Acute patients discharged without an established diagnosis: risk of mortality and readmission of nonspecific diagnoses compared to disease-specific diagnoses.

BACKGROUND: Nonspecific discharge diagnoses after acute hospital courses represent patients discharged without an established cause of their complaints. These patients should have a low risk of adverse outcomes as serious conditions should have been ruled out. We aimed to investigate the mortality and readmissions following nonspecific discharge diagnoses compared to disease-specific diagnoses and assessed different nonspecific subgroups. METHODS: Register-based cohort study including hospital courses beginning in emergency departments across 3 regions of Denmark during March 2019-February 2020. We identified nonspecific diagnoses from the R- and Z03-chapter in the ICD-10 classification and excluded injuries, among others-remaining diagnoses were considered disease-specific. Outcomes were 30-day mortality and readmission, the groups were compared by Cox regression hazard ratios (HR), unadjusted and adjusted for socioeconomics, comorbidity, administrative information and laboratory results. We stratified into short (3-<12 h) or lengthier (12-168 h) hospital courses. RESULTS: We included 192,185 hospital courses where nonspecific discharge diagnoses accounted for 50.7% of short and 25.9% of lengthier discharges. The cumulative risk of mortality for nonspecific vs. disease-specific discharge diagnoses was 0.6% (0.6-0.7%) vs. 0.8% (0.7-0.9%) after short and 1.6% (1.5-1.7%) vs. 2.6% (2.5-2.7%) after lengthier courses with adjusted HRs of 0.97 (0.83-1.13) and 0.94 (0.85-1.05), respectively. The cumulative risk of readmission for nonspecific vs. disease-specific discharge diagnoses was 7.3% (7.1-7.5%) vs. 8.4% (8.2-8.6%) after short and 11.1% (10.8-11.5%) vs. 13.7% (13.4-13.9%) after lengthier courses with adjusted HRs of 0.94 (0.90-0.98) and 0.95 (0.91-0.99), respectively. We identified 50 clinical subgroups of nonspecific diagnoses, of which Abdominal pain (n = 12,462; 17.1%) and Chest pain (n = 9,599; 13.1%) were the most frequent. The subgroups described differences in characteristics with mean age 41.9 to 80.8 years and mean length of stay 7.1 to 59.5 h, and outcomes with < 0.2-8.1% risk of 30-day mortality and 3.5-22.6% risk of 30-day readmission. CONCLUSIONS: In unadjusted analyses, nonspecific diagnoses had a lower risk of mortality and readmission than disease-specific diagnoses but had a similar risk after adjustments. We identified 509 clinical subgroups of nonspecific diagnoses with vastly different characteristics and prognosis.

Feasibility of Assessing Older Patients in the Acute Setting: Findings From the Copenhagen PROTECT Study.

OBJECTIVES: Older patients are typically underrepresented in clinical trials despite representing a major proportion of the patient population. We aim to describe the feasibility of performing body composition measures, physical function measures, and patient-reported questionnaires within the first 24 hours of admission in a large sample of older acutely admitted medical patients. In addition, we aim to characterize patients with missing measurements. DESIGN: Secondary analyses of cross-sectional data from a cohort study. SETTING AND PARTICIPANTS: A total of 1071 acutely admitted patients aged ≥65 years from the acute medical ward at Bispebjerg Hospital, were enrolled within the first 24 hours of hospitalization. METHODS: Body composition was investigated using direct segmental multifrequency bioelectrical impedance analyses (DSM-BIA) and physical function was assessed using hand grip strength (HGS) and the 30-second sit-to-stand test (STS). The orientation-memory-concentration test (OMC) was used to evaluate the prevalence of cognitive impairments within 24 hours of hospitalization, and the OMC in conjunction with the Strength, Assistance walking, Rise from a chair, Climb stairs, and Falls questionnaire (SARC-F) was used to assess the feasibility of patient-reported outcomes (PROs). RESULTS: Mean age was 78.8 ± 7.8 years (53.0% female). HGS was performed in 96.2% of the enrolled patients, whereas the PRO, 30-second STS, and DSM-BIA were performed in 91.2%, 69.2%, and 59.8% of patients, respectively. The main barrier for performing the 30-second STS and body composition measurements was an inability to mobilize the patient from the hospital bed. CONCLUSIONS AND IMPLICATIONS: The assessment of HGS and PROs show excellent feasibility in clinical research including older patients, even when the patients are enrolled and tested within 24 hours of an acute admission. Assessments of DSM-BIA and the 30-second STS show good feasibility but are less feasible in immobile patients often presenting as more frail, weaker, and cognitively impaired.

Oral ketone esters acutely improve myocardial contractility in post-hospitalized COVID-19 patients: A randomized placebo-controlled double-blind crossover study.

Background: COVID-19 is associated with subclinical myocardial injury. Exogenous ketone esters acutely improve left myocardial function in healthy participants and patients with heart failure, but the effects have not been investigated in participants previously hospitalized for COVID-19. Methods: This is a randomized placebo-controlled double-blind crossover study comparing a single oral ketone ester dose of 395 mg/kg with placebo. Fasting participants were randomized to either placebo in the morning and oral ketone ester in the afternoon or vice versa. Echocardiography was performed immediately after intake of the corresponding treatment. Primary outcome was left ventricular ejection fraction (LVEF). Secondary outcomes were absolute global longitudinal strain (GLS), cardiac output and blood oxygen saturation. Linear mixed effects models were used to assess differences. Results: We included 12 participants previously hospitalized for COVID-19 with a mean (±SD) age of 60 ± 10 years. The mean time from hospitalization was 18 ± 5 months. Oral ketone esters did not increase LVEF between placebo and oral ketone ester [mean difference: -0.7% (95% CI -4.0 to 2.6%), p = 0.66], but increased GLS [1.9% (95% CI: 0.1 to 3.6%), p = 0.04] and cardiac output [1.2 L/min (95% CI: -0.1 to 2.4 L/min), p = 0.07], although non-significant. The differences in GLS remained significant after adjustment for change in heart rate (p = 0.01). There was no difference in blood oxygen saturation. Oral ketone esters increased blood ketones over time (peak level 3.1 ± 4.9 mmol/L, p < 0.01). Ketone esters increased blood insulin, c-peptide, and creatinine, and decreased glucose and FFA (all p ≤ 0.01) but did not affect glucagon, pro-BNP, or troponin I levels (all p > 0.05). Conclusion: In patients previously hospitalized with COVID-19, a single oral dose of ketone ester had no effect on LVEF, cardiac output or blood oxygen saturation, but increased GLS acutely. Clinical trial registration: https://clinicaltrials.gov/, identifier NCT04377035.

Comparison of two frailty screening tools for acutely admitted elderly patients.

INTRODUCTION: Frailty is a clinical syndrome that arises due to age-related decline, diseases, malnutrition and lifestyle. Two major perspectives on frailty exists: frailty as a phenotype and frailty as an accumulation of deficits. The two types are measured by Fried's Phenotype (FP) and the Clinical Frailty Scale (CFS), respectively. The aim of this study was to investigate which model best predicts 90-day mortality in elderly patients acutely admitted to an emergency department in Denmark. METHODS: This study comprised a prospective cohort with the following inclusion criteria: age > 65 years, acute admission and admission >24 h. Bispebjerg Hospital, Odense University Hospital and Hospital of Southwest Jutland participated in the study. The FP and the CFS were measured in all patients. Descriptive statistics, relative risk (RR), odds ratio (OR), risk difference and receiver-operating characteristics (ROC) analysis were performed. The outcome was 90-day mortality. RESULTS: A total of 1,030 patients participated (mean age: 78.2 years, 54% female). Among these, 221 were frail by the FP (score > 3) and 555 participants were frail by the CFS (score > 5). Within 90 days, 128 died. The analyses revealed significant associations between frailty and 90-day mortality. For the FP, the RR was 2.67 (95% confidence interval (CI): 1.93-3.69), p less-than 0.001; and for the CFS, the RR was 4.12 (95% CI: 2.65-6.42), p less-than 0.001. The adjusted OR for the CFS was 4.38 (95% CI: 2.68-7.13); for the FP, 3.88 (95% CI: 2.51-6.01). CONCLUSION: A significant association existed between frailty and 90-day mortality in the Danish cohort. However, the CFS is a better predictor of 90-day mortality the FP. Even so, the CFS still has a lack of sensitivity and specificity. FUNDING: none TRIAL REGISTRATION. not relevant.

Triage Strategies Based on C-Reactive Protein Levels and SARS-CoV-2 Tests among Individuals Referred with Suspected COVID-19: A Prospective Cohort Study.

C-reactive protein (CRP) has prognostic value in hospitalized patients with COVID-19; the importance of CRP in pre-hospitalized patients remains to be tested. Methods: Individuals with symptoms of COVID-19 had a SARS-CoV-2 PCR oropharyngeal swab test, and a measurement of CRP was performed at baseline, with an upper reference range of 10 mg/L. After 28 days, information about possible admissions, oxygen treatments, transfers to the ICU, or deaths was obtained from the patient files. Using logistic regression, the prognostic value of the CRP and SARS-CoV-2 test results was evaluated. Results: Among the 1006 patients included, the SARS-CoV-2 PCR test was positive in 59, and the CRP level was elevated (>10 mg/L) in 131. In total, 59 patients were hospitalized, only 3 of whom were SARS-CoV-2 positive, with elevated CRP (n = 2) and normal CRP (n = 1). The probability of being hospitalized with elevated CRP was 4.21 (95%CI 2.38-7.43, p < 0.0001), while the probability of being hospitalized with SARS-CoV-2 positivity alone was 0.85 (95%CI 0.26-2.81, p = 0.79). Conclusions: CRP is not a reliable predictor for the course of SARS-CoV-2 infection in pre-hospitalized patients. CRP, while not a SARS-CoV-2 positive test, had prognostic value in the total population of patients presenting with COVID-19-related symptoms.

Biomarkers for length of hospital stay, changes in muscle mass, strength and physical function in older medical patients: protocol for the Copenhagen PROTECT study-a prospective cohort study.

INTRODUCTION: Sarcopenia is generally used to describe the age-related loss of muscle mass and strength believed to play a major role in the pathogenesis of physical frailty and functional impairment that may occur with old age. The knowledge surrounding the prevalence and determinants of sarcopenia in older medical patients is scarce, and it is unknown whether specific biomarkers can predict physical deconditioning during hospitalisation. We hypothesise that a combination of clinical, functional and circulating biomarkers can serve as a risk stratification tool and can (i) identify older acutely ill medical patients at risk of prolonged hospital stays and (ii) predict changes in muscle mass, muscle strength and function during hospitalisation. METHOD AND ANALYSIS: The Copenhagen PROTECT study is a prospective cohort study consisting of acutely ill older medical patients admitted to the acute medical ward at Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark. Assessments are performed within 24 hours of admission and include blood samples, body composition, muscle strength, physical function and questionnaires. A subgroup of patients transferred to the Geriatric Department are included in a smaller geriatric cohort and have additional assessments at discharge to evaluate the relative change in circulating biomarker concentrations, body composition, muscle strength and physical function during hospitalisation. Enrolment commenced 4 November 2019, and proceeds until August 2021. ETHICS AND DISSEMINATION: The study protocol has been approved by the local ethics committee of Copenhagen and Frederiksberg (H-19039214) and the Danish Data Protection Agency (P-2019-239) and all experimental procedures were performed in accordance with the Declaration of Helsinki. Findings from the project, regardless of the outcome, will be published in relevant peer-reviewed scientific journals in online (www.clinicaltrials.gov). TRIAL REGISTRATION NUMBER: NCT04151108.

Comparison between temporal and rectal temperature measurement.

INTRODUCTION: Various digital thermometers for non-invasive use have been used increasingly in Danish hospitals, including the temporal artery thermometer (TAT). However, previous studies have concluded that the accuracy of the TAT is unsatisfying for paediatric, surgical, cancer and intensive care patients. The purpose of this study was to compare the accuracy of the TAT with that of a conventional rectal thermometer (REC) within acutely admitted medical patients at an emergency department. METHODS: This was a prospective, comparative study. For two months, 381 patients were included. At a maximum interval of seven minutes, the temperature was measured first with a temporal artery thermometer and then with an REC. The measurements were analysed in a Bland-Altman plot, and the sensitivity and specificity of the TAT were calculated. RESULTS: The differences between the TAT and the REC ranged from -1.7 °C to 1.7 °C. The mean of the difference was drawn in the Bland-Altman plot through 0.17 with a standard deviation of ± 0.47. The sensitivity and specificity were calculated to 67% and 96%, respectively. CONCLUSIONS: Based on this study, we do not recommend the use of the TAT as an alternative to an REC for non-invasive measuring of the body temperature in acutely admitted medical patients. FUNDING: All authors received honoraria from The Capital Region of Denmark. TRIAL REGISTRATION: Study procedures were approved by the local ethical committee and submitted to www.clinicaltrials.org (NCT01817881).

Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study.

ABSTRACT: To determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients. METHODS: Prospective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy. RESULTS: 2493 patients, with median age 78-80 years (DK-Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7-8.6 vs. 5.8 95% CI 5.6-5.9) and Danish mean 7.1 (95% CI 6.6-7.5 vs. 5.5 95% CI 5.4-5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL's accuracy was only modest for in-hospital death prediction in either setting. CONCLUSIONS: The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician's confidence in initiating earlier end-of-life discussions.

Efficacy of a tool to predict short-term mortality in older people presenting at emergency departments: Protocol for a multi-centre cohort study.

BACKGROUND: Prognostic uncertainty inhibits clinicians from initiating timely end-of-life discussions and advance care planning. This study evaluates the efficacy of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist in emergency departments. METHODS: Prospective cohort study of patients aged ≥65 years with any diagnosis admitted via emergency departments in ten hospitals in Australia, Denmark and Ireland. Electronic and paper clinical records will be used to extract risk factors such as nursing home residency, physiological deterioration warranting a rapid response call, personal history of active chronic disease, history of hospitalisations or intensive care unit admission in the past year, evidence of proteinuria or ECG abnormalities, and evidence of frailty to be concurrently measured with Fried Score and Clinical Frailty Scale. Patients or their informal caregivers will be contacted by telephone around three months after initial assessment to ascertain survival, self-reported health, post-discharge frailty and health service utilisation since discharge. Logistic regression and bootstrapping techniques and AUROC curves will be used to test the predictive accuracy of CriSTAL for death within 90 days of admission and in-hospital death. DISCUSSION: The CriSTAL checklist is an objective and practical tool for use in emergency departments among older patients to determine individual probability of death in the short-term. Its validation in this cohort is expected to reduce clinicians' prognostic uncertainty on the time to patients' death and encourage timely end-of-life conversations to support clinical decisions with older frail patients and their families about their imminent or future care choices.

[Bowel ischaemia treated with stent placement]. / Tarmiskaemi behandlet med stentanlaeggelse.

This is a case report of a younger woman admitted to hospital with abdominal pain and weight loss. Four weeks after admittance, she was diagnosed with severe bowel ischaemia at laparotomy. Arteriography showed occlusive disease in the mesenteric arteries, which were treated with a stent. The entire intestine was preserved, apart from 10 cm of jejunum due to bowel perforation. The diagnosis of polyarteritis nodosa was confirmed based on biopsy and clinical symptoms.