The impact of anticholinergic burden on clinical outcomes in older hospitalised surgical patients.

Polypharmacotherapy is an ever-increasing issue with an ageing patient population. Anticholinergic medications make up a large proportion of patient medication but cause significant side effects, contributing to well-documented issues within the older population and in hospital medicine. This review explores the documented impact of anticholinergic burden in older surgical patients on postoperative delirium, infection, length of stay and readmission, urinary retention, ileus and mortality. It also highlights the need for further high-quality research into anticholinergic burden management among older surgical patients to further impact practice and policy in the area.

Elevated procalcitonin concentrations in severe Covid-19 may not reflect bacterial co-infection.

BACKGROUND: The variability of Covid-19 severity between patients has driven efforts to identify prognosticating laboratory markers that could aid clinical decision-making. Procalcitonin is classically used as a diagnostic marker in bacterial infections, but its role in predicting Covid-19 disease severity is emerging. We aimed to identify the association between procalcitonin and Covid-19 disease severity in a critical care setting and whether bacterial co-infection is implicated. METHODS: We retrospectively reviewed Covid-19 patients with procalcitonin concentrations measured in a critical care setting at our institution between February and September 2020. Laboratory markers including peak procalcitonin values and a range of bacterial culture results were analysed. Outcomes were the requirement and duration of invasive mechanical ventilation as well as inpatient mortality. RESULTS: In total, 60 patients were included; 68% required invasive mechanical ventilation and 45% died as inpatient. Univariate analysis identified higher peak procalcitonin concentrations significantly associated with both the requirement for invasive mechanical ventilation (OR: 3.2, 95% CI 1.3-9.0, P = 0.02) and inpatient mortality (OR: 2.6, 95% CI 1.1-6.6, P = 0.03). Higher peak procalcitonin concentrations was an independent predictor of mortality on multivariate analysis (OR 3.7, 95% CI 1.1-12.4, P = 0.03). There was a significant positive correlation between increased peak procalcitonin concentrations and duration on invasive mechanical ventilation. No significant difference was found between peak procalcitonin concentrations of patients with positive and negative bacterial cultures. CONCLUSIONS: Elevated procalcitonin concentrations in Covid-19 patients are associated with respiratory failure requiring prolonged invasive mechanical ventilation and inpatient mortality. This association may be independent of bacterial co-infection.

Lessons of the month: HLA-B27-associated syndrome and spontaneous intracranial hypotension resulting in behavioural variant frontotemporal dementia.

Spontaneous intracranial hypotension is uncommon and results from a cerebrospinal fluid (CSF) leak. We describe the case of a marathon runner who presented with postural headache attributable to CSF venous fistulation originating from a lower thoracic nerve root cyst. Subsequent investigations confirmed a unifying de novo diagnosis of human leukocyte antigen B27-associated syndrome. With unmitigated CSF loss over the following 3 months, the patient became bedbound and developed rapidly progressive behavioural variant frontotemporal dementia. Behavioural changes were somewhat reversible on restoration of CSF volume after surgical intervention.

Lessons of the month 1: Polytrauma in a geriatric patient resulting in reactivation of cytomegalovirus infection and secondary cold agglutinin disease-induced haemolytic anaemia.

Haemolysis is a rare but serious complication of cytomegalovirus (CMV) infection, described mostly in immunocompromised patients, the pathogenesis of which is yet to be fully elucidated. We describe a case of Coombs-positive haemolytic anaemia in an older Caucasian immunocompetent woman after polytrauma, resulting from suspected reactivation of CMV infection and secondary cold agglutinin disease. Clinicians should consider CMV infection in the differential diagnosis of haemolytic anaemia in immunocompetent older adults who are admitted with significant musculoskeletal trauma. Early treatment with B-cell depletion therapy to halt cold agglutinin production can be life-saving.

Lessons of the month 3: Gone but not forgotten - Osler - a reminder of the syndrome not bearing his name.

Streptococcus pneumoniae is the most frequently implicated microbial agent in community acquired bacterial pneumonia and meningitis. It is also responsible for between 1 and 3% of cases of native valve infective endocarditis, with mortality rates up to 60%. Osler first described the association between pneumococcal pneumonia, endocarditis, and meningitis secondary to bacteria that he described as 'micrococci', subsequently elucidated to be S pneumoniae by Robert Austrian, and the syndrome bears his name. We report a case of fulminant pneumococcal native aortic valve endocarditis and perforation in a young male patient with chronic alcoholism and splenectomy who exhibited poor compliance to pneumococcal prophylaxis.

Neuro-Behçet's masquerading as progressive bulbar palsy: a case report and literature review.

In patients with progressive bulbar palsy without an obvious cause, there should be a high index of suspicion for the potential diagnosis of Neuro-Behçet's Disease, even in the absence of the acute classical peripheral manifestations of Bechet's Disease, with emphasis in prompt diagnosis using 'The International Criteria for Behçet's Disease' and rapid, effective treatment in order to improve outcome.