Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review.

BACKGROUND: Among older adults with delirium and positive urinalysis, antibiotic treatment for urinary tract infection is common practice, but unsupported by literature or guidelines. We sought to: i) determine the rate of antibiotic treatment and the proportion of asymptomatic patients (other than delirium) in this patient population, and ii) examine the effect of antibiotic treatment on delirium resolution and adverse outcomes. METHODS: A health record review was conducted at a tertiary academic centre from January to December 2020. Inclusion criteria were age ≥ 65, positive delirium screening assessment, positive urinalysis, and admission to general medical units. Outcomes included rates of antibiotic treatment, delirium on day 7 of admission, and 30-day adverse outcomes. We compared delirium and adverse outcome rates in antibiotic-treated vs. non-treated groups. We conducted subgroup analyses among asymptomatic patients. RESULTS: We included 150 patients (57% female, mean age 85.4 years). Antibiotics were given to 86%. The asymptomatic subgroup (delirium without urinary symptoms or fever) comprised 38% and antibiotic treatment rate in this subgroup was 68%. There was no significant difference in delirium rate on day 7 between antibiotic-treated vs. non-treated groups, (entire cohort RR 0.94 [0.41-2.16] and asymptomatic subgroup RR 0.69 [0.22-2.15]) or in 30-day adverse outcomes. CONCLUSIONS: Older adults with delirium and positive urinalysis in general medical inpatient units were frequently treated with antibiotics - often despite the absence of urinary or other infectious symptoms. We failed to find evidence that antibiotic treatment in this population is associated with delirium resolution on day 7 of admission.

Survey on Current Practice of Canadian Physicians Regarding the Investigation in Older Patients with Delirium.

Background: The current literature provides heterogeneous recommendation regarding the investigation of older delirious patients, which may lead to over-testing. Our study aims to describe Canadian physicians' current practice for the investigation of older patients with delirium. Our secondary objective is to define specific indications for performing a CT head scan in this population. Methods: Design: cross-sectional online survey. Participants: physicians who conduct their clinical practice in Canada and who care for older patients with delirium. Potential study participants were reached through Canadian associations: Canadian Geriatrics Society, the Canadian Association of Emergency Physicians, the Association des Médecins d'Urgence du Québec, and members of Choosing Wisely Canada. Results: We received 296 survey responses. More than 80% of respondents always order complete blood count, urea, and creatinine and electrolytes. Extended electrolytes, TSH, chest X-ray, electrocardiogram, urinalysis and urinary culture tests tend to be ordered somewhat frequently. Physicians mostly agreed to order a head CT scan for loss of consciousness, altered mental status, fall, and anticoagulation. Conclusions: Physicians' investigations for older patients with delirium are highly variable, even with the lack of evidence supporting a broad workup. Also, respondents mostly align with current recommendations of indications for CT head scans.

Machine learning versus traditional methods for the development of risk stratification scores: a case study using original Canadian Syncope Risk Score data.

Artificial Intelligence and machine learning (ML) methods are promising for risk-stratification, but the added benefit over traditional statistical methods remains unclear. We compared predictive models developed using machine learning (ML) methods to the Canadian Syncope Risk Score (CSRS), a risk-tool developed with logistic regression for predicting serious adverse events (SAE) after emergency department (ED) disposition for syncope. We used the prospective multicenter cohort data collected for CSRS development at 11 Canadian EDs over an 8-year period to develop four ML models to predict 30-day SAE (death, arrhythmias, MI, structural heart disease, pulmonary embolism, hemorrhage) after ED disposition. The CSRS derivation and validation cohorts were used for training and testing, respectively, and the 43 variables used included demographics, medical history, vital signs, ECG findings, blood tests and the diagnostic impression of the emergency physician. Performance was assessed using the area under the receiver-operating-characteristics curve (AUC) and calibration curves. Of the 4030 patients in the training set and 3819 patients in the test set overall, 286 (3.6%) patients suffered 30-day SAE. The AUCs for model validation in test data were CSRS 0.902 (0.877-0.926), regularized regression 0.903 (0.877-0.928), gradient boosting 0.914 (0.894-0.934), deep neural network 0.906 (0.883-0.929), simplified gradient boosting 0.904 (0.881-0.927). The AUCs and calibration slopes for the ML models and CSRS were similar. Two ML models used fewer predictors than the CSRS but matched its performance. Overall, the ML models matched the CSRS in performance, with some models using fewer predictors.

Investigation and treatment of asymptomatic bacteriuria in older patients with delirium: a cross-sectional survey of Canadian physicians.

OBJECTIVES: Current guidelines suggest assessing non-infectious causes and careful observation before giving antibiotics to delirious patients with asymptomatic bacteriuria. Our study aims to describe the current practice of Canadian physicians regarding the investigation and treatment of asymptomatic bacteriuria in delirious older patients (aged ≥ 65 years). METHODS: Our team of medical experts designed and reviewed a cross-sectional online survey. Study participants were physicians who conduct their clinical practice in Canada and care for older patients with delirium in their current practice. Potential study participants were reached through Canadian associations: Canadian Geriatrics Society, the Canadian Association of Emergency Physicians, the Association des Médecins d'Urgence du Québec and members of Choosing Wisely Canada. RESULTS: 297 physicians were included. The main results show 79.4% of our participants request a urine dipstick or urinalysis in delirious patients and 52.4% immediately order a urine culture with the urinalysis. If bacteriuria is found in delirious but afebrile patients without urinary symptoms, 38% of physicians immediately treat with antibiotics, 33.8% wait for culture before initiating treatment, 14.4% treat if no other cause is found for delirium and only 13.7% would refrain from giving antibiotics. Results from respondents were similar for delirious patients with known cognitive impairment. Participants were almost unanimous (92.5%) in saying they need clear guidelines regarding the treatment of bacteriuria in older delirious patients. CONCLUSIONS: This survey highlights the heterogeneous clinical management of asymptomatic bacteriuria in delirious patients and the need for clear guidelines for patients.

RéSUMé: OBJECTIFS: Les directives actuelles suggèrent d'évaluer les causes non infectieuses et de procéder à une observation attentive avant d'administrer des antibiotiques aux patients délirants présentant une bactériurie asymptomatique. Notre étude vise à décrire la pratique actuelle des médecins canadiens concernant l'investigation et le traitement de la bactériurie asymptomatique chez les patients âgés délirants (âgés ≥ 65 ans). MéTHODES: Notre équipe d'experts médicaux a conçu et examiné une enquête transversale en ligne. Les participants à l'étude étaient des médecins qui exercent leur pratique clinique au Canada et qui soignent des patients âgés atteints de délire dans leur pratique actuelle. Les participants potentiels à l'étude ont été contactés par le biais d'associations canadiennes: Société Canadienne de Gériatrie, l'Association Canadienne des Médecins d'Urgence, l'Association des Médecins d'Urgence du Québec et les membres de Choisir avec soin (Choosing Wisely Canada). RéSULTATS: 297 médecins ont été inclus. Les principaux résultats montrent que 79,4% de nos participants demandent une bandelette urinaire ou une analyse d'urine chez les patients délirants et 52,4% demandent immédiatement une culture d'urine avec l'analyse d'urine. En cas de découverte d'une bactériurie chez des patients délirants mais afébrile sans symptômes urinaires, 38% des médecins traitent immédiatement avec des antibiotiques, 33,8% attendent la culture avant de commencer le traitement, 14,4% traitent si aucune autre cause n'est trouvée pour le délire et seulement 13,7% s'abstiendraient de donner des antibiotiques. Les résultats des répondants étaient semblables chez les patients délirants ayant une déficience cognitive connue. Les participants étaient presque unanimes (92,5%) à dire qu'ils avaient besoin de lignes directrices claires concernant le traitement de la bactériurie chez les patients délirants plus âgés. CONCLUSIONS: Cette étude met en évidence la prise en charge clinique hétérogène de la bactériurie asymptomatique chez les patients délirants et la nécessité de lignes directrices claires pour les patients.

Urinary Tract Infection Investigation and Treatment in Older Adults Presenting to the Emergency Department with Confusion: a Health Record Review of Local Practice Patterns.

BACKGROUND: The rate of urinary tract infection (UTI) investigation and treatment in confused older emergency department (ED) patients has not been described in the literature. We aim to describe the pattern of practice in an academic tertiary care ED for this common presentation. METHODS: A health record review was conducted on 499 adults aged ≥65 presenting to academic EDs with confusion. Exclusion criteria: Glasgow Coma Scale < 13, current treatment for UTI, indwelling catheters, nephrostomy tubes, transfer from another hospital. Outcomes were the prevalence of UTI investigation, diagnosis and antibiotic treatment. RESULTS: 64.9% received urine tests, 11.4% were diagnosed with UTI, and 35.2% were prescribed antibiotics. In the subgroup with no urinary symptoms, fever, or other obvious indication for antibiotics, these numbers were 58.2%, 7.6%, and 18.1%, respectively. Patients who had urine tests or received antibiotics were older than those who did not (p values < .01). Patients receiving antibiotics had higher admission rates and 30-day and six-month mortality (OR of 2.9 [2.0-4.3], 4.0 [1.6-11], and 2.8 [1.4-5.8], respectively). CONCLUSION: Older patients presenting to ED with confusion were frequently investigated and treated for UTI, even in the absence of urinary symptoms. Antibiotic treatment was associated with higher hospitalization and mortality.

Clinical analysis of acute drug intoxication and foreign body ingestion in Wonju: comparison between the 1990s and the 2000s / 소아과

PURPOSE: The purpose of this study is to find out the changing pattern of drug or foreign body ingestion between 1990s and 2000s in Wonju Christian Hospital, which is located in one of the most rapidly urbanizing cities in Korea. METHODS: We retrospectively reviewed the medical records of patients with acute drug intoxication and foreign body ingestion from January 1991 to December 1994 and from January 2001 to December 2004. We performed clinical analysis and compared the results of the 1990s and 2000s. RESULTS: There were 43 cases of acute drug intoxication in the 1990s, and 35 cases in the 2000s. Foreign body ingestion was 47 cases in the 1990s and 22 cases in the 2000s. The ingested foreign bodies were chiefly coins (46.8 percent), Weiqi chips (14.9 percent), plastic toys (6.4 percent) and others (31.9 percent) in the 1990s. In the 2000s, others (58.2 percent) were the most commonly ingested foreign body with mercury batteries (23.8 percent), nails (9 percent), pins (9 percent) following. The most common cause of drug intoxication was medical drugs (37.2 percent) others (23.2 percent), agricultural agents (13.9 percent), carbon monoxide (11.6 percent), rodenticide (9.3 percent), insecticide (9.3 percent) in the 1990s. In the 2000s the most common causes were others (34.3 percent), medical drug (31.4 percent), agriculture agents (20 percent), detergent (11.4 percent), insecticide (2.9 percent) and carbon monoxide (2.9 percent). The highest incidence age group was the 1-3 year old group, both in acute drug intoxication and foreign body ingestion. There were no changes in the incidence age group between the 1990s and the 2000s. CONCLUSION: There were some significant changes in the cause of acute drug intoxication and foreign body ingestion between the 1990s and 2000s. New education programs for preventing acute drug intoxication and foreign body ingestion are important and necessary.

Intraspecific molecular phylogeny, genetic variation and phylogeography of Reticulitermes speratus (Isoptera: Rhinotermitidae).

Population structure was investigated in Reticulitermes speratus populations in the Korean Peninsula and the Japanese Archipelago. All trees derived from analyses of the combined sequence dataset of two mitochondrial genes, COII and COIII, showed that R. speratus populations cluster into two major clades comprising the Korean/southern Japanese populations and the north-ern Japanese populations. Analysis of population ge-netic structure showed strong genetic partitioning between populations of the two clades. To understand historical migration routes and current distributions, the phylogeographic history of R. speratus was inferred from intra-/interspecific phylogeny and diver-gence times estimated between the clades of the phylogenetic tree. The estimated migration route and divergence time of ancestral R. speratus are congruent with recent paleogeographic hypotheses involving land-bridge connections between the Asian continent and the Japanese Archipelago. We suggest that ancestral R. speratus separated into northern and southern Japanese populations after its migration into the Japanese main islands from East China during the early Pleistocene via the East China Sea basin, which may have been exposed during that period. The Korean populations seem to have diverged recently from southern Japanese populations; this may explain the current distribution of R. speratus in the Japanese Arachipelago, and account for why it is restricted to northern areas of the Tokara Strait.

A Case of Moyamoya Disease with Neurofibromatosis Type I / 소아과

Neurofibromatosis type I is an autosomal dominant disorder with varied manifestations in bone, soft tissue, the nervous system and skin. This is characterized by cafe-au-lait spots, neurofibromas, Lisch nodules, optic glioma, bony displasia, and intertriginous freckling. One of the more serious aspect of the disease relates to the arterial involvement. Vascular changes in neurofibromatosis may occur in any arterial tree from the proximal aorta to the small arteries but these changes are most common in the renal arteries, aorta, celiac arteries and mesenteric arteries. Of the many complications observed in neurofibromatosis type I, cerebrovascular lesions may be the least appreciated. About 40 cases of neurofibromatosis type I associated with occlusive cerebrovascular disorders have been reported in the literature, but MRI and angiographic findings typical of moyamoya disease are rarely described. We experienced a case of moyamoya disease associated with neurofibromatosis type I in a 3-year-old girl who of complained gait disturbance and paraparesis and showed findings typical of moyamoya disease on MRI and carotid angiogram.

Intrahepatic Arterio-Venous Shunts in a Patient with Hypergalactosemia Detected by Neonatal Screening

We report a case of 15 days old newborn presenting with hypergalactosemia detected by newborn screening who had intrahepatic arterio-venous shunts with multiple pin-head sized cutaneous hemangiomas. Plasma level of galactose was elevated to 11.3 mg/dL at age of 7 days, but the activity of galactose-metabolizing enzymes including galactose-1- phosphate uridyltransferase, galactokinase, and uridine diphosphate galactose-4-epimerase were all normal. Intrahepatic arterio-venous shunts were diagnosed by abdominal ultrasonography with color doppler ultrasonography and abdominal computed tomography. At age of 3 months, the plasma level of galactose further elevated to 14.73 mg/dL, at which time lactose-free cows milk formula was started. At age of 6 months, the plasma level of galactose decreased to within normal range with disappearance of previously noted multiple cutaneous hemangiomas. In hypergalactosemia of the newborn, the intrahepatic shunts should be considered as a possible cause, once hereditary enzyme deficiencies have been ruled out.