Internal Medicine Journal最新文献

Schnitzler syndrome is a rare autoinflammatory syndrome caused by a dysregulation of the interleukin-1β signalling pathway. Symptoms tend to appear in middle age and include urticariform skin lesions, fever, bone pain, lymphadenopathy and IgM monoclonal gammopathy. Interleukin-1 (IL-1) targeted therapy constitutes the basis for treatment and can lead to complete resolution of symptoms. We report a case of Schnitzler syndrome in a 49-year-old man refractory to anakinra and subsequently treated successfully with canakinumab.

Background: The presence of a general physician assessing patients upon referral in the emergency department (ED) may improve patient outcomes compared with the traditional model of post-take ward rounds.

Aim: This study examines the impact of such an intervention on patient discharge rates and readmissions in a single centre.

Methods: From July 2019 to June 2020, a general physician was rostered to review patients on the day of referral from the ED. Four cohorts were compared: pre-intervention, intervention, concurrent controls (admitted during the intervention period but not reviewed) and post-intervention. Multivariate analyses evaluated the association between same-day consultant review and the likelihood of same-day discharge, as well as other variables including median length of stay (LoS) and readmission rate.

Results: Among 22 620 admissions, median LoS was shorter in the intervention period than in the before or after period (87 h vs. 97 and 93 h (P < 0.001)). Same-day general physician assessment increased the odds of day zero discharge by fivefold compared with before the intervention (adjusted odds ratio (aOR) 5.47, 95% confidence interval (CI): 3.62-8.26, P < 0.001). This effect was not sustained after the intervention ended (aOR 0.47, 95% CI 0.27-0.80, P < 0.006). Lower triage acuity and younger age were associated with discharge on day zero. Notably, longer ED decision time correlated with higher day zero discharge (aOR 1.09, 95% CI: 1.03-1.15), possibly reflecting appropriate consultant involvement in cases with an unclear disposition. Day zero discharge rates varied among individual general physicians (range 4.1%-14.0%). Increased day zero discharges did not lead to higher 7-day readmission rates.

Conclusions: This large trial showed that early general physician review was associated with decreased median LoS and increased rate of day zero discharge, with no increase in readmission rates or mortality. Variability between physicians suggests potential for further optimisation in practice.

The recent NEJM Evidence trial questioned the benefit of enoxaparin for venous thromboembolism (VTE) prevention among older hospitalised medical patients. We conducted a retrospective, observational audit of 142 elderly inpatients at a large Australian tertiary institution; most received enoxaparin unless contraindicated, with excellent adherence to guidelines. Clinical events were rare with two VTE (1.4%) and five minor bleeds (3.5%) recorded and no major bleeding observed. Approximately 10% of patients were ambulant and prescribed thromboprophylaxis outside guideline criteria, yet bleeding rates were low. Our findings suggest high guideline compliance and minimal bleeding associated with enoxaparin prophylaxis in this population. There is a need for simple and practical risk stratification tools with clear ambulation definitions, routine mobility assessments where appropriate and consideration of patient-accepted approaches such as oral thromboprophylaxis options.

Diabetes is a leading cause of kidney failure, and individuals with both diabetes and chronic kidney disease (CKD) experience significantly higher rates of complications and mortality. The international guideline developer Kidney Disease: Improving Global Outcomes (KDIGO) has produced clinical practice guidelines that reflect recent advances in pharmacotherapy for this population, extending beyond glycaemic control to include cardio-renal benefits. However, these guidelines were developed without specific consideration of the healthcare systems, access issues and population needs in Australia and New Zealand. In response, the Caring for Australians and New Zealanders with Kidney Impairment (CARI) Guidelines Working Group has provided a regional commentary on the KDIGO 2022 guideline. This commentary highlights key recommendations and contextualises their implementation within the Australian and New Zealand healthcare environments. It addresses issues such as medication access, equity for Indigenous populations and the importance of shared decision-making, aiming to support clinicians in delivering evidence-based, locally relevant care for people living with diabetes and CKD.

Background: Longitudinal data on in-hospital glycaemia from Australian hospitals are limited.

Aims: The aim of this study was to evaluate the efficacy and safety of current inpatient management strategies in New South Wales hospitals and to compare hospital-acquired complication (HAC) rates in patients with and without diabetes. We also evaluated trends in diabetes admissions, glycaemia and HAC between 2017 and 2024.

Methods: This was a retrospective, observational study of adult medical and surgical admissions to three hospitals over an 8-year period.

Results: Diabetes was observed in 21% of admissions (n = 84 864/398 803), with the proportion increasing over time (OR 1.008 per year (95% CI 1.005, 1.011), P < 0.001). Among diabetes admissions, the mean blood glucose (BG) of the hospital admission was 9.17 ± 2.82 mmol/L. The odds of BG <3 mmol/L (OR 0.996 per quarter (CI 0.994, 0.997), P < 0.001) or of BG >15 mmol/L (OR 0.999 per quarter (CI 0.998, 0.999), P = 0.012) during the admission decreased over time. The odds of hospital-acquired infection (HAI) (OR 0.977 per year (95% CI 0.962, 0.992), P < 0.001) and hospital-acquired cardiac complication (OR 0.973 per year (95% CI 0.947, 0.999), P < 0.039) decreased over time. However, the age-standardised HAI rate ratio increased in diabetes compared with non-diabetes admissions (Exp(B) 1.028 per year (95% CI 1.004, 1.032), P = 0.020). The composite HAC rate decreased in non-diabetes admissions (OR 0.982 per year (95% CI 0.975, 0.989), P < 0.001) but increased in diabetes admissions (OR 1.020 (95% CI 1.009, 1.032), P < 0.001).

Conclusion: We demonstrate marginal improvements in glycaemia. While some HACs improved, the gains were of greater magnitude in those without diabetes. These findings highlight both progress and persisting inequities in hospital outcomes for people with diabetes.

Background: Encephalitis is a condition of brain dysfunction and parenchymal inflammation with many aetiologies. Guidelines for Australia and Aotearoa New Zealand on diagnosis and management were published in 2015. There have been no recently published local studies of encephalitis.

Aims: This study assessed guideline adherence for recommended investigations and antimicrobial management of suspected community-acquired encephalitis cases. Secondary aims were to compare clinical diagnoses to the International Encephalitis Consortium (IEC) consensus case definition and to provide descriptive epidemiology of encephalitis in Sydney, Australia.

Methods: A retrospective review of medical records was conducted for all adults with a cerebrospinal fluid (CSF) sample collected between 1 July 2018 and 30 June 2019 to investigate suspected community-onset meningoencephalitis or encephalitis at four Sydney metropolitan hospitals.

Results: Two hundred and nine suspected cases were reviewed including 35 ultimately diagnosed as encephalitis. Adherence to guideline recommendations was variable but overall better in cases subsequently diagnosed as encephalitis, significantly so for some investigations. Viral polymerase chain reaction testing of non-CSF samples, serology for human immunodeficiency virus and syphilis, repeat herpes simplex virus (HSV) PCR when indicated and anti-N-methyl-D-aspartate receptor antibody testing were areas for improvement. Empiric aciclovir was not given in 30% of suspected cases but was at the appropriate dose and frequency when prescribed. Ten of 35 cases with clinical encephalitis diagnoses did not meet the IEC case definition criteria. The most common infectious aetiology was HSV, while the most common mimics were drug-associated presentations.

Conclusions: Guideline application was variable, with areas identified for improvement. Prospective studies are needed to investigate guideline-adherence barriers.

Background: Malnutrition in hospitalised patients is common and increases morbidity, mortality and health care costs.

Aim: This study aimed to determine the risk of malnutrition at hospital admission and its associated risk factors among patients admitted to the internal medicine ward.

Methods: In this prospective observational study, 1052 patients hospitalised in the internal medicine ward of a tertiary care hospital were evaluated. Malnutrition risk was assessed using the Nutritional Risk Screening 2002 (NRS-2002), and demographic characteristics, history of hospitalisation, comorbidity burden, anthropometric measurements and biochemical parameters (haemoglobin, C-reactive protein (CRP), albumin, urea, creatinine, uric acid) were recorded. Binary logistic regression analysis was performed to identify independent predictors of malnutrition risk.

Results: Of all participants, 61.4% were at high risk of malnutrition. In-hospital mortality rate (5.3%), comorbidity burden (5.70 ± 3.70) and length of hospital stay (11.0 (13.0)) were higher in the high malnutrition risk group (P < 0.05). Age, duration of hospitalisation, body mass index (BMI), CRP and albumin levels were significantly associated with malnutrition risk (P < 0.05). In binary logistic regression analysis, older age (odds ratio (OR) = 1.019; 95% confidence interval (CI): 1.006-1.032), low BMI (OR = 0.969; 95% CI: 0.948-0.990), high CRP (OR = 0.997; 95% CI: 0.995-0.999) and low albumin (OR = 0.911; 95% CI: 0.882-0.942) were independent predictors of high risk of malnutrition after adjustment for potential confounders.

Conclusion: Advanced age, prolonged hospitalisation, inflammation and hypoalbuminemia are associated with an increased risk of malnutrition. Routine screening using the NRS-2002 is likely to be more effective than subjective clinical assessment in identifying patients at risk of malnutrition and guiding appropriate nutritional interventions.