General Medical Admissions Research Articles

Prediction of medical admissions after psychiatric inpatient hospitalization in bipolar disorder: a retrospective cohort study.

Bipolar Disorder (BD) is a severe mental illness associated with high rates of general medical comorbidity, reduced life expectancy, and premature mortality. Although BD has been associated with high medical hospitalization, the factors that contribute to this risk remain largely unexplored. We used baseline medical and psychiatric records to develop a supervised machine learning model to predict general medical admissions after discharge from psychiatric hospitalization. In this retrospective three-year cohort study of 71 patients diagnosed with BD (mean age=52.19 years, females=56.33%), lasso regression models combining medical and psychiatric records, as well as those using them separately, were fitted and their predictive power was estimated using a leave-one-out cross-validation procedure. The proportion of medical admissions in patients with BD was higher compared with age- and sex-matched hospitalizations in the same region (25.4% vs. 8.48%). The lasso model fairly accurately predicted the outcome (area under the curve [AUC]=69.5%, 95%C.I.=55-84.1; sensitivity=61.1%, specificity=75.5%, balanced accuracy=68.3%). Notably, pre-existing cardiovascular, neurological, or osteomuscular diseases collectively accounted for more than 90% of the influence on the model. The accuracy of the model based on medical records was slightly inferior (AUC=68.7%, 95%C.I. = 54.6-82.9), while that of the model based on psychiatric records only was below chance (AUC=61.8%, 95%C.I.=46.2-77.4). Our findings support the need to monitor medical comorbidities during clinical decision-making to tailor and implement effective preventive measures in people with BD. Further research with larger sample sizes and prospective cohorts is warranted to replicate these findings and validate the predictive model.

Medical Emergency Team call within 24 h of medical admission with a focus on sepsis: a retrospective review.

Clinical deterioration within the first 24 h of patient admission triggering a Medical Emergency Team (MET) call is a common occurrence. A greater understanding of these events, with a focus on the recognition and management of sepsis, could lead to quality improvement interventions. A retrospective observational review of general and subspecialty medical admissions triggering a MET call within 24 h of admission at a quaternary Australian hospital. 2648 MET calls occurred (47.9/1000 admissions), 527 (20% of total MET events, 9.5/1000 admissions) within 24 h of admission, with the trigger more likely to be hypotension (odds ratio: 1.5, P = 0.0013). There were 263 MET calls to 217 individual medical patients within 24 h of admission, of which 84 (38.7%) were admitted with suspected infection, 69% of which fulfilled sepsis criteria. Of these, 36.2% received antimicrobial therapy within the recommended timeframe and 39.6% received antibiotics in line with hospital guidelines. Sepsis was initially missed in 11% of patients. Afferent limb failure occurred in 29% of patients with 40.5% experiencing a failure of the ward-based response to deterioration prior to MET call. Median hospital length of stay was increased in patients admitted with suspected infection (7 vs 5 days, P = 0.015) and in those with sepsis not receiving antimicrobial therapy within guideline timeframes (9 vs 4 days, P = 0.017). There is a significant opportunity to improve care for patients who trigger a MET within 24 h of admission. This study supports the implementation of a hospital sepsis management guideline.

#3311 INDEPENDENT PREDICTORS FOR COMMUNITY-ACQUIRED ACUTE KIDNEY INJURY: A PROSPECTIVE COHORT STUDY

Abstract Background and Aims Acute Kidney Injury (AKI) is a syndrome characterized by an abrupt drop in glomerular filtration and/or a decrease in urinary output. The awakening to a different kind of AKI that also occurs outside the hospital named community-acquired AKI (CA-AKI) occurred in 1991, however, few data have been published about its epidemiology, risk factors and outcome, especially in low-income countries. The recognition of risk factors for CA-AKI and development of symptom-based risk tool that aims to predict the risk of AKI might be able to avoid delays in its recognizing, improve the timely diagnosis and patient outcomes in this frequent syndrome. We aimed to assess CA-AKI incidence, characteristics and independent risk factors associated with CA-AKI; to evaluate the discriminatory capacity of a clinical score tool to AKI prediction to predict CA-AKI in our sample. Method We conducted a prospective observational study of general medical admissions to a tertiary hospital in Campinas (São Paulo) between 10th January 2019 and 16th September 2021; we included patients ≥ 14 years, medical suspicion of infection (or confirmed) and /or presence of at least one of the signs or symptoms on admission: fever, dyspnea, decrease in urine output, edema, hypotension, hemodynamic shock, jaundice, petechiae, ecchymosis or decreased level of consciousness. We excluded patients with stage 5 chronic kidney disease at baseline and pre-existing renal replacement therapy (undergoing dialysis and renal transplantation), and also patients with COVID diagnosis. All patients included were assessed utilizing a symptom-based risk score to predict the development of severe AKI, the need for dialysis and mortality. Patients were subjected to complete history taking, socioeconomic and education data were collected. Healthy literacy was assessed using the test of functional health literacy in adults – short version (S- TOFHLA). Predictors of CA-AKI risk were assessed using multivariate logistic regression analysis. Patients were followed up until discharged hospital. The study outcomes were development of CA-AKI, hospital mortality, dialytic need. Results We enrolled 261 patients. CA-AKI was diagnosed in 65 (25%) patients. The CA-AKI patients were older [59 (51-66) vs. 54 (38-65) years, p = 0,02], had higher basal serum creatinine [0,7 (0,5–0,9) vs. 0,6 (0,5-0,8) mg/dL; p = 0,01], lower baseline estimated glomerular filtration rate (eGFR) [103 (88–113) vs. 109 (97–121) mL/min/1,73 m2; p = 0,01] and lower eGFR on admission [64 (44 – 81) vs. 104 (82 – 116) mL/min/1,73 m2; p = 0,0001]. Liver and heart disease were most common comorbidities in the group CA-AKI [10 (16%) vs. 14 (7%) patients, p = 0.04 and 21 (33%) vs. 39 (20%), p = 0,03, respectively]. The risk score did not show significant accuracy to predicting CA-AKI, however, logistic regression showed that scores ≥7 points (OR 95% CI 1.282, 6.133 p = 0.010) followed by age (OR 95% CI 1.007, 1.044 p = 0.008] and liver disease (95% CI 1.063, 6.379 p = 0,036) were independent factors associated with increased risk for CA-AKI in our population. A higher percentage of patients in our sample declared household income < $ 719.73 (month) and the CA-AKI group maintained the same distribution. Only 41 (16%) patients were able to perform the S-TOFHLA and 18 (44%) were considered inadequate or insufficient health literacy. For hospitalized patients, the mean hospital stay in CA-AKI group was longer [8 (4-18) vs. 4 (2-11) days p = 0,001] than without CA-AKI. Overall mortality rate during the follow up was 5% (13 patients), need dialysis 1% (2 patients) and were not statistically significant between the groups. Conclusion Healthy literacy, education, and social class did not show association with CA-AKI; dialysis needed and mortality were not different between the groups CA-AKI or without CA-AKI. Covariates and factors associated with risk for CA-AKI were age, liver disease and scores ≥7 points. The main limitation of our study was not feasible to screen all the patients due to the high numbers seen daily.

Predicting length of stay for acute medical admissions in New Zealand: the MALICE score.

Predicting length of stay (LoS) in hospital can help guide patient placement, facilitate rapid discharge and aid identification of patients at risk of prolonged stay, in whom early multidisciplinary intervention is warranted. We aimed to pilot the applicability of a modified decision aid (MALICE score) for predicting LoS for acute medical admissions at a New Zealand hospital. A prospective pilot study of 220 acute general medical admissions was performed. Clinical records were reviewed and MALICE scores were calculated for each patient and compared with LoS data using the Kruskal-Wallis H test. A statistically significant increase in LoS was seen with rising MALICE scores (H value 26.85, P < 0.001). MALICE scoring could be employed to guide patient placement and identify patients at risk of prolonged stays, though further study of bedside feasibility and applicability is required.

Development of an acute medical unit to optimize patient flow and early discharges in a tertiary care hospital in the United Arab Emirates

BackgroundHospitals worldwide are seeing an increased number of acute admissions, with resultant emergency department (ED) crowding and increased length of stay (LOS). Acute Medical Units (AMUs) have developed throughout the United Kingdom and other Western countries to reduce the burden on EDs and improve patient flow. Limited information is available on AMUs in the Middle East. The purpose of this study is to describe the development of the first AMU in the United Arab Emirates (UAE) for general medical patients and its impact on LOS, early discharges, ED boarders, and readmission rates.MethodsWe established a consultant-led AMU in a tertiary hospital in the UAE. A retrospective comparative review of all general medical admissions to the AMU between August 1, 2020 and December 31, 2020 and all admissions to the traditional medical wards between August 1, 2019 and December 31, 2019 was conducted.ResultsThe average LOS reduced from 10 to 5 days (95% CI [4.14–6.25], p < 0.001) after the introduction of AMU. Early discharges increased by 22%. The number of outliers and number of patients boarding in ED reduced significantly (111 in 2019 vs. 60 in 2020, p < 0.05; 938 in 2019 vs. 104 in 2020, p < 0.001 respectively), with a decrease in ED waiting time from 394 min to 134 min (95% CI [229.25–290.75], p < 0.001). There was no increase in 30-day readmission rates.ConclusionRestructuring the system of care can reduce LOS, overcome discharge barriers and improve patient flow. Similar units can be developed in hospitals throughout the UAE and the region to reduce LOS and improve patient flow through acute care units.

Antibiotic review kit for hospitals (ARK-Hospital): a stepped-wedge cluster-randomised controlled trial

Strategies to reduce antibiotic overuse in hospitals depend on prescribers taking decisions to stop unnecessary antibiotic use. There is scarce evidence for how to support these decisions. We evaluated a multifaceted behaviour change intervention (ie, the antibiotic review kit) designed to reduce antibiotic use among adult acute general medical inpatients by increasing appropriate decisions to stop antibiotics at clinical review. We performed a stepped-wedge, cluster (hospital)-randomised controlled trial using computer-generated sequence randomisation of eligible hospitals in seven calendar-time blocks in the UK. Hospitals were eligible for inclusion if they admitted adult non-elective general or medical inpatients, had a local representative to champion the intervention, and could provide the required study data. Hospital clusters were randomised to an implementation date occurring at 1-2 week intervals, and the date was concealed until 12 weeks before implementation, when local preparations were designed to start. The intervention effect was assessed using data from pseudonymised routine electronic health records, ward-level antibiotic dispensing, Clostridioides difficile tests, prescription audits, and an implementation process evaluation. Co-primary outcomes were monthly antibiotic defined daily doses per adult acute general medical admission (hospital-level, superiority) and all-cause mortality within 30 days of admission (patient level, non-inferiority margin of 5%). Outcomes were assessed in the modified intention-to-treat population (ie, excluding sites that withdrew before implementation). Intervention effects were assessed by use of interrupted time series analyses within each site, estimating overall effects through random-effects meta-analysis, with heterogeneity across prespecified potential modifiers assessed by use of meta-regression. This trial is completed and is registered with ISRCTN, ISRCTN12674243. 58 hospital organisations expressed an interest in participating. Three pilot sites implemented the intervention between Sept 25 and Nov 20, 2017. 43 further sites were randomised to implement the intervention between Feb 12, 2018, and July 1, 2019, and seven sites withdrew before implementation. 39 sites were followed up for at least 14 months. Adjusted estimates showed reductions in total antibiotic defined daily doses per acute general medical admission (-4·8% per year, 95% CI -9·1 to -0·2) following the intervention. Among 7 160 421 acute general medical admissions, the ARK intervention was associated with an immediate change of -2·7% (95% CI -5·7 to 0·3) and sustained change of 3·0% (-0·1 to 6·2) in adjusted 30-day mortality. The antibiotic review kit intervention resulted in sustained reductions in antibiotic use among adult acute general medical inpatients. The weak, inconsistent intervention effects on mortality are probably explained by the onset of the COVID-19 pandemic. Hospitals should use the antibiotic review kit to reduce antibiotic overuse. UK National Institute for Health and Care Research.

Laboratory-derived early warning score for the prediction of in-hospital mortality, intensive care unit admission, medical emergency team activation and cardiac arrest in general medical wards.

General medical wards admit a varied cohort of patients from the emergency department, some of whom deteriorate during their hospital stay. Currently, we use vital signs based warning scores to predict patients at risk of imminent deterioration, but there is now a growing body of literature that commonly available laboratory results may also help to identify those at risk. To assess whether a laboratory-based admission score can predict in hospital mortality, intensive care unit (ICU) admission, medical emergency team (MET) activation or cardiac arrest in a cohort of Australian general medical patients admitted through the emergency department (ED). We performed a retrospective observational study of all general medical admissions to hospital through the ED in 2015. Admission pathology was used to calculate a risk score. In-patient outcomes of death, ICU transfer, MET call activation or cardiac arrest were collected from hospital records. We studied 2942 admissions derived from 2521 patients, with a median age of 81 years. There were 143 in-patient deaths, 82 ICU admissions, 277 MET calls and 14 cardiac arrest calls. The laboratory-based admission score had an area under the receiver operating characteristic curve (AUC-ROC) of 0.76 (95% confidence interval (CI): 0.72-0.80) for inpatient death, an AUC-ROC of 0.79 (95% CI: 0.66-0.93) for inpatient cardiac arrest, an AUC-ROC of 0.64 (95% CI: 0.58-0.70) for ICU transfer and an AUC-ROC of 0.59 (95% CI: 0.55-0.62) for MET call activation. When patients aged over 75 were analysed separately, the AUC-ROC for prediction of in-patient death was 0.74 (95% CI: 0.70-0.78) and increased to 0.86 (95% CI: 0.73-0.98) for the prediction of in-patient cardiac arrest. A simple laboratory-derived score obtained at patient admission is a fair to good predictor of subsequent in-patient death or cardiac arrest in general medical patients and in the older patient cohort. Prospective interventional studies are required to ascertain the clinical utility of this admission score.

Suboptimal management of hypernatraemia in acute medical admissions.

Hypernatraemia arises commonly in acute general medical admissions. Affected patients have a guarded prognosis with high rates of morbidity and mortality. Age-related physiology and physical/cognitive barriers to accessing water predispose older patients to developing hypernatraemia. This study sought to perform a descriptive retrospective review of hypernatraemic patients admitted under acute general medicine teams. A retrospective cross-sectional study of a sample of acute medical in-patients with serum[sodium]>145 mmol/L was conducted. Patients were exclusively older(>69 years) and admitted from Nursing homes (NH)(41%) and non-NH pathways(59%). A comparison of management of NH /non-NH patients including clinical presentation, comorbidities, laboratory values, [sodium] monitoring, intravenous fluid regimes and patient outcomes was performed. In total, 102 consecutive patients (males, n=69(67.6%)) were included. Dementia and reduced mobility were more common in NH residents and admission serum [Sodium] higher (148 vs 142 mmol/L/p=0.003). Monitoring was inadequate: no routine bloods within the first 12h in >80% of patients in both groups. No patient had calculated free water deficit documented. More NH patients received correct fluid management (60% vs 33%/p%0.015). Incorrect fluid regimes occurred in both groups (38% vs 58%/p=0.070). Length of stay in discharged patients was lower in NH, (8(4-20) vs 20.5(9.8-49.3 days)/p=0.003). Time to death for NH residents was shorter (9(5.5-11.5) vs 16 (10.25-23.5) days/p=0.011). This study highlights suboptimal management of hypernatraemia. Implementation of hypernatraemia guidelines for general medical older inpatients are clearly required with mechanisms to confirm adherence. Health care workers require further education on diagnostic challenges of dehydration in older people and the importance of maintaining adequate hydration.

Physician-initiated HIV testing leads to missed opportunities in an East London Hospital Acute Admissions Unit

Background The United Kingdom National Guidelines for Human Immunodeficiency Virus (HIV) Testing 2008 suggest that an HIV test should be considered in all general medical admissions, when diagnosed HIV prevalence exceeds 2 in 1000 in the local population. We evaluated physician-initiated HIV testing rates in the Acute Assessment Unit of an East London hospital. Methods All acute presentations over one month were reviewed retrospectively, using electronic records. Patients with confirmed HIV were identified and the requested diagnostic HIV tests were measured. The number of patients with clinical indicator conditions for adult HIV infection, as defined in the United Kingdom National Guidelines for HIV Testing 2008, who did not receive appropriate testing, was calculated. Results In the cohort of 1023 patients, two patients had known HIV. 58 diagnostic HIV tests were performed, including 40 tests in patients with no clinical indicator diseases. There were five admissions with ‘AIDS-defining conditions’, all of which were pulmonary tuberculosis and four out of five (80.0%) were tested. There were 118 admissions with ‘conditions where HIV testing should be offered’, 14 of which (11.9%) were tested. All HIV tests were negative. Conclusion Physician-initiated HIV testing was inadequate for such a high prevalence area, even in clinical indicator diseases. Physician-initiated HIV testing should be replaced with routine opt-out HIV testing in acute medical admissions units in areas of high HIV prevalence, as suggested by BHIVA (British HIV Association) guidelines, as we progress towards ending the HIV epidemic in the United Kingdom.

Prediction of general medical admission length of stay with natural language processing and deep learning: a pilot study.

Length of stay (LOS) and discharge destination predictions are key parts of the discharge planning process for general medical hospital inpatients. It is possible that machine learning, using natural language processing, may be able to assist with accurate LOS and discharge destination prediction for this patient group. Emergency department triage and doctor notes were retrospectively collected on consecutive general medical and acute medical unit admissions to a single tertiary hospital from a 2-month period in 2019. These data were used to assess the feasibility of predicting LOS and discharge destination using natural language processing and a variety of machine learning models. 313 patients were included in the study. The artificial neural network achieved the highest accuracy on the primary outcome of predicting whether a patient would remain in hospital for > 2days (accuracy 0.82, area under the received operator curve 0.75, sensitivity 0.47 and specificity 0.97). When predicting LOS as an exact number of days, the artificial neural network achieved a mean absolute error of 2.9 and a mean squared error of 16.8 on the test set. For the prediction of home as a discharge destination (vs any non-home alternative), all models performed similarly with an accuracy of approximately 0.74. This study supports the feasibility of using natural language processing to predict general medical inpatient LOS and discharge destination. Further research is indicated with larger, more detailed, datasets from multiple centres to optimise and examine the accuracy that may be achieved with such predictions.

Changing perceptions: a multicentre survey of final-year medical students’ and junior doctors’ perceptions of diabetes and endocrinology

Purpose of the studyThe National Health Service is experiencing a recruitment crisis across many medical specialties. Diabetes and endocrinology (D&E) is failing to fill training posts with only 77%, 83%...

Audit of Early Mortality among Patients Admitted to the General Medical Ward at a District Hospital in Botswana.

Background:Mortality among adult general medical admissions has been reported to be high across sub-Saharan Africa, yet there is a paucity of literature on causes of general medical inpatient mortality and quality-related factors that may contribute to the high incidence of deaths. Based on a prior study at our hospital as well as our clinical experience, death early in the hospitalization is common among patients admitted to the adult medical wards.Objective:Quantify early inpatient mortality and identify factors contributing to early in-hospital mortality of medical patients in a resource-limited hospital setting in Botswana.Methods:Twenty-seven cases of patients who died within 48 hours of admission to the general medical wards at Scottish Livingstone Hospital in Molepolole, Botswana from December 1, 2015–April 25, 2016 were retrospectively reviewed through a modified root cause analysis.Findings:Early in-hospital mortality was most frequently attributed to septic shock, identified in 20 (74%) of 27 cases. The most common care management problems were delay in administration of antibiotics (15, 56%), inappropriate fluid management (15, 56%), and deficient coordination of care (15, 56%). The most common contributing factors were inadequate provider knowledge and skills in 25 cases (93%), high complexity of presenting condition in 20 (74%), and inadequate communication between team members in 18 (67%).Conclusions:Poor patient outcomes in low-and middle-income countries like Botswana are often attributed to resource limitations. Our findings suggest that while early in-hospital mortality in such settings is associated with severe presenting conditions like septic shock, primary contributors to lack of better outcomes may be healthcare-provider and system-factors rather than lack of diagnostic and therapeutic resources. Low-cost interventions to improve knowledge, skills and communication through a focus on provider education and process improvement may provide the key to reducing early in-hospital mortality and improving hospitalization outcomes in this setting.

Resuscitation status in psychogeriatric and general medical inpatients aged 65 years and older: a retrospective comparison study

Objective The aims of the present study were to establish rates of resuscitation order documentation of patients aged ≥65 years from both psychogeriatric and general medical units and to compare patients on predictors of resuscitation status, particularly examining the effect of depression. Methods A retrospective case note audit of psychogeriatric (n=162) and general medical (n=135) unit admissions within a tertiary teaching hospital was performed. Multivariate logistic regression was used to determine significant clinical and demographic predictors of resuscitation status. Results Resuscitation orders were documented in more psychogeriatric (94.4%) than general medical (48.1%) files. Depression did not significantly predict resuscitation status in either group. Having undergone competency assessment significantly predicted resuscitation status for the total sample and separately for psychogeriatric and medical patients. Older age (overall sample), poorer prognosis (overall sample), living in residential care (overall sample and medical group) and self-consenting to resuscitation status (overall sample and medical group) significantly predicted resuscitation status. Conclusions Resuscitation orders were more frequently documented on the psychogeriatric unit. Further prospective analysis is needed of how resuscitation orders are made before depression is discounted as a predictor of end-of-life decision-making. What is known about the topic? Despite increased community, media and research attention to end-of-life decision-making, resuscitation preferences of older patients are often poorly documented. Existing research into patient clinical and demographic factors that influence end-of-life decision-making have largely focused on general medical rather than psychogeriatric settings. There is a need to investigate rates of resuscitation documentation in psychogeriatric and general medical units and specific factors associated with having a 'do not attempt resuscitation' order in place, particularly the effect of current depression on decision-making. What does this paper add? Resuscitation orders were more frequently documented on the psychogeriatric than medical unit. Depression was not a significant predictor of resuscitation status in either group of patients. Although having undergone a competency assessment, older age and poorer prognosis predicted not being for resuscitation for the total sample, living in residential care and self-consenting to resuscitation status predicted not being for resuscitation for the overall sample and the medical group specifically. What are the implications for practitioners? This paper suggests that the need for clinicians to ensure documentation of preferences is a focus of day-to-day work with older patients. Clinicians should consider patient competency in end-of-life decision-making and how factors associated with depression, such as helplessness, may be more closely related to resuscitation decision-making in older patients.

Managing side effects of cancer immunotherapy for the acute physician.

Immunotherapy is a novel type of anti-cancer treatment that works by upregulating the host's immune system to fight against cancer cells. Landmark immunotherapy trials have demonstrated improvements in response rates and survival compared to cytotoxic chemotherapy. Specific immunotherapies known as checkpoint inhibitors are now routinely used in a range of cancers including melanoma, lung, renal and urological cancers. Immunotherapies are associated with immune-related adverse events which are very different to those seen with traditional cytotoxic chemotherapies. This can present a new challenge to oncologists, acute physicians and the wider team of health-care professionals who look after patients receiving immunotherapy. Generally, these side effects are easily managed but some, if untreated, can be subtle and potentially life-threatening. Patients on immunotherapy may present to a wide variety of medical professionals including the emergency department, primary care and general medical admissions units. It is therefore vital that there is increased awareness and education to identify and manage side effects of immunotherapy effectively.

Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis

BackgroundReduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality.MethodsWe conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model.ResultsFrom 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias).ConclusionsReduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium.

093 EPIDEMIOLOGY AND OUTCOMES OF COMMUNITY ACQUIRED VERSUS HOSPITAL ACQUIRED ACUTE KIDNEY INJURY IN PATIENTS ADMITTED TO HOSPITAL KAJANG

Category: Epidemiology and Outcomes from AKI Presenter: DR. NURUL IZAH AHMAD Keywords: acute kidney injury, community acquired, hospital acquired Epidemiological data on AKI from an urban district is very limited. There is even less attention paid on the prevalence of community acquired AKI (CA-AKI) versus hospital acquired AKI (HA-AKI). Early detection and management of AKI will improve patients’ outcomes and reduce the burden of disease. To study the incidence and short term outcomes of patient with CA-AKI versus HA-AKI in a district hospital. A retrospective cohort study of general medical admissions to Hospital Kajang between 1st November 2016 to 31st December 2016 was conducted. Case notes of all patients were reviewed. Based on Kidney Disease: Improving Global Outcome (KDIGO) classification for AKI, the patients with serum creatinine increased 26μmol/L or more than the baseline during admission identified into CA-AKI group whereas HA-AKI was defined as the development of AKI at any time after 48 hours of hospitalization. The treatment outcomes were recorded on discharge day. Data was statistically analyzed. A total of 1319 adult were admitted to general medical wards. There were 105 (56.5%) male and 81 (43.5%) female having AKI, giving a total of 186 patients. The incidence of AKI was 14.1%. Mean age of the AKI patients was 55.6 years old. In this study, 135 (72.6%) patients developed AKI in the community, whereas 51 (27.4%) patients had AKI during hospital stay. Average length of stay for CA-AKI versus HA-AKI patients was 6.8 days and 9.1 days respectively; P=0.06. Patients with CA-AKI had lower inpatient mortality (15.6% versus 47.1% in HA-AKI group; P<0.001). Among CA-AKI patients, 76 (66%) had recovery of renal function compared to 10 (37%) patients in HA-AKI group; (P<0.01). Meanwhile, HA-AKI patient is more likely to be labeled as having de novo CKD as compared to patients with CA-AKI (63% versus 34%; P<0.005). Renal replacement therapy was done to 11 (5.9%) patients and only 19 (13%) patients had renal follow up after discharge. CA-AKI carries better implication in terms of development of progressive renal disease and inpatient mortality.

HIV testing in general medical admissions – a missed ­opportunity

To assess the rate of HIV testing in general medical admissions to a London teaching hospital. All general medical admissions under the acute medical team from 1–14 January 2016 were recorded using the medical take list. The virology results and discharge summaries of all these patients were

Mimics and chameleons in stroke

Ischaemic stroke is a treatable medical emergency. In an era of time-dependent reperfusion techniques, it is crucial that an accurate and prompt diagnosis is made. Approximately 30% of patients admitted to hyperacute stroke units are subsequently found not to have a final diagnosis of acute stroke although some of these patients do have incidental or previously symptomatic cerebrovascular disease. These patients do not benefit from thrombolysis and may require the input of other specialists or treatments. Meanwhile, a proportion of patients with acute stroke have unusual presentations and are sometimes initially admitted to general medical admissions units prior to accessing stroke unit care. It is important that atypical presentations of stroke are recognised so that patients are not denied the benefits of stroke unit care and secondary prevention. This article describes some characteristics of common stroke mimics and chameleons, considers how to avoid diagnostic mistakes and discusses the contributory role of imaging.

Recreational drug use and chemsex among HIV-infected in-patients: a unique screening opportunity.

While a high rate of recreational drug use (RDU) has been documented among HIV-infected out-patients, particularly in men who have sex with men (MSM), there is a distinct lack of data for HIV-infected in-patients. Hospital admission offers a unique opportunity to engage drug users. We aimed to establish and characterize RDU among new admissions to a large dedicated London HIV in-patient unit and compare it to RDU among general medical admissions to inform clinical pathways. A prospective opt-out survey was administered to all new HIV-positive admissions over a 10-week period (cases) and all medical Acute Assessment Unit admissions over two 24-h periods (controls). All provided consent for urine toxicology upon admission. Data were collected in 59 of 65 (91%) newly admitted HIV-positive individuals and in 48 of 54 (89%) non-HIV-positive medical admissions. HIV-infected in-patients were more likely than non-HIV-positive medical admissions to be male (P < 0.0001) (71% MSM), to be younger (P < 0.0001), to report current RDU (41 vs. 10%, respectively; P = 0.0001), to have a positive urine toxicology screen (19 vs. 2%, respectively; P = 0.0091) and to be a drug-related admission (15% vs. none; P = 0.004). Thirteen of 26 HIV-infected current recreational drug users admitted to sexualized drug taking and nine to injecting drugs. Twenty-seven per cent (seven of 26) were known to drug services. Crystal methamphetamine, mephedrone, gamma butyrolactone/gamma hydroxybutyrate and ketamine were exclusively taken by MSM. In total, 13 of 59 HIV-infected in-patients had current or past infection with hepatitis C virus, of whom 92% reported lifetime drug use. These data strongly support the use of formal screening and drug service referral pathways at the time of admission to hospital to engage HIV-positive drug users.

Incidence, aetiology and outcome of community-acquired acute kidney injury in medical admissions in Malawi

BackgroundEpidemiological data on Acute Kidney Injury (AKI) from low-income countries is sparse. The aim of this study was to establish the incidence, severity, aetiology, and outcomes of community-acquired AKI in Malawi.MethodsWe conducted a prospective observational study of general medical admissions to a tertiary hospital in Blantyre between 27th April and 17th July 2015. All patients were screened on admission with a serum creatinine; those with creatinine above laboratory reference range were managed by the nephrology team. Hospital outcome was recorded in all patients.ResultsEight hundred ninety-two patients were included; 188 (21 · 1%) had kidney disease on admission, including 153 (17 · 2%) with AKI (median age 41 years; 58 · 8% HIV seropositive). 60 · 8% of AKI was stage 3. The primary causes of AKI were sepsis and hypovolaemia in 133 (86 · 9%) cases, most commonly gastroenteritis (n = 29; 19 · 0%) and tuberculosis (n = 18; 11 · 8%). AKI was multifactorial in 117 (76 · 5%) patients; nephrotoxins were implicated in 110 (71 · 9%). Inpatient mortality was 44 · 4% in patients with AKI and 13 · 9% if no kidney disease (p <0.0001). 63 · 2% of patients who recovered kidney function left hospital with persistent kidney injury.ConclusionAKI incidence is 17 · 2% in medical admissions in Malawi, the majority is severe, and AKI leads to significantly increased in-hospital mortality. The predominant causes are infection and toxin related, both potentially avoidable and treatable relatively simply. Effective interventions are urgently required to reduce preventable young deaths from AKI in this part of the world.