Cardio pulmonary resuscitation (CPR) in the frail and those with multiple health conditions: Outcomes before and during the COVID pandemic.

Coronavirus 2019 (COVID-19)-era resuscitation guidelines advised personal protective equipment before chest compressions and proactive advanced care planning. We investigated the impact of COVID-19 on cardiopulmonary resuscitation (CPR) outcomes according to scoring of frailty and of multiple health conditions. A retrospective single-centre analysis of clinical and electronic records for all adult cardiac arrest calls on wards between June 2020 and June 2021 was performed. Data were compared with a cohort pre-COVID (March 2017-March 2018). In total, 62 patients received CPR in 2020-21 compared with 113 in 2017-18. Similar rates of return of spontaneous circulation (ROSC) and a statistically insignificant survival increase from 23.8% to 32.2% (p=0.210). There were linear relationships between Clinical Frailty Scale (CFS) or Charlson Comorbidity Index (CCI) and diminished survival in the pooled data (both p<0.001). Both increasing frailty (measured by CFS) and comorbidity (measured by CCI) were associated with reduced survival from CPR. However, survival and ROSC during COVID-19 were no worse than before the pandemic.

Barriers to Home Haemodialysis.

INTRODUCTION: Significant variation exists in the prevalence of home haemodialysis (HHD) among UK renal centres. Our centre has a HHD prevalence of 2%, and we aimed to study how many patients who chose HHD as their preferred mode of renal replacement therapy (RRT) went on to receive this treatment and the barriers to starting this treatment. METHODS: A retrospective single-centre analysis of electronic medical records for all patients who chose HHD at the time of RRT education was performed, and data were collected on patient demographics, comorbidity, frailty, RRT events, and barriers to HHD. RESULTS: 116 patients chose HHD as their preferred mode of RRT between 2006 and 2018. Of these patients, 93 required RRT, but only 28 patients ever received HHD. No statistical difference was identified between those patients who only received unit haemodialysis (UHD) and those who went onto receive HHD with respect to age, gender, comorbidity, frailty, and socioeconomic deprivation. Patient choice, change in clinical condition, transplantation, home environment, vascular access problems, and training delays were identified as reasons patients did not start HHD. No documented reason could be found in 9 patients with a breakdown of communication between clinics and peripheral dialysis units attributed as a significant contributor in some of these patients. Of the 26 patients who started HHD after UHD, 19 did so within 1 year of starting UHD. CONCLUSION: Most patients who choose HHD do not receive HHD. Many patients never start HHD because of potentially reversible barriers including inadequate communication among clinicians about patient choices, patients changing their minds once in a dialysis unit, and inadequate timely training support.

Frailty, multimorbidity and in-hospital cardiopulmonary resuscitation: predictable markers of outcome?

BACKGROUND: This study's aim was to investigate an association between outcome from in-hospital cardiopulmonary resuscitation (CPR) and increasing burden of comorbidities and frailty. METHODS: Retrospective analysis of prospectively collected data from contemporaneous patient notes and electronic records of all patients who suffered an in-hospital cardiac arrest between 1 April 2017 and 31 March 2018 in a hospital that includes a tertiary cardiology department. RESULTS: A total of 113 patient records were assessed. Patient frailty was assessed based on calculation of Rockwood clinical frailty score (CFS) and comorbidity assessment based on Charlson comorbidity index (CCI). A linear correlation has been identified between increasing CCI and reduced survival (ANOVA = p<0.001) and rates of return of spontaneous circulation (ROSC) (ANOVA = 0.013). No patients with a CFS above 6 survived to 1 year. A linear correlation was identified between increasing CFS and reduced probability of ROSC (ANOVA p=0.002), survival to discharge (ANOVA p=0.003) and 1 year (ANOVA p=0.001). CONCLUSION: Our findings suggest an association between increasing patient multimorbidity and frailty and poorer outcome post cardiac arrest.

Slumped posture on chest X-ray-association with mortality and length of hospital stay in older hospitalised patients.

INTRODUCTION: frail, older patients are occasionally incapable of keeping their head out of the field of view of a chest radiograph (CXR) resulting in a 'slumpogram'. This study aims to explore a possible link between a slumped appearance on a CXR; mortality and length of hospital stay. METHODS: the CXRs of patients aged over 65 admitted to a Health Board with a catchment area of approximately 300,000 were investigated in a retrospective analysis of all CXRs taken during the first week of January 2015. Slumped patients were compared to age matched controls. The degree of slumping was measured by the number of ribs covered and the MA/C factor (the shortest distance between the angle of the mandible and a line drawn between the heads of both acromion divided by the length of the patient's clavicle). Outcomes investigated included length of hospital stay and 18-month mortality. RESULTS: 806 CXRs were viewed with 53 slumped patients and 53 matched controls identified. In all patients aged over 65 there was a statistically significant correlation between the length of stay and the number of ribs covered by the patients' head (P = 0.038). The MA/C factor was also associated with length of stay (P = 0.025). In patients over 80 there was a significant association between the number of ribs covered and death (P = 0.015). CONCLUSION: a slumped CXR may be associated with longer hospitalisation or death. The results of this small study require further revalidation but if true could help inform clinical decision making.

Mirtazapine-induced steatosis
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Mirtazapine is a commonly used drug indicated for the treatment of severe depression. It works as a presynaptic α2-adrenoreceptor antagonist that increases central noradrenergic and serotonergic neurotransmission, and it is metabolized by the p450 cytochrome oxidase system. There is evidence within the literature to suggest a link between antidepressants and increased liver enzymes, although case reports demonstrating a link between mirtazapine specifically and steatosis are sparse. Here, we present a case of mirtazapine-induced steatosis in a 48-year-old office worker. She presented with painless jaundice of 2 days duration and generalized lethargy and peripheral edema present for 3 weeks beforehand. Extensive investigations were undertaken to identify the cause of her jaundice but no biochemical, blood-borne, or anatomical cause could be found. Mirtazapine was subsequently stopped, and her liver function, both clinically and biochemically, improved rapidly. She made a full recovery after discontinuation of her mirtazapine.
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