Prevalence of adrenal insufficiency among patients with euvolemic hyponatremia

Background: The diagnosis of SIAD requires the exclusion of secondary adrenal insufficiency (AI) among patients with euvolemic hyponatremia (EuVHNa). Studies have suggested about 2.7% to 3.8% of unselected patients presenting to the emergency room with EuVHNa have undiagnosed AI and it is as high as 15% among patients admitted to specialized units for evaluation of hyponatremia. Objective: To study the prevalence of AI among inpatients with EuVHNa in a general medical ward setting Methods: This was a prospective, single centre observational study conducted among general medical inpatients with EuVHNa, defined as patients with a serum Na <135 mmol/L, clinical euvolemia and urine spot sodium >30mmol/L. Additionally patients with recent vomiting, current renal failure, diuretic use and those with uncontrolled hyperglycemia were excluded. Adrenal functions were assessed by a modified ACTH stimulation test called Acton Prolongatum™ stimulation test (APST). A cut off cortisol value of <18mg/dl after 60 minutes of ACTH injection was used to diagnose AI. Results: One hundred and forty-one (141) patients were included and underwent an APST. APST suggested 20/141 (14.2%) had undiagnosed AI. The most common cause of AI (9/20) was secondary AI because of the use of steroids including inhaled steroids and indigenous medicines contaminated with steroids. In 5 (3.5%) patients hypopituitarism was newly diagnosed. Despite primary adrenal insufficiency not commonly presenting as EuVHNa, 2/20 patients had primary adrenal insufficiency. Conclusions: AI is much commoner in our country among inpatients with EuVHNa primarily driven by exogenous steroid use and undiagnosed hypopituitarism.

SPINAL TUBERCULOSIS REVISTED : STUDY OF CLINICALPRESENTATION, DIAGNOSIS, AND MANAGEMENT OF SPINAL TUBERCULOSIS IN A TERTIARY CARE CENTRE IN SOUTH INDIA

Introduction: Tuberculosis is a disease that affects mostly young individuals in their productive formative years. The risk is 20–37 times greater in HIV co- infected individuals than among those without HIV. Spinal tuberculosis is uncommon in the western world as compared to Asian countries. But it is e-emerging in Western Countries due to the HIV pandemic. Aim Of The Study: This study analysis the clinical presentation, neuroradiology manifestations, and treatment aspects of spinal tuberculosis. Design: Observational study. Materials And Methods: Patients admitted in government Royapettah hospital during the year July 2018- February 2020 in the general medical ward with the diagnosis of paraplegia / paraparesis and subsequently diagnosed with spinal tuberculosis were recruited for the study. 35 of them were diagnosed to have spinal tuberculosis after Inclusion and exclusion criteria. Detailed history was taken, examination was done and appropriate imaging (MRI Spine, CT Chest) was taken. Results: 1 (2.9 %) patient had intramedullary lesion in the form of longitudinally extensive transverse myelitis. 34 (97.1 %) patients had extra medullary lesion. 26 (74.3 %) patients underwent medical management. All of them were started on CAT I ATT DOTS regimen along with steroids. 9 (25.7 %) of them underwent both surgical and medical management. Conclusion: The prime aim of treatment of spinal tuberculosis is prevention of deformity so that patients can have a better quality of life. Paramount to this is a high index of suspicion, early detection and initiation of treatment. A holistic treatment approach in all cases of spinal tuberculosis is needed to prevent this dreaded complication.

High-Flow Nasal Cannula for Patients with Acute Respiratory Failure Treated in a General Medical Ward: A Prospective Cohort Study

Background: Hypoxemia and the need for oxygen administration are frequent causes of hospital admission. High-flow nasal cannula (HFNC) delivers heated humidified high-flow gas at an adjustable inspired oxygen fraction via a large-bore nasal cannula and provide specific physiological benefits. The efficacy of HFNC has been investigated in the intensive care unit but data in other care settings are scarce, especially in low- and middle-income countries. Objective: To describe the safety and associated clinical outcomes of HFNC used in patients admitted to general medical wards. Materials and Methods: The present study was a prospective cohort study that enrolled adult patients with acute respiratory failure and no other major organ failures admitted to the general medical wards at Siriraj Hospital in Bangkok and treated with HFNC. Enrolled subjects were managed by a multidisciplinary care team trained in HFNC usage. The primary outcome was to determine the rate of HFNC failure, defined as the subsequent need for endotracheal intubation, non-invasive ventilation (NIV), reintubation, or death within 48 hours. Secondary outcomes included determining the in-hospital mortality, 28-day mortality, and the factors associated with HFNC failure. Results: Seventy-one subjects were enrolled. In these patients, acute de novo hypoxemic respiratory failure was the most common indication for HFNC (42.3%), followed by prophylaxis after extubation (38.0%), and cardiogenic pulmonary edema (19.7%). The overall rate of HFNC failure was 25.4%. The overall in-hospital and 28-day mortality rates were 14.1% and 21.1%, respectively. The only factor associated with HFNC failure was the respiratory rate at day 1. Conclusion: The use of HFNC in general medical wards is feasible, but a 25% rate of failure within 48 hours can be expected. A higher respiratory rate at day 1 is associated with the failure of HFNC. Keywords: Acute respiratory failure; General medical ward; High-flow oxygen therapy; Outcomes; Safety

Post-infectious and post-acute sequelae of critically ill adults with COVID-19

Background Data on the post-acute and post-infectious complications of patients who have recovered from severe coronavirus disease 2019 (COVID-19) are limited. While studies report that approximately 5–15% of COVID-19 hospitalized patients require intensive care and mechanical ventilation, a substantially higher number need non-invasive ventilation and are subject to prolonged hospitalizations, with long periods of immobility and isolation. The purpose of this study is to describe the post-infectious sequelae of severe viral illness and the post-acute complications of intensive care treatments in critically ill patients who have recovered from severe COVID-19 infection. Methods We performed a retrospective chart review of adult patients initially hospitalized with confirmed COVID-19 infection, who recovered and were transferred to a general medical ward or discharged home between March 15, 2020 and May 15, 2020, dates inclusive, after an intensive care unit (ICU) or high dependency unit (HDU) admission in a designated COVID-19 hospital in the United Arab Emirates. Demographic data, underlying comorbidities, treatment, complications, and outcomes were collected. Descriptive statistical analyses were performed. Results Of 71 patients transferred out of ICU (n = 38, 54%) and HDU (n = 33, 46%), mean age was 48 years (SD, 9.95); 96% men; 54% under age 50. Mean ICU stay was 12.4 days (SD, 5.29), HDU stay was 13.4 days (SD, 4.53). Pre-existing conditions were not significantly associated with developing post-acute complications (Odds Ratio [OR] 1.1, 95% confidence interval [CI] 0.41, 2.93, p = 1.00). Fifty nine percent of patients had complications; myopathy, swallowing impairments, and pressure ulcers were most common. Delirium and confusion were diagnosed in 18% (n = 13); all were admitted to the ICU and required mechanical ventilation. Of note, of all patients studied, 59.2% (n = 42/71) had at least 1 complication, 32.4% (n = 23) had at least 2 complications, and 19.7% (n = 14) suffered 3 or more sequelae. Complications were significantly more common in ICU patients (n = 33/38, 87%), compared to HDU patients (n = 9/33, 27%) (OR 17.6, 95% CI 5.23, 59.21, p <0.05). Conclusion In a subset of critically ill patients who recovered from severe COVID-19 infection, there was considerable short-term post-infectious and post-acute disability. Long-term follow-up of COVID-19 survivors is warranted.

What happens to people admitted to a specialist dementia unit in the west of Scotland?

AimsRecent local research examined mortality rates following admission to a dementia ward. We wanted to expand on this work and include other important health outcomes for patients admitted to our specialist in-patient dementia unit in the west of Scotland. This would provide a comprehensive overview of our in-patient population, aid service review and improve care. We hypothesised that patients admitted would be physically frail, have a significant mortality rate and would likely require long-term care post discharge.MethodThe clinical notes for each admission to the unit for one year were examined (total 62). We extracted data from a number of different areas such as demographics, mortality rates, discharge destination, readmission rates and prescribed medications.Result60% had an Alzheimer's/mixed dementia diagnosis. Average length of stay was 64 days. 62% were discharged to a care home (50% of this total had lived at home prior to admission), 18% to complex care and 20% to the community. 66% were prescribed an antipsychotic and the average number of medications was 8.4. 35% had a readmission under general medicine within a year of discharge. 19% died whilst an inpatient and a further 30% had died one year post-discharge (total one-year mortality of 44%).ConclusionPeople admitted to our dementia unit are physically frail, with only 20% returning to live in the community, 35% being readmitted to a general medical ward within a year of discharge and 44% dying during the admission or within a year of discharge. We need to bear these results in mind when considering if hospital admission is appropriate and ultimately further develop our skills in palliative and end of life care in order to provide those people admitted to our dementia unit (and those who remain at home) with the highest standard of care.

Properties of Staphylococcus lugdunensis in Children

Background. Staphylococcus lugdunensis is one of the clinically important coagulase-negative staphylococci. The purpose of this study was to elucidate the microbiological features of S. lugdunensis in hospitalized children. Methods. From January 2012 to December 2019, all isolates were retrospectively screened for S. lugdunensis. Results. Twenty-five children were eligible for study. Nineteen and six children were classified into a critical care unit group (Group A) and a general medical ward group (Group B), respectively. The prevalence of methicillin-resistant S. lugdunensis was significantly higher in Group A than in Group B (68.4% vs 0%; P < .01). Eleven children (44%) had S. lugdunensis infections, while the remaining children were colonized. Six of the 11 infected children (55%) had healthcare-associated infections. Moreover, 3 isolates exhibited the methicillin resistance. Conclusions. The bacteriological characteristics of S. lugdunensis differ depending on patient background. Selection of antibiotic treatment should in part rely on patient background data.

Unpacking the learning on consultant-led ward rounds: Lessons from ethnography in paediatrics

Introduction: Consultant-led ward round education in a busy paediatric setting is a complex process and is often ad hoc. We aimed to observe ward rounds to better understand the education opportunities available.Methods: Drawing on Argyris and Schön's (1974) theory of action, we used an ethnographic approach to observe 30 general medical ward rounds over a 3-month period, from September to December 2016. For this study we analysed the learning opportunities and the content that is explicitly taught in relation to the domains of professional practice that we espouse to teach.Results: There were many layers of learning potential observed in ward round practice. These included clinical learning, communication, professional skills and identity and institutional cultural context. Clinical learning was prioritised; however, other learning domains remained implicit and were often ignored.Discussion: Our findings highlight great complexity in ward round learning and teaching. There was significant missed educational potential in the ward round environment as well as a need for a major shift in educational focus from clinical to other professional domains. Following Argyris and Schön (1974), it is necessary to examine what we espouse against our actual educational practice. This can inform a planned or structured approach to exploit the maximum potential of ward round learning and teaching.Conclusions: Ward round education is a priority that benefits from observation, reflection and development of new models of practice. If we are not conscious of what we are teaching on rounds, and how this is occurring, we risk losing opportunities to draw on all of the learning potential available.

What information do patients want about their medicines? An exploration of the perspectives of general medicine inpatients

Background Medicines are one of the most common healthcare interventions, yet evidence shows patients often do not receive the information they want about their medicines. This affects their adherence and healthcare engagement. There is limited research exploring what information patients want about their medicines, from whom and in what format. The aim of this study was to determine the medicines information needs of patients admitted to the general medical service of a large New Zealand (NZ) hospital, and identify the barriers and enablers to meeting these needs. Methods A descriptive exploratory approach using semi-structured interviews was used to understand the needs and preferences of patients for information about their regular medicines and the barriers and facilitators to obtaining this information. Patients admitted to a general medical ward at a large NZ hospital, aged 18 years and over, prescribed one or more regular medicines, and self-managing their own medicines prior to hospitalisation were included. Semi-structured interviews were conducted with each participant (n = 30) and transcribed, then analysed using a general inductive thematic analysis approach. Results Five overarching themes captured the medicines information needs of patients: (1) autonomy; (2) fostering relationships; (3) access; (4) communication; and (5) minimal information needs. Patients desired information to facilitate their decision-making and self-management of their health. Support people, written information, and having good relationships with health providers enabled this. Having access to information at the right time, communicated in a clear and consistent way with opportunities for follow-up, was important. A significant portion of participants were satisfied with receiving minimal information and had no expectations of needing more medicines information. Conclusions Although patients’ medicines information needs varied between individuals, the importance of receiving information in an accessible, timely manner, and having good relationships with health providers, were common to most. Considering these needs is important to optimise information delivery in general medical patients.

Survival and Estimation of Direct Medical Costs of Hospitalized COVID-19 Patients in the Kingdom of Saudi Arabia

Objectives: Assess the survival of hospitalized coronavirus disease 2019 (COVID-19) patients across age groups, sex, use of mechanical ventilators (MVs), nationality, and intensive care unit (ICU) admission in the Kingdom of Saudi Arabia. Methods: Data were retrieved from the Saudi Ministry of Health (MoH) between 1 March and 29 May 2020. Kaplan–Meier (KM) analyses and multiple Cox proportional-hazards regression were conducted to assess the survival of hospitalized COVID-19 patients from hospital admission to discharge (censored) or death. Micro-costing was used to estimate the direct medical costs associated with hospitalization per patient. Results: The number of included patients with complete status (discharge or death) was 1422. The overall 14-day survival was 0.699 (95%CI: 0.652–0.741). Older adults (>70 years) (HR = 5.00, 95%CI = 2.83–8.91), patients on MVs (5.39, 3.83–7.64), non-Saudi patients (1.37, 1.01–1.89), and ICU admission (2.09, 1.49–2.93) were associated with a high risk of mortality. The mean cost per patient (in SAR) for those admitted to the general Medical Ward (GMW) and ICU was 42,704.49 ± 29,811.25 and 79,418.30 ± 55,647.69, respectively. Conclusion: The high hospitalization costs for COVID-19 patients represents a significant public health challenge. Efficient allocation of healthcare resources cannot be emphasized enough.