOD: A cross-sectional study of 168 geriatric inpatients >65 years old was performed from August to December 2016. Patients of non-English speaking background, with impaired cognition (MMSE <24), severe hearing or visual impairment or active delirium were excluded. Oral health, nutrition and frailty were assessed using previously validated tools, namely the Geriatric Oral Health Assessment Index (GOHAI), Mini Nutrition Assessment (MNA) and Reported Edmonton Frailty Scale (REFS). Other data collected included demographics, co-morbidities, level of education and smoking/alcohol history. RESULTS: On univariate analysis, the REFS score decreased with better nutritional status/higher MNA (P < 0.001) and better self-reported oral health/higher GOHAI (P = 0.023). Nutritional status accounted for 17% of variability in frailty assessment. On multivariate analysis, co-morbidities (P < 0.001), MNA (P < 0.001) and living in residential care (P < 0.001) were independent predictors of frailty. After adjusting for nutrition and co-morbidities, self-reported oral health was found to have an independent negative association with frailty (P = 0.019). CONCLUSION: Poor self-reported oral health was found to be independently associated with frailty. Further research should be directed at whether interventions to maintain good oral health can prevent or slow the progression of frailty.

Retrospective evaluation of statin prescription in the elderly.

BACKGROUND: Statins are one of the most commonly prescribed medications in Australia. Although the cardioprotective effects of statins are well documented, questions remain regarding their risk-benefit profile in elderly adults, especially those with limited life expectancies. AIM: To describe the prevalence and pattern of statin use in elderly patients admitted to a General Medicine Unit. METHODS: We retrospectively reviewed medical records of patients aged ≥80 years who were admitted to the General Medical Unit at Monash Medical Centre between 1 January 2015 and 30 June 2015. Patients receiving statin therapy prior to admission were identified and included. Data including patient demographics, indication for statin, comorbidities, co-prescription of interacting medications, presence of muscle-related toxicity and any change to statin prescription were collected and described. RESULTS: Of 852 patients admitted to hospital, 359 (42%) were taking statins prior to admission. Statins were used for the secondary prevention of cardiovascular disease in 63% of patients and for primary prevention in 24%. Most patients were taking high- (16%) or medium-intensity statins (78%); 46% of patients were co-prescribed medications with the potential to increase the risk of statin toxicity. Statins were discontinued in 16% of patients; however, the majority of patients had no change to their statin prescription. Muscle-related toxicity was documented in 4% of patients. CONCLUSION: Statin use and the co-prescription of potentially interacting medications are common in elderly adults admitted to hospital. Statin prescription in elderly patients with multiple comorbidities is rarely reviewed unless directly relevant to their admission diagnosis.

A Cross-Sectional Study of Hyponatremia Associated with Acute Central Nervous System Infections.

Hyponatremia can occur with central nervous system (CNS) infections, but the frequency and severity may depend on the organism and nature of CNS involvement. In this cross-sectional study at a large Australian hospital network from 2015 to 2018, we aimed to determine the prevalence and severity of hyponatremia associated with CNS infection clinical syndromes, and the association with specific organisms. We examined the results of cerebrospinal fluid analysis from lumbar punctures performed in 184 adult patients with a serum sodium below 135 mmol/L who had abnormal cerebrospinal fluid analysis and a clinical syndrome consistent with an acute CNS infection (meningitis or encephalitis). Hyponatremia affected 39% of patients and was more severe and frequent in patients with encephalitis compared to meningitis (odds ratio = 3.03, 95% CI: 1.43-6.39, after adjusting for age). Hyponatremia was present on admission in 85% of cases. Herpes simplex virus infection was associated with the highest odds of hyponatremia (odds ratio = 3.25, 95% CI: 1.13-7.87) while enterovirus infection was associated with the lowest (odds ratio = 0.36, 95% CI: 0.14-0.92), compared to cases without an isolated organism. We concluded that the risk of hyponatremia may vary by the organism isolated but the clinical syndrome was a useful surrogate for predicting the probability of developing hyponatremia.

A Cross-Sectional Study of the Relationship between Serum Creatine Kinase and Liver Biochemistry in Patients with Rhabdomyolysis.

Abnormal liver function tests are commonly observed with rhabdomyolysis, but the nature of this association is not fully defined. This study aims to determine the functional relationship between serum creatine kinase, as a marker of rhabdomyolysis severity, and liver biochemistry. We used linear regression to model the relationship between liver biochemistry and peak serum creatine kinase. A total of 528 patients with a median age of 74 years were included. The distribution of creatine kinase, bilirubin, alkaline phosphatase, alanine aminotransferase, and γ-glutamyl transferase were significantly skewed, and these variables were log-transformed prior to regression. There was a positive linear correlation between log-alanine aminotransferase and log-creatine kinase. In the multiple regression analysis, log-creatine kinase, age, acute kidney injury stage, and chronic liver disease were independently associated with log-alanine aminotransferase. This model explained 46% of the variance of log-alanine aminotransferase. We found no correlation between the log-creatine kinase and the log-bilirubin, log-alkaline phosphatase, or log-γ-glutamyl transferase. Serum alanine aminotransferase was not associated with inpatient mortality but a higher creatine kinase-alanine aminotransferase ratio was associated with lower odds of mortality. In conclusion, an isolated elevation in alanine aminotransferase can occur in rhabdomyolysis, and it may be possible to anticipate the level of increase based on the peak creatine kinase.

Invasive Streptococcus anginosus group infection-does the species predict the outcome?

OBJECTIVE: To determine whether there is an association between the species of Streptococcus anginosus group (SAG) bacteria and the clinical outcome. METHODS: Isolates from invasive infections caused by SAG bacteria at our institution between January 2004 and February 2009 were identified phenotypically to the taxonomic level of species. Clinical data from the medical records of the patients from whom these isolates were recovered were obtained retrospectively and analyzed. RESULTS: Patients with invasive Streptococcus intermedius infections had a significantly longer hospital stay than patients infected with S. anginosus (p = 0.024) and a significantly higher 30-day all-cause mortality than patients infected with Streptococcus constellatus (p = 0.049). CONCLUSION: Identification of SAG bacteria to the taxonomic level of species may be of prognostic importance.

Late-stage human African trypanosomiasis in a Sudanese refugee.

A 19-year-old Sudanese woman, who had lived for about a decade in Ugandan refugee camps, was referred for investigation of a 12-month history of a generalised rash. Two months later, her condition had deteriorated to include cachexia and drowsiness. Despite initial negative findings on investigation, human African trypanosomiasis (HAT) was suspected, and parasites were found in a double-centrifuged sample of cerebrospinal fluid. Eflornithine, the appropriate drug for treatment of late-stage disease, was obtained through the World Health Organization. This case highlights the diagnostic and therapeutic difficulties in managing late-stage HAT in a non-endemic country.