Icatibant in angiotensin-converting enzyme (ACE) inhibitor-associated angioedema.

BACKGROUND: Angioedema occurs in up to 2% of those taking angiotensin-converting enzyme (ACE) inhibitors. Upper airway angioedema may potentially require endotracheal intubation or cricothyrotomy, and is usually unresponsive to adrenaline. The bradykinin receptor antagonist icatibant is proven to be effective in the treatment of acute attacks of hereditary angioedema, and has also been reported effective in the treatment of angioedema associated with ACE inhibitors. AIM: To describe the use of icatibant for ACE inhibitor-associated airway angioedema. METHODS: We treated 13 consecutive emergency department (ED) patients, who had not improved with adrenaline and/or corticosteroids, with icatibant 30 mg subcutaneously for ACE inhibitor-associated upper respiratory tract angioedema according to an agreed protocol. RESULTS: Four patients were intubated in the ED either before or after receiving icatibant; three of these were extubated within 24 h of treatment. Eight patients received early icatibant and did not require intubation. The time from onset of airway angioedema to ED presentation ranged from 1 h to 3 days (median 4 h); from ED presentation to receiving icatibant, from 30 minutes to 3 days (median 3 h); and to onset of symptom improvement after icatibant, 15 minutes to 7 h (median 2 h). One patient received a second dose of icatibant. CONCLUSION: All patients improved after receiving icatibant, consistent with its bradykinin receptor blocking mechanism. Icatibant rapidly reversed symptoms, and appeared to avert the need for intubation or expedite extubation. Timely use of icatibant in ACE inhibitor-associated angioedema may avert the need for invasive airway procedures and intensive care unit admission.

Characteristics and outcomes of discharges against medical advice among hospitalised patients.

BACKGROUND: Discharge against medical advice (DAMA) occurs when an in-patient chooses to leave the hospital before discharge is recommended by the treating clinicians. The long-term outcomes of patients who DAMA are not well documented. AIM: The objective of this long-term and hospital-wide study is to examine characteristics of patients who DAMA, their rates of readmission and mortality after self-discharge. METHODS: Administrative data of admissions to Flinders Medical Centre between July 2002 and June 2011 were used to compare readmissions and mortality among patients who DAMA with those who did not. The outcomes were adjusted for age, gender, emergency admission status, comorbidity, mental health diagnoses, and alcohol and substance abuse. RESULTS: In the study period, 1562 episodes (1.3%) of 121,986 admissions to Flinders Medical Centre were DAMA. Compared with those who did not leave against medical advice, these patients were younger, more often male, more likely of indigenous ethnicity and had less physical comorbidity, but greater mental health comorbidity. Half of the DAMA group stayed less than 3 days. In multivariate analysis, the relative risk for 7-day, 28-day and 1-year readmission in the DAMA group was 2.36 (95% confidence interval (CI), 1.99-2.81; P < 0.001), 1.66 (95% CI, 1.44-1.92; P < 0.001) and 1.31 (95% CI, 1.19-1.45; P < 0.001), respectively, compared with standard discharges. Furthermore, DAMA was associated with twofold (P = 0.02), 1.4-fold (P = 0.025) and 1.2-fold (P = 0.049) increase in 28-day, 1-year and up-to-9-year mortality, respectively, compared with non-DAMA. CONCLUSIONS: Patients who self-discharged against medical advice carry a significant risk of readmission and mortality. Patients with characteristics of 'at risk of DAMA' should have greater attention paid to their care before and especially after any premature discharge.

The significance of reduced kidney function among hospitalized acute general medical patients.

BACKGROUND: Inpatient general medical units often look after older patients who have more complex co-morbidity including renal insufficiency. The consequences of renal insufficiency with respect to length of hospital stay (LOS) and mortality have not been well described in hospitalized general medical patients. AIM: To use a general medical inpatient population to evaluate the impact of reduced kidney function. DESIGN: Retrospective cross-sectional study. METHODS: We studied 504 acute medical admissions through an Acute Assessment Unit between February and November 2007. Patients were classified as having chronic kidney disease (CKD), acute kidney injury (AKI), neither (control) or both. LOS, in-hospital mortality and post-discharge survival were evaluated. RESULTS: Renal impairment was present in 151 patients. Ninety patients had CKD only and 61 had AKI with or without CKD. In-hospital mortality was increased in those with renal impairment compared with controls (9.3 vs. 3.4%; P = 0.006). Within 4 years of admission, 187 (39%) patients had died. Post-discharge mortality was significantly higher in all renal failure populations (hazard ratio: 2.57-4.38; P < 0.01). Adjustment for patient age, gender and Charlson index explained the increased mortality during and after hospital admission but did not explain increased LOS. Only a small proportion (13%) of admitted patients with renal insufficiency had renal disease documented in their discharge summaries. CONCLUSION: Many general medical inpatients (30%) have reduced kidney function at the time of admission. This study provides validation of the Modification of Diet in Renal Disease equation as a predictor of poor outcomes. Reduced renal function was associated with increased hospital LOS and mortality. Mortality rose with AKI and was explicable on the basis of the patients' age and co-morbidities. Renal insufficiency is documented infrequently in discharge summaries.

Visual deterioration caused by vitamin A deficiency in patients after bariatric surgery.

Vitamin A deficiency (VAD) after bariatric surgery is recognised as a significant post-operative complication that can lead to visual impairment. We report two cases of night blindness and visual impairment caused by VAD after malabsorptive bariatric surgery. Both patients were treated with intramuscular vitamin A replacement and made near complete recovery in their vision. Ocular complications due to VAD should be diagnosed and treated promptly in patients after bariatric surgery because these complications are reversible.

Host-parasite relationships in experimental airborne tuberculosis. VII. Fate of Mycobacterium tuberculosis in primary lung lesions and in primary lesion-free lung tissue infected as a result of bacillemia.

Evidence suggests that in humans tuberculous disease usually arises at apical or subapical sites in the lungs seeded as a consequence of an early bacillemic phase of the infection. This study examined the fate of bacilli transported via the bloodstream to metastatic sites in the lungs of guinea pigs after aerosol infection with approximately two viable virulent Mycobacterium tuberculosis. The results revealed that, even after logarithmic-phase multiplication of bacilli in primary lesions had been terminated, bacilli seeded via the bloodstream to metastatic sites in the lung were able to multiply. These observations, made in an animal model that mimics the conditions under which tuberculosis develops in human subjects, challenge the relevance of systemic macrophage activation in experimental airborne tuberculosis in guinea pigs.

Host-parasite relationships in experimental airborne tuberculosis. V. Lack of hematogenous dissemination of Mycobacterium tuberculosis to the lungs in animals vaccinated with Bacille Calmette-Guérin.

The influence of bacille Calmette-Guérin (BCG) on the pathogenesis of experimental airborne tuberculosis was studied. In a model that approximates the conditions under which man is vaccinated and infected, BCG-vaccinated and unvaccinated guinea pigs were infected by the respiratory route with an inoculum that resulted in the inhalation and retention (by each animal) of approximately three virulent tubercle bacilli (Mycobacterium tuberculosis strain H37Rv). Hematogenous seeding of the lungs occurred in unvaccinated animals about three weeks after aerosol infection but did not occur in BCG-vaccinated animals. Furthermore, the lungs of BCG-vaccinated animals failed to kill H37Rv that was introduced intravenously; however, evidence of mycobacteriostatic activity was found throughout the lungs. In view of the importance of hematogenous dissemination to the apex of the lungs in the establishment of pulmonary tuberculosis in man, the foregoing observations suggest a means by which vaccination with BCG may confer acquired resistance to tuberculosis.