Period Of Acute Illness Research Articles

Managing End of Life Needs of Frail, Older Adults in the Community: The Role of a Hospital-Based Community Outreach Team

Abstract Background Our current healthcare systems are designed around periods of acute illness and are ill equipped to meet the needs of multimorbid and frail adults with worsening mobility, cognition and function. According to The Irish Longitudinal Study on Aging (TILDA), Ireland has a high proportion of hospital deaths, indicating inadequate community and home care supports. Recognizing patients who are likely to benefit from supportive and palliative approaches with a goal to die at home can be done using a combination of tools and based on advanced care planning discussions. Methods In 2021, our Department for Older Persons Services allocated a team consisting of a Registrar and Advanced Nurse Practitioner in Frailty to form an outreach service. Inpatients who appear nearing end of life who have expressed wishes to avoid further hospitalization and to die at home are identified during their admission. Home visits allow for a holistic assessment and family members are given the opportunity to ask questions. We provide education on end of life, trying to anticipate needs and often see patients and families through periods of deterioration until they stabilize again in a ‘new normal’ or begin the process of active dying. We communicate with Public Health Nurses, General Practitioners and the Community Palliative Care Team. Results Families and carers supporting loved ones who wish to avoid further hospitalization and die at home benefit from combined medical and nursing support & specialist expertise the team brings. Conclusion Addressing end of life for multimorbid patients living with severe frailty is a global challenge. Hospital admission is an ideal time to begin conversations regarding goals of care and initiate advanced care planning. The outreach team work together with hospital and community colleagues to the common goal of following patients’ wishes at end of life.

Patient activated rapid response – the ‘999’ for patients admitted to hospital

Background Patient activated rapid response (PARR) services allow patients and family members to escalate care in hospital without agreement by their primary care team. Methods This paper explores the evidence base for PARR and examines the experience of a sample of patients to identify barriers and opportunities for PARR. These are then used to develop a framework for the measurement of PARR that can be applied to quantify clinical impact and develop new research. Results The observed number of escalation events by patients and family members is small. Interviews with patients suggested concerns of patients in undermining staff and difficulties to recall the mechanics of escalation during periods of acute illness. The Quadruple aim could be used as a framework to quantify impact: In a functioning PARR system earlier recognition of illness can be facilitated by patients and this should lead to 1. a reduction in cardiac arrests and preventable deaths, 2. timely admission to critical care with shorter (cheaper) length of stay, 3. better patient engagement and Patient Reported Experience measures and 4. flatter hierarchies with higher staff satisfaction. Conclusion PARR services are in the early stages of implementation. We present a framework to measure improvement of services and research.

Recognising, reducing and preventing deconditioning in hospitalised older people.

Deconditioning is caused by complex physiological changes occurring as a result of immobility, for example during or after a period of acute illness or injury and hospitalisation. It leads to functional decline and compounds or contributes to conditions such as frailty and sarcopenia. In the past, prolonged bed rest was considered therapeutic, but the need to reduce or avoid prolonged immobility is now widely recognised. Hospital-associated deconditioning can be reduced or prevented through mobilisation strategies such as those promoted by the #EndPJparalysis campaign. This article explains the importance of reducing or preventing hospital-associated deconditioning and nurses' role in this.

Methods for detecting probable COVID-19 cases from large-scale survey data also reveal probable sex differences in symptom profiles.

Daily symptom reporting collected via web-based symptom survey tools holds the potential to improve disease monitoring. Such screening tools might be able to not only discriminate between states of acute illness and non-illness, but also make use of additional demographic information so as to identify how illnesses may differ across groups, such as biological sex. These capabilities may play an important role in the context of future disease outbreaks. Use data collected via a daily web-based symptom survey tool to develop a Bayesian model that could differentiate between COVID-19 and other illnesses and refine this model to identify illness profiles that differ by biological sex. We used daily symptom profiles to plot symptom progressions for COVID-19, influenza (flu), and the common cold. We then built a Bayesian network to discriminate between these three illnesses based on daily symptom reports. We further separated out the COVID-19 cohort into self-reported female and male subgroups to observe any differences in symptoms relating to sex. We identified key symptoms that contributed to a COVID-19 prediction in both males and females using a logistic regression model. Although the Bayesian model performed only moderately well in identifying a COVID-19 diagnosis (71.6% true positive rate), the model showed promise in being able to differentiate between COVID-19, flu, and the common cold, as well as periods of acute illness vs. non-illness. Additionally, COVID-19 symptoms differed between the biological sexes; specifically, fever was a more important symptom in identifying subsequent COVID-19 infection among males than among females. Web-based symptom survey tools hold promise as tools to identify illness and may help with coordinated disease outbreak responses. Incorporating demographic factors such as biological sex into predictive models may elucidate important differences in symptom profiles that hold implications for disease detection.

Probing the functional consequence and clinical relevance of CD320 p.E88del, a variant in the transcobalamin receptor gene.

The biological and clinical significance of the p.E88del variant in the transcobalamin receptor, CD320, is unknown. This allele is annotated in ClinVar as likely benign, pathogenic, and of uncertain significance. To determine functional consequence and clinical relevance of this allele, we employed cell culture and genetic association studies. Fibroblasts from 16 CD320 p.E88del homozygotes exhibited reduced binding and uptake of cobalamin. Complete ascertainment of newborns with transiently elevated C3 (propionylcarnitine) in New York State demonstrated that homozygosity for CD320 p.E88del was over-represented (7/348, p < 6× 10-5 ). Using population data, we estimate that ~85% of the p.E88del homozygotes born in the same period did not have elevated C3, suggesting that cobalamin metabolism in the majority of these infants with this genotype is unaffected. Clinical follow-up of 4/9 homozygous individuals uncovered neuropsychological findings, mostly in speech and language development. None of these nine individuals exhibited perturbation of cobalamin metabolism beyond the newborn stage even during periods of acute illness. Newborns homozygous for this allele in the absence of other factors are at low risk of requiring clinical intervention, although more studies are required to clarify the natural history of various CD320 variants across patient populations.

Effective Medical Therapy for Cushing Disease Can Increase the Susceptibility to Relative Hypocortisolism

ABSTRACT Objective: Pasireotide is approved for treatment of adults with Cushing disease (CD) with persistent hypercortisolism for whom surgery has failed or is not an option. Effective medical therapy for CD may increase the susceptibility of relative hypocortisolism during acute stress because of a patient's inability to compensate by increasing endogenous adrenocorticotropic hormone (ACTH) and cortisol secretion. We describe a patient with CD on pasireotide therapy for 7 years in whom biochemical eucortisolemia was achieved but subsequently experienced several distinct episodes of relative hypocortisolism during periods of acute illness. Methods: A 67-year-old man with biochemical confirmation of CD exhibited clinical and biochemical features of persistent hypercortisolism after transsphenoidal surgery despite pituitary magnetic resonance imaging showing no residual or recurrent tumor. He was enrolled into a phase 3 study (NCT00434148) and was initated on twice-daily subcutaneous pasireotide. Results: ...

Early Life Rhinovirus Wheezing, Allergic Sensitization, and Asthma Risk at Adolescence

FJ Rubner, DJ Jackson, MD Evans. J Allergy Clin Immunol. 2017;129(2):501–507 To define the relationships among specific viral illnesses and the type and timing of aeroallergen sensitization with the persistence of asthma into adolescence. This is a prospective cohort study that enrolled 289 newborns who had a parental history of respiratory allergies and/or asthma and were followed to age 13 years ( n = 213). After enrollment, the infants had scheduled visits at ages 2, 4, 6, 9, and 12 months and annually thereafter. They were also seen during periods of acute illness. At these visits, nasal lavage was collected and analyzed for respiratory viruses. The viral panel included RSV, RV, influenza types …

Workplace Accommodation for Persons With IBD: What Is Needed and What Is Accessed

People with inflammatory bowel disease (IBD) often experience periods of illness that interfere with their ability to work. We aimed to understand the need for workplace accommodation during periods of acute illness among persons IBD. Participants were recruited from the population-based University of Manitoba Research Registry and received a survey including questions assessing experiences with workplace accommodations. Data were analyzed using descriptive statistics and multivariate logistic regression modelling. A total of 1143 individuals responded to the survey (46% response rate), of whom 881 had experienced IBD symptoms in the workplace and were included in the analysis. The mean age was 48.3 years (standard deviation, 10.9); 61% were female. Mean IBD duration was 20.6 years (standard deviation, 10.5). Most respondents (73%) described IBD symptoms experienced in the workplace as severe to very severe. The most commonly required accommodations were time to go to medical appointments during working hours (81%), easy access to a toilet (71%), and a chance to take a break when not feeling well (54%). Most accommodations were arranged informally or through a supervisor. The accommodations required were very or somewhat easy to arrange about half the time. Being female, having high symptom severity, and high level of current distress were associated with a need for more accommodations, difficulty implementing accommodations, and not asking for needed accommodations. This study provides important information as to the types of accommodations that are necessary, common practices arranging for these, and level of difficulty arranging accommodations. Furthermore, characteristics associated with greater need for accommodation, reluctance to ask for them, and difficulty in arranging them were identified.

The Health Burden of Invasive Meningococcal Disease: A Systematic Review.

Although relatively rare, invasive meningococcal disease continues to be a health concern, especially in young children. This systematic review clearly delineates both the near- and long-term morbidities that can occur after, and persist beyond, the period of acute illness. Although rare, invasive meningococcal disease (IMD) continues to be a health concern in high-income countries because of its severe morbidity and relatively high case fatality rate, especially in young children. However, studies measuring sequelae of IMD across the spectrum of invasive syndromes have not been systematically reviewed. We conducted a systematic review of sequelae attributable to IMD and quality of life (QoL) in IMD survivors in high-income countries. We searched Medline, Embase, and HealthSTAR for primary studies that assessed sequelae or QoL in individuals of any age with and without IMD. Two independent reviewers screened articles, abstracted data, and performed quality appraisal. The findings were summarized qualitatively. Of 1884 citations screened, 17 studies were included. The most commonly assessed sequelae were hearing impairment, cognitive impairment, and psychological problems. In general, children with IMD had a greater incidence of hearing loss and psychological disorders, including attention-deficit/hyperactivity disorder. However, its effects on intelligence in children remain unclear. No statistical differences in overall cognitive function in adults were reported. The odds of death were significantly increased with IMD at hospital discharge and up to 30 years after disease. Lower overall QoL was observed in those who had IMD versus controls. The results of this systematic review delineate both the short- and long-term morbidities that can occur after, and persist beyond, the period of acute illness. A better understanding of the full spectrum of IMD sequelae is critical for assessing the burden of IMD and supporting healthcare planning and decision making in light of new vaccines.

Evaluation of pulmonary dysfunctions and acid–base imbalances induced by Chlamydia psittaci in a bovine model of respiratory infection

Background: Chlamydia psittaci (Cp) is a respiratory pathogen capable of inducing acute pulmonary zoonotic disease (psittacosis) or persistent infection. To elucidate the pathogenesis of this infection, a translational large animal model was recently introduced by our group. This study aims at quantifying and differentiating pulmonary dysfunction and acid–base imbalances induced by Cp.&#x0D; Methods: Forty-two calves were grouped in (i) animals inoculated with Cp (n = 21) and (ii) controls shaminoculated with uninfected cell culture (n = 21). For pulmonary function testing, impulse oscillometry, capnography, and FRC (functional residual capacity) measurement were applied to spontaneously breathing animals. Variables of acid–base status were assessed in venous blood using both (i) traditional Henderson-Hasselbalch and (ii) strong ion approach.&#x0D; Results: Both obstructive and restrictive pulmonary disorders were induced in calves experimentally inoculated with Cp. Although disorders in respiratory mechanics lasted for 8–11 days, the pattern of spontaneous breathing was mainly altered in the period of acute illness (until 4 days post inoculation, dpi). Expiration was more impaired than inspiration, resulting in elevated FRC. Ventilation was characterised by a reduction in tidal volume (−25%) combined with an increased percentage of dead space volume and a significant reduction of alveolar volume by 10%. Minute ventilation increased significantly (+50%) due to a compensatory doubling of respiratory rate. Hyperventilatory hypocapnia at 2–3 dpi resulted in slightly increased blood pH at 2 dpi. However, the acid–base equilibrium was additionally influenced by metabolic components, i.e. the systemic inflammatory response, all of which were detected with help of the strong ion theory. Decreased concentrations of albumin (2–10 dpi), a negative acute-phase marker, resulted in a decrease in the sum of non-volatile weak acids (Atot), revealing an alkalotic effect. This was counterbalanced by acidic effects of decreased strong ion difference (SID), mediated by the interplay between hypochloraemia (alkalotic effect) and hyponatraemia (acidic effect).&#x0D; Conclusions: This bovine model was found to be suitable for studying pathophysiology of respiratory Cp infection and may help elucidating functional host-pathogen interactions in the mammalian lung.

Evaluation of pulmonary dysfunctions and acid–base imbalances induced by Chlamydia psittaci in a bovine model of respiratory infection

BackgroundChlamydia psittaci (Cp) is a respiratory pathogen capable of inducing acute pulmonary zoonotic disease (psittacosis) or persistent infection. To elucidate the pathogenesis of this infection, a translational large animal model was recently introduced by our group. This study aims at quantifying and differentiating pulmonary dysfunction and acid–base imbalances induced by Cp.MethodsForty-two calves were grouped in (i) animals inoculated with Cp (n = 21) and (ii) controls sham-inoculated with uninfected cell culture (n = 21). For pulmonary function testing, impulse oscillometry, capnography, and FRC (functional residual capacity) measurement were applied to spontaneously breathing animals. Variables of acid–base status were assessed in venous blood using both (i) traditional Henderson-Hasselbalch and (ii) strong ion approach.ResultsBoth obstructive and restrictive pulmonary disorders were induced in calves experimentally inoculated with Cp. Although disorders in respiratory mechanics lasted for 8–11 days, the pattern of spontaneous breathing was mainly altered in the period of acute illness (until 4 days post inoculation, dpi). Expiration was more impaired than inspiration, resulting in elevated FRC. Ventilation was characterised by a reduction in tidal volume (−25%) combined with an increased percentage of dead space volume and a significant reduction of alveolar volume by 10%. Minute ventilation increased significantly (+50%) due to a compensatory doubling of respiratory rate. Hyperventilatory hypocapnia at 2–3 dpi resulted in slightly increased blood pH at 2 dpi. However, the acid–base equilibrium was additionally influenced by metabolic components, i.e. the systemic inflammatory response, all of which were detected with help of the strong ion theory. Decreased concentrations of albumin (2–10 dpi), a negative acute-phase marker, resulted in a decrease in the sum of non-volatile weak acids (Atot), revealing an alkalotic effect. This was counterbalanced by acidic effects of decreased strong ion difference (SID), mediated by the interplay between hypochloraemia (alkalotic effect) and hyponatraemia (acidic effect).ConclusionsThis bovine model was found to be suitable for studying pathophysiology of respiratory Cp infection and may help elucidating functional host-pathogen interactions in the mammalian lung.

Pursed lips breathing

It is pleasing to see increased research activity that focuses on therapeutic management of dyspnoea and, in particular, greater recognition of the important role that breathing techniques can provide in the amelioration of symptoms associated with Chronic Obstructive Pulmonary Disease (COPD). For many years, the concept of breathing exercises has been poorly understood and, therefore, treatments underutilised. Pursed lip breathing (PLB) sits within that poorly defined toolbox termed ‘breathing exercises’. Traditionally, breathing exercises are insufficiently described, the terminology used is at best, arbitrary, and frequently the same name is given to different interventions. Generally, there is little attempt to standardise the therapy delivered or the breathing technique performed. The American Thoracic Society guidelines describe the technique of PLB as involving ‘a nasal inspiration followed by expiratory blowing against partially closed lips, avoiding forceful exhalation’. Bhatt et al. in the article published in this edition of Chronic Respiratory Disease ‘Volitional pursed lips breathing in stable COPD patients improves exercise’ make the further distinction that ‘exhalation should continue slowly over 4 to 6 seconds without cheek puffing or forced exhalation’. This description of PLB enables better standardisation of a technique that has been the focus of debate for many years. The primary contention surrounding PLB is not so much whether it is effective; over a decade ago, there was sufficient evidence to say that PLB reduces respiratory rate, minute ventilation, and carbon dioxide level; increases tidal volume, arterial oxygen pressure, and oxygen saturation; and we ourselves showed positive effects on respiratory rate and time to recovery post exercise. As such, many people with COPD spontaneously adopt this technique; the contention around PLB concerns its use in people with COPD who do not naturally perform the technique and whether reductions in respiratory rate and oxygen saturation translate into improved exercise tolerance and perception of dyspnoea. Bhatt’s article addresses this question nicely. Giving patients adequate training in the technique and excluding any subjects who used it automatically (none did) they performed, in a randomised order, two 6-minute walk tests (6MWT), including an earlier practice test, with and without the use of PLB. These were patients with severe lung impairment (mean FEV1 38% predicted). Interestingly, the population was, on average, relatively young (mean age 53 years) with a fairly short duration of symptoms for such impairment suggesting that these may be patients who have not had sufficient time, or experience, to develop additional coping strategies such as PLB. One memorable patient from our clinic, when asked why he used PLB, told us it was because he was taught it by another patient in the rehabilitation class and finding it helpful he had continued to use it. Clinically we see patients adopting PLB during periods of acute illness, and the use of PLB at rest is an indicator of increased work of breathing. In Bhatt’s article, use of PLB in this group of patients with severe COPD, unaccustomed to the technique, resulted in a small but statistically significant improvement in a 6-minutewalk distance (6MWD); the improvement however just failed to reach the lower confidence interval of the minimally clinically important difference in 6MWD. Whether these effects are accompanied by improvements in the perception of dyspnoea are as yet unknown. Furthermore, since oxygen saturation was not recorded, we cannot make a comment on the role of PLB in patients who show exercise desaturation. In this study, as in others, there was no consistent

A Hard Pill to Swallow: Medication, Empathy, and the Value of Collaborative Recovery

Recovery from mental illness is a complex journey that is greatly facilitated when client and professional helper collaborate in the decision making process. It is further aided when the latter has an empathetic awareness of the client's experience, especially with regard to the impact of pharmacological treatment. The following article describes one psychologist's experience of being prescribed medication during a period of acute illness. Analysis of this experience is via a narrative, phenomenological approach. Results suggest that even when taken as directed, a medication can augment one's subjective feeling of illness. It further shows how challenging it can be for the ailing individual to assert his or her needs for something other than hospitalization. Although only one case is analyzed, it points to the impact that medication may have on the life of a person with mental illness, reinforcing the importance of collaboration and empathetic understanding of the other's experience.

Exploring the negative social evaluation of patients by specialist physiotherapists working in residential intermediate care

BackgroundResidential intermediate care represents an innovative model of care that facilitates early hospital discharge and avoids unnecessary hospital admission. It also represents an environment where patients may demonstrate emotional vulnerability following a period of acute illness or injury, and this may impact on the quality of the patient/physiotherapist relationship. ObjectiveTo gain an understanding of the negative social evaluation of patients by specialist physiotherapists, and to explore possible coping strategies in order to engage patients in appropriately designed rehabilitation programmes. MethodUsing a grounded theory approach, physiotherapists working in an intermediate care facility in a senior role were invited to participate in a focus group. Following the focus group analysis, a further four physiotherapists, with similar levels of experience to those in the focus group, were recruited to participate in semi-structured interviews to explore the emerging categories in greater depth. ResultsThe findings revealed some categories that the therapists believed resided with the patients (alcohol dependency, failing to adapt/accept their condition and patients whose families hindered the process of rehabilitation) and some that appeared to reside within the context of intermediate rehabilitation (labelling, the 6-week model of intermediate care and the process of transition into the service). Coping strategies cited were workforce planning, goal setting and reflective practice. ConclusionWhile supportive strategies have been developed locally to assist staff in managing their anxiety related to therapeutic interactions with ‘difficult patients’, it is also recognised that they have the potential for demotivation and are a possible precursor for stress.

Unusual Presentation of Pneumocystis Pneumonia in an Immunocompetent Patient Diagnosed by Open Lung Biopsy

Pneumocystis pneumonia (PCP) is the most common opportunistic infection in acquired immune deficiency syndrome (AIDS) patients. It is a fungal infection with Pneumocystis jiroveci which can be isolated from bronchoalveolar lavage of healthy subjects. The infection occurs mainly in HIV patients; with CD4 lymphocyte count drop to less than 200 cells/μL. PCP has been reported in non-HIV patients with other risk factors such as immunosuppressive medications, malignancies, and other inflammatory conditions. PCP has been rarely reported in immunocompetent subjects. However, in most of these patients, PCP occurred after a period of acute illness with bacterial pneumonia and antibiotic therapy. In this report, we describe a case of PCP in an immunocompetent patient with nonreactive HIV and no immunosuppressive risk factors. The patient had large pulmonary nodules discovered incidentally on chest film as preoperative evaluation for hip surgery. Bronchoalveolar lavage, transbronchial biopsies (TBB), and computed tomography (CT) guided needle biopsy were all negative for P. jiroveci. PCP diagnosis was made after open lung biopsy and wedge resection. To our knowledge, this is the first case of PCP in immunocompetent patient with negative BAL, TBB and CT guided biopsy. The diagnosis of PCP required open lung biopsy and the patient recovered without complications.

Hypocalcemia in multiple myeloma secondary to unrecognised vitamin D deficiency: A case report

Vitamin D deficiency is now recognized as one of the most common nutritional deficiency world wide. The primary function of the vitamin is to maintain calcium homeostasis by enhancing intestinal calcium absorption and mobilising calcium from the skeleton. Vitamin D also has important nonskeletal actions. It has been suggested that the production of 1,25 (OH)2D by macrophages locally regulates both activated T and B lymphocyte activities. The consequences of vitamin D deficiency on the skeleton are two fold. The secondary hyperparathyroidism induced by vitamin D deficiency will increase the number of osteoclasts, causing the removal of the mineral and matrix from the skeleton, which can result in osteopenia and osteoporosis. The secondary hyperparathyroidism also causes phosphaturia which can result in osteomalacia. Recent studies have reported a high prevalence of vitamin D deficiency in multiple myeloma (MM) patients (Badros et al. 2008). We present a case to illustrate how unrecognised vitamin D deficiency can lead to refractory hypocalcemia during periods of acute illness, in patients with MM.

The ART of caring for patients with HIV infection in the ICU

The ART of caring for patients with HIV infection in the ICU

Paediatrics: Caring for children with type 1 diabetes

Children with type1 diabetes receive ongoing care from a multidisciplinary paediatric diabetes team, usually in a secondary care setting. Healthcare support workers have a role in paediatric diabetes care when children attend routine clinic or are admitted to hospital at diagnosis or during periods of acute illness. In this article, the management of childhood diabetes is explored.

Gabapentin Toxicity in Renal Failure: The Importance of Dose Adjustment

This case report outlines a significant type of morbidity due to continued use of gabapentin during an episode of acute renal failure. Setting. University teaching hospital. Gabapentin is widely used in the management of pain. It is entirely excreted through the renal system so this needs to be considered in any patient becoming acutely ill and developing renal failure. We describe a patient who developed significant deterioration in her conscious level due to iatrogenic gabapentin overdose. All doctors need to be aware of the need to review the indications for gabapentin use during periods of acute illness, especially with regard to renal impairment. Off-label use should be discouraged.

Self-reported involvement of family members in the care of adults with CF

Background Few empirical studies have examined the role of family caregivers in the lives of adults with CF. Methods As part of the Project on Adult Care in CF (PAC-CF), an on-going prospective, longitudinal panel study of adults with CF, 119 family members and friends of adults with CF completed a mail survey in which they reported the frequency of help they provide for their family member with CF during routine care, hospitalization, and home IV treatment. Results The 119 caregivers were mainly spouses or unmarried partners (56%) and parents (29%). Fifteen percent of caregivers were children, friends, siblings or roommates. Family caregivers for adults with CF report assisting mainly with communication and social support during routine treatment, although one third provide some clinical care on a regular basis. Family caregivers report an increase in assistance during periods of acute illness, such as during a hospitalization and home IV treatment, especially with clinical care tasks. Conclusions The depth of commitment required of families of children with CF has been well documented for decades. Our results suggest that the responsibilities of family members diminish only moderately as those with CF reach adulthood.