Prediction admission in the older population in the Emergency Department: the CLEARED tool.

BACKGROUND: Length of stay (LOS) in the Emergency Department (ED) is correlated with an extended in-hospital LOS and may even increase 30-day mortality. Older patients represent a growing population in the ED and they are especially at risk of adverse outcomes. Screening tools that adequately predict admission could help reduce waiting times in the ED and reduce time to treatment. We aimed to develop and validate a clinical prediction tool for admission, applicable to the aged patient population in the ED. METHODS: Data from 7,606 ED visits of patients aged 70 years and older between 2012 and 2014 were used to develop the CLEARED tool. Model performance was assessed with discrimination using logistic regression and calibration. The model was internally validated by bootstrap resampling in Erasmus Medical Center and externally validated at two other hospitals, Medisch Spectrum Twente (MST) and Leiden University Medical Centre (LUMC). RESULTS: CLEARED contains 10 predictors: body temperature, heart rate, diastolic blood pressure, systolic blood pressure, oxygen saturation, respiratory rate, referral status, the Manchester Triage System category, and the need for laboratory or radiology testing. The internally validated area under the curve (AUC) was 0.766 (95% CI [0.759;0.781]). External validation in MST showed an AUC of 0.797 and in LUMC, an AUC of 0.725. CONCLUSIONS: The developed CLEARED tool reliably predicts admission in elderly patients visiting the ED. It is a promising prompt, although further research is needed to implement the tool and to investigate the benefits in terms of reduction of crowding and LOS in the ED.

Investigating screening for diabetes in women with a history of gestational diabetes.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is encountered more frequently in women with a history of gestational diabetes (GD). Screening for T2DM after pregnancy is, therefore, recommended every ≥ 1-3 years in this population. Early detection could allow for timely intervention strategies, especially in women of childbearing age. Data on adherence to diabetes screening recommendations and the prevalence of T2DM in this population are not available in the Dutch population. AIM: To investigate the T2DM screening rate and evaluate the risk of T2DM in the five-year period following GD pregnancy. METHODS: Single-centre survey in 85 women diagnosed with GD in 2010, using electronic medical records. Primary care physicians were asked to complete a survey regarding the screening frequency and the onset of T2DM in the five-year period following the GD pregnancy. RESULTS: On average 33% underwent yearly screening. The screening rate, however, went up to 61.2% after primary care physicians were requested to screen this population in 2015. Of the women who were screened, 10 (19.2%) developed T2DM within five years after GD. CONCLUSION: Current screening recommendations are poorly met, leading to missed, or delayed diagnosis of T2DM in our population. T2DM is a frequently occurring long-term complication in those who were screened in the five-year period after delivery. Optimising awareness amongst health care professionals of GD as a risk factor for T2DM is warranted and strategies to improve surveillance are necessary.

Effects of DDAVP on renal hemodynamics and renin secretion in subjects with essential hypertension.

Intravenous (i.v.) infusion of the selective vasopressin (V2) agonist 1-desamino-8-D-arginine vasopressin (DDAVP, Desmopressin) in humans causes a fall in blood pressure, an increase in heart rate, and a rise in plasma renin and noradrenaline. The present study was designed to demonstrate the vasodilatory properties of DDAVP in the renal circulation and to describe the effect of DDAVP on renin secretion. Seven male subjects (31-63 years) with hypertension, who showed no signs of renal parenchymal disease, received an i.v. infusion of DDAVP (400 ng/kg in 10 minutes). They were studied at the time they were undergoing renal vein renin sampling and renal angiography as part of the diagnostic work-up of their hypertension. 131I-Hippurate clearance was used to measure effective renal plasma flow (ERPF). True renal plasma flow was calculated as ERPF divided by the renal extraction ratio of 131I-hippurate. 125I-Thalamate clearance was used to measure glomerular filtration rate (GFR). Measurements were made before and 15-20 minutes after administration of DDAVP. Angiography was performed in the same session after the last blood samples had been collected. In all patients the renal arteries were normal and the extraction ratios of 131I-hippurate and 125I-thalamate (Ehip, Ethal) were not different for the left and right kidney, and in all seven patients a diagnosis of essential hypertension was made. After DDAVP systolic blood pressure decreased by 14.4 mmHg (2.0-26.8) (mean, 95% confidence interval, p < 0.05). Diastolic blood pressure decreased by 12.1 mmHg (2.9-21.7, p < 0.01). Heart rate increased by 17.5 bpm (11.7-23.2, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Phosphate binders do not reduce bioavailability of oral cefuroxime-axetil in patients on peritoneal dialysis treatment.

Cefuroxime is a second-generation cephalosporin that can be used for the treatment of peritoneal dialysis-related peritonitis. Cefuroxime-axetil is an orally available pro-drug of cefuroxime. The effect of concomitant use of a phosphate binder on the bioavailability of cefuroxime-axetil was studied in 7 continuous ambulatory peritoneal dialysis (CAPD) patients who had not recently suffered from peritonitis. On two occasions, we measured cefuroxime levels in plasma, peritoneal effluent, and urine for 24 h after the ingestion of 1 g of cefuroxime-axetil: once together with a phosphate binder (+PB) and once without (-PB). Peak plasma concentrations (Cmax) were +PB: 22.7 mg/L (15.3-32.6) (median and range) and -PB: 23.2 mg/L (18.9-27.4). The area under the curve (AUC) of the plasma levels was +PB: 364 mg h/L (247-530) and -PB: 368 mg h/L (296-438). The plasma elimination half-life (t1/2) was +PB: 13.9 h (11.5-14.6) and -PB: 13.8 h (12.2-15.4). Cefuroxime concentrations in the peritoneal effluent from the first exchange were 1.9 mg/L (0.5-6.2) (+PB) and 3.4 mg/L (2.1-4.7) (-PB). In the peritoneal effluent from the second up to the last exchange, the cefuroxime levels were stable at +PB: 5.0 mg/L (2.0-8.8) and -PB: 5.3 mg/L (1.8-7.5). The total amount of cefuroxime excreted into peritoneal effluent and urine was +PB: 82 mg (30-124), -PB: 100 mg (36-129). So Cmax, AUC, t1/2 and the total amount of excreted cefuroxime were not different. Therefore, the bioavailability of cefuroxime-axetil is not reduced by the use of a phosphate binder.

1-Desamino-8-D-arginine vasopressin (DDAVP) in patients with congenital nephrogenic diabetes insipidus.

In healthy subjects, intravenous infusion of the selective V2-vasopressin receptor agonist 1-desamino-8-D-arginine vasopressin (DDAVP, 400 ng/kg in 10 min) causes a marked increase in heart rate with a slight decrease in diastolic blood pressure. These haemodynamic responses are associated with increments in the plasma levels of renin, noradrenaline (NA), clotting factor VIII (FVIII:C), von Willebrand factor (vWF:ag), and tissue-type plasminogen activator (t-PA), and a fall in the plasma level of plasminogen activator inhibitor (PAI). None of these changes was observed in 3 patients with congenital nephrogenic diabetes insipidus (NDI), who had a genetic defect of the V2-receptor. Plasma AVP levels in these patients were normal or slightly elevated, which makes it unlikely that the lack of DDAVP responsiveness was caused by down-regulation of vasopressin V1-receptors. In one NDI patient, arginine vasopressin (AVP) was given in incremental doses (62.5-4000 pg/kg/min). The heart rate and blood pressure responses to AVP were normal, indicating the absence of a V1-receptor defect. The responses of vWF:ag and t-PA to venous occlusion in the patients with NDI were similar to those in 5 healthy volunteers, which indicates that in NDI the endothelial release of both vWF:ag and t-PA is normal. We conclude that DDAVP causes its effects on heart rate and blood pressure, and on the plasma levels of renin, noradrenaline, FVIII:C, vWF:ag, and t-PA through V2-receptor stimulation.