Acute Medicine最新文献

There are a wide number of indications for extracorporeal therapies in the critical care environment. A common indication seen by the acute physician is continuous renal replacement therapy (CRRT) in a proportion of patients with acute kidney injury. It is therefore important that acute physicians have a sound understanding of the principles of CRRT in the acutely unwell patient. This review will outline the indications for its use, commonly used methods and anticoagulation considerations. It will discuss when to start and stop CRRT as well as describing potential treatment complications. This review will also discuss the role of therapeutic plasma exchange in critical care and novel extracorporeal therapies including blood purification in sepsis and carbon dioxide removal in acute respiratory distress syndrome and acute exacerbations of obstructive lung disease. Extracorporeal membrane oxygenation is outside of the scope of this article.

Introduction: Readmission after hospital discharge is an ongoing challenge that healthcare systems face worldwide, with multimorbidity increasing the readmission risk significantly. Identifying higher risk groups of patients allows for safety netting at discharge to be implemented to prevent harm. The aim of this study was to compare readmission rates and reasons across common diagnostic groups presenting to the acute medical unit.

Method: A retrospective analysis was performed on an anonymous dataset extracted from Salford Royal Hospital from 2014 - 2022 covering all non-elective inpatient admissions to AMU or medical same day emergency care where the patient survived to discharge. Episodes were grouped according to ICD-10 diagnostic codes, with readmission rates and reasons at 30 and 90 day calculated and compared using descriptive statistics. Further subgroups were evaluated according to demographic and co-morbid features.

Results: There were 89,897 admissions to AMU and SDEC where patients survived to discharge: age 68±19 years, 53% female. 5,880 episodes were excluded due to inpatient death. The most common first admission reasons were pneumonia (n=9,121), COPD (4,800) and sepsis (3,440). The overall 30 day readmission rate was 12.3%, with the highest rates being found where first admission episode was due to liver disease (21.9%), chronic obstructive pulmonary disease (COPD, 21.1%), and falls (17.9%). 6% of all patients were readmitted within 30 days due to recurrence of the primary presenting illness, representing 49% of all readmissions. After primary illness recurrence, pneumonia was the second most common readmission reason in 17 of 22 diagnostic groups and accounted for 25% of all readmissions excluding primary illness recurrence. Overall 90 day readmission rate was 24.2% with the same 3 most common diagnostic groups (liver disease 44%, COPD 39% and falls 34%). For 90 day readmission reasons according to specified comorbidities, the highest rates were seen in heart failures (34.1%) and COPD (33.1%). The highest readmission reason in the diagnostic groups was 41.4% of heart failure patients being readmitted with respiratory causes. Heart failure was the most impactful co-morbid factor associated with higher likelihood of 90 day readmission in other disease presentations (34.4% with heart failure, 22.8% without).

Discussion: Readmission rates vary significantly between diagnostic and co-morbid groups meaning that targeting high risk groups for safety netting may be possible using only simple admission details.

Objective: To determine factors affecting inpatient sleep and assess the range and effectiveness of non-pharmacological interventions aimed at improving the sleep of patients admitted to regular care wards.

Methods: A systematic literature search was conducted in five scientific databases, including articles published from inception to June 23rd, 2023. Eligible studies evaluated sleep disturbing factors or the effect of non-pharmacological intervention(s). Meta-analyses on intervention studies were conducted using a random effects model. Certainty of evidence was assessed using the GRADE approach.

Results: Out of 591 potentially eligible studies, 229 were included in this review. Sleep disturbers were identified in 153 studies, and 102 studies were eligible for meta-analysis. Common factors contributing to poor sleep included noise, light, care-related interruptions, pain, and anxiety. The meta-analyses revealed large pooled effects in favor of sleep for the use of eye masks and earplugs, headphones and white noise, aromatherapy, massage, muscle relaxation and breathing exercises, and advanced nursing strategies. However, the certainty of the evidence ranged from moderate to very low.

Conclusion: Inpatient sleep is often disturbed by patient-related, care-related, and environmental factors. While there are promising non-pharmacological interventions, the overall quality of studies, heterogeneity in study populations, and differences in outcome measures present challenges for drawing definitive conclusions.

Objective: Emergency department (ED) crowding is a worldwide problem and one of the main causes internationally is an increase in presentations by older patients with complex and chronic care needs. Although there has been a 4,3% reduction in total ED visits from 2016-2019 in the Netherlands, the EDs still experience crowding. National crowding research has not focused on the older group in detail, hence their possible role remains ill defined. The primary aim of this study was to map the trend in ED visits by older patients in the Netherlands. The secondary aim was to identify healthcare utilization 30 days before/after ED visit.

Methods: We conducted a nationwide retrospective cohort study, using longitudinal health insurance claims data (2016-2019). The data encompasses all Dutch patients of 70 years or older who visited the ED.

Results: The number of older patients who visited the ED followed by admission, increased from 231,223 patients (2016), to 234,817 (2019). The number without admission also increased from 244,814 patients, to 274,984. There were 696,005 total visits by older patients (2016) increasing to 730,358 visits (2019).

Conclusion: The slight rise in older patients at the ED is consistent with overall population growth of older people in the Netherlands. These results indicate that Dutch ED crowding cannot be explained by mere numbers of older patients. More research is needed with data on patient level, to study other contributing factors, such as complexity of care needs within the ageing population.

Liquid fertilizers are widely used for fertilizing in- and outdoor vegetation. Despite the easy accessibility and widespread use, serious intoxications are rare. This case report describes a 61-year-old woman who was treated for life-threatening hyperkalemia, metabolic acidosis and ECG changes after intentional ingestion of liquid fertilizer. Our case shows that intake of liquid fertilizer, though infrequent, can cause serious, life threatening complications.

Aim: To compare outcomes in Emergency Department (ED) final diagnoses of (non-specific complaint) NSC, dyspnoea and pain.

Methods: We studied all ED final diagnoses of NSC, dyspnoea, and pain over 6 years (2015-2020). Multivariable logistic regression was performed.

Results: There were 49,965 admissions. 30-day in-hospital mortality was significantly lower for pain, 3.0% (95%CI 2.4%, 3.6%), compared to NSC, 4.2% (95%CI 3.8%, 4.7%), and dyspnoea, 4.6% (95%CI 4.2%, 5.0%). NSC did not predict 30-day in-hospital mortality- univariate OR 1.05 (95%CI 0.93, 1.19), multivariable OR 1.07 (95%CI 0.93, 1.23). Comorbidity and Acute Illness Severity Scores demonstrated a curvilinear relationship with 30-day in-hospital mortality.

Conclusion: An ED final diagnosis of NSC did not predict 30-day in-hospital mortality.

The Society for Acute Medicine (SAM) and Intensive Care Society (ICS) have produced joint guidance on the standards of care and infrastructure required to deliver enhanced care within Acute Medicine. The cohort of patients this relates to are in the most part already being looked after on the AMU, but co-location and providing enhanced monitoring and nursing input will ensure safe, high-quality care can be delivered to them. We strongly support the development of enhanced care units, whilst clearly acknowledging that they are not a replacement for critical care where that is indicated. Enhanced care and critical care complement each other and will help foster the close working between the two specialties that modern acute care requires. This guidance draws on expertise and existing relevant guidance from the two societies, alongside that from the Faculty of Intensive Care Medicine (FICM), British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE) and NHS England / Improvement (NHSE/I). We recognise this is an area with limited evidence and so will aim to review it regularly as the knowledge and experience in this area increases.

Listeria Monocytogenes is transmitted via ingestion of contaminated food products and can cause invasive disease in susceptible hosts. Risk factors include immunocompromise; pregnancy; being elderly; and new-born. Listeriosis is uncommon but can occur in immunocompetent individuals and has a high mortality rate. We report a case of a 62-year-old female with no obvious risk factors who presented with atypical meningism. The patient was subsequently diagnosed with listeria meningitis and made a good recovery. The patient was a gardener regularly handling soil and ingested vegetables from her allotment patch; this case is reported to highlight less common risk factors and atypical ways in which listeria may present to the acute medical take.

This commentary explores the potential impact of artificial intelligence (AI) in acute medicine, considering its possibilities and challenges. With its ability to simulate human intelligence, AI holds the promise for supporting timely decision-making and interventions in acute care. While AI has significantly contributed to improvements in various sectors, its implementation in healthcare remains limited. The development of AI tools tailored to acute medicine can improve clinical decision-making, and AI's role in streamlining administrative tasks, exemplified by ChatGPT, may offer immediate benefits. However, challenges include uniform data collection, privacy, bias, and preserving the doctor-patient relationship. Collaboration among AI researchers, healthcare professionals, and policymakers is crucial to harness the potential of AI in acute medicine and create a future where advanced technologies synergistically enhance human expertise.

Objective: To compare the SUHB mobility scale (i.e., stable(S), unstable gait(U), needing help to walk(H), or bedridden(B)) and the Emergency Severity Index (ESI) associations with admission and mortality outcomes.

Design: Post-hoc analysis of a prospective observational study including all consenting presenting to the ED over a period of 3 weeks. Odd ratios and AUCs were calculated to assess predictive performance of SUHB and compared with ESI.

Results: Out of 2422 patients, 65% presented with a stable gait, 45% with an ESI level 3. With increasing mobility impairment on the SUHB scale, the probability for admission and mortality increased. SUHB had a higher AUC than ESI for 1-year mortality.

Conclusion: SUHB was a better predictor than ESI of long-term mortality. The scale, which is rapid, requires little additional training, and no extra costs, could be used as a useful supplement to the triage process.