Ward Consultations Research Articles

#1900 Should we prescind of KDIGO Stage 2 in AKI severity classification?

Abstract Background and Aims The most worldwide used classification system for staging AKI is KDIGO-2012, it was based on a combination of the RIFLE and AKIN criteria. KDIGO severity stages are defined: Stage 1 ↑ in SCr by >0.3 mg/dl or increase in SCr to >1.5x baseline. Stage 2 ↑ in SCr ≥2.0–2.9x baseline. Stage 3 ↑ in SCr ≥3.0x baseline, ↑ in SCr to >4.0 mg/dl, or initiation of RRT. Some authors advocate for the elimination of the Stage 2 level and its incorporation in the severer stage; the justification is that this stage has a smaller number of individuals, and they show poorer clinical outcomes. We tested this hypothesis in a real-world setting. Method We retrospectively included all patients admitted to nephrology ward and nephrology consultations with AKI diagnosis by KDIGO-2012 classification, during a 3-y period. We compared clinical outcomes between KDIGO-AKI Stage 2 and 3. We excluded need for HD (because it is a criterion for Stage 3) and HD dependence at discharge (a consequence of initiating HD). In addition, we calculated the proportion of patients classified in Stage 2 by the rate of SCr increment, that were re-classified into Stage 3 by KDIGO criteria. Results 1130 individuals met inclusion criteria. 458 (41%) Stage-1, 148 (13%) Stage-2, 524 (46%) in Stage-3. We found no statistically significant differences in age, Charlson's Index, HTN and DM prevalence, hospitalization in medical wards, and hospital acquired AKI between groups. We found significant differences in sex distribution (61% Stage-2, 70% Stage-3) (see Table A: Features). Hospital stay was significantly shorter in Stage1-15d (±12) but not significantly different between Stage-2 19d (±16) and Stage-3 20d (±17). Median of time to nephrology consultation was 6-7d in all groups. Rate of in-hospital mortality incremented gradually in every severity stage: 9% Stage-1, 18% Stage-2 and 31% Stage-3 (see Table B: Results). When using only the rate of SCr increment as the classification criterion, 265 (24%) of patients would have been catalogued in the moderate AKI stratum. Of the 117 patients that were reclassified as AKI Stage-3, 36 needed HD, and 81 reached a SCr >4.0 mg/dl. Conclusion The proportion of subjects classified in KDIGO AKI Stage-2 is small but not negligible. We found that Stage-2 individuals show longer hospital stay and increased mortality than Stage-1, and slightly better outcomes than Stage-3; therefore, we consider that an increase in SCr ≥2.0–2.9x from baseline still leads to deleterious consequences. We also observed that possibly KDIGO AKI Stage 3 criteria lead to a skew to classification in the severer stage, (almost half of individuals are reclassified). With these findings, should we prescind of KDIGO Stage-2 in AKI severity classification?

Antibiotic-loaded spacer arthroplasty in a terrible triad injury with unreconstructable radial head fracture: a case report

BackgroundRadial head arthroplasty is a viable option in cases with terrible triad injuries of elbow, wherein the radial head sustains significant comminution that precludes reconstruction. Nevertheless, this alternative is not recommended for individuals with poor elbow skin conditions, accompanied neuropsychiatric disorders, or low patient compliance. This case report presents a patient with bilateral terrible triad injury, along with the aforementioned conditions. The report outlines the treatment challenges of such a case and proposes potential solutions.Case presentationA 37-year-old Persian male patient presenting with a bilateral terrible triad fracture–dislocation and a history of psychoactive substance abuse, was admitted to our emergency department. The patient underwent radial head replacement using a cement spacer containing antibiotics, due to the comminuted radial head in the presence of a contaminated wound on the left elbow. The fracture of the right side was successfully fixed. Subsequent to discharge, the patient did not attend any follow-up appointments. After a period of 6 months, he was admitted to the psychiatric ward and orthopedic consultation was requested to evaluate the patient.ConclusionIn acute terrible triad injuries with unreconstructable radial head fractures where arthroplasty with metallic prostheses may not be suitable due to contaminated wounds, unstable psychiatric condition, and low patient cooperation, temporary orthopedic cement spacers can maintain elbow biomechanics, stability, and sterility.

Impact of Access Block Is Increasing Mortality in Emergency Departments in Nepal

Introduction:Emergency patients have to stay in the Emergency Department (ED) for hours to days to get ward admission for definite care in Nepal. Access block is a major issue in the ED of University Level Teaching Hospitals (ULTH) in Nepal. This study aimed to analyze the impact of access blocks in the EDs of Nepal.Method:Meta-analysis of different publications on ‘duration of ED Boarding’ and ‘mortality outcome of ED’ of ULTHs of Nepal till November 15, 2022Results:9.7% of ED patients were admitted to the ward. The time period from ED arrival to respective ward team consultation is 5.7 hours, consultation to ward admission is 5.6 hours, and admission to ward transfer is 8 hours. The average ED boarding time is 18.1 hours. 38% of patients arrived in ED via Ambulances. The time period from ED arrival to ward team consultation for those who need transfer to another center are 6.9 hours, consultation to admission is 5.7 hours, and admission to transfer is 8.7 hours (ED Boarding time 21.3 hours). Meta-analysis of three major ULTH’s showed mortality with respect to ED boarding time to be 17% in < 1 hour, 40.4% in 1 - 6 hours, 27.4% in 6-12 hours, 9.1% in 12-24 hours, 4% in 24-28 hours and 2.1% in >48 hours. Among them, higher age, greater mortality rate. The immediate causes of mortality comparing 2018 vs 2010 are Sepsis & Septic shock 32.2% vs 18%, Cardiac Causes 21.8% vs 14.8%, Aspiration Pneumonia 19.5% vs 14.8%, Severe Lung Diseases 12.7% vs 16.4%, Hypovolumic & Haemorrhagic Shock 9.2% vs 34.4% and Poisoning 4.6% vs 1.6%.Conclusion:Prolonged ED boarding due to Access Block is triggering increased mortality in the ED.

Antibiotic treatment duration in diverticulitis, complicated urinary tract infection, and endocarditis: a retrospective, single-center study

ObjectivesDespite the availability of international guidelines advocating shorter treatment durations, nonadherence to them is common. We assessed duration of antibiotic treatment for diverticulitis, complicated urinary tract infection (UTI), and endocarditis. MethodsMedical records of patients hospitalized with the previously stated diseases in 2017 and 2018 were randomly selected at a Swiss tertiary care hospital. The appropriateness of antibiotic treatment duration was assessed according to international and local guidelines. ResultsA total of 243 patients were included in the study: 100 with diverticulitis, 200 with complicated UTI, and 43 with endocarditis. The dherence to local and international guidelines was 11% and 18% in diverticulitis, 39% and 40% in complicated UTI, and 84% and 86% in endocarditis, respectively. Nonadherence was primarily due to the prolonged treatment in diverticulitis and complicated UTI with a median duration of antibiotic treatment of 11 days (interquartile range 10-13) and 14 days (interquartile range 10-15), respectively. When pooling diverticulitis and complicated UTI cases, the identification of a pathogen in any microbiological sample was associated with an improved adherence to local guidelines in addition to hospitalization in a medical ward and infectious diseases consultation. ConclusionProlonged courses of antibiotic treatment were common and the treatment adherence to guidelines were poor in diverticulitis, moderate in complicated UTI, and excellent in endocarditis.

Genetics education in primary care residency training: satisfaction and current barriers

BackgroundGenetics education can be integrated into general care medicine through primary care residency programs. A study of primary care residents was done to evaluate quality, satisfaction, and barriers in genetics education in residency training programs. Thus, providing more evidence for the necessity for its development and progress.MethodsA cross-sectional descriptive self-administered questionnaire survey was delivered to four primary care West Virginia University (WVU) residency training programs in 2020–2021. The anonymous 14-item survey included the following questionnaire domains: general data, genetics training satisfaction, and genetics education barriers.ResultsThe survey response rate was 52% (70/123) and 59 participants completed the survey. Overall, respondents viewed genetic education as critical to their chosen specialty (90%). Trainees at all educational levels obtained their education mostly from class based educational curricula (77% from lectures, 65% from didactic and 49% from grand rounds). The majority of survey respondents indicated insufficient experience with genetic patient care (34% ward genetic consultation, 5% clinic experience, 0% genetic department rotation). The percentage of residents who were satisfied with genetic topics were as follows: basic genetics (57%), capturing family history (82%), initiating basic genetic workup (15%), a basic understanding of the genetic report (23%), basic management surveillance in the genetic patient (18%), understanding the genetic referral and explaining it to a patient (47%).Residents reported barriers to genetic interest included complexity of the field (87%), followed by limited utility of genetics testing (41%). The most common suggestions for improving the genetic education component were to provide more lectures (61%), followed by enhanced advertisement of genetic education resources specifically rotations in the genetics department (22%). Other suggestions include the integration of genetic education in inpatient learning (20%) and providing research experience (7%).ConclusionPrimary care residents were satisfied with their genetic knowledge in the classroom and stated a clear need for enhanced hands-on clinical skills and research experience in their current residency training. The survey suggestions for improvement can enhance primary care residents’ genetic training that can lead to advances in rare disease recognition, precision medicine, and improve access to genetics testing.

1016 USING VIDEO TELEMEDICINE FOR INPATIENT WORKING: A NOVEL APPROACH TO REMOTE WORKING DURING THE COVID-19 PANDEMIC

BackgroundOrthogeriatrics inpatient ward.IntroductionThe COVID-19 pandemic changed working patterns for many trainees. Remote telephone or video outpatient consultations became established practice, with clinically vulnerable staff able to support this provision. We adapted the use of telemedicine to provide remote clinical working for inpatient care and continued speciality training opportunities.MethodMicrosoft Teams video conferencing facilitated interaction between the specialist registrar working remotely and the on-site multidisciplinary team (MDT). Daily activities included virtual handover attendance, inpatient ward round consultations and MDT discussions. A portable computer enabled the clinician to see and interact with inpatients remotely. Access to electronic patient records facilitated timely decision making and enactment of management plans. Anonymous MDT feedback was collected via online questionnaires. This project conformed to service evaluation guidelines and ethical approval was not required.ResultsFourteen staff members completed the feedback survey. Results were overwhelmingly positive, with 78.6% of respondents strongly agreeing that the senior doctor working remotely supported the MDT, facilitated complex clinical decision making and was beneficial to patient care. Feedback noted that some patients praised the ‘clever’ and ‘innovative’ method. Limitations included technical difficulties due to Wi-Fi connection, which contributed to communication not being as fluid as face-to-face consultations and increased ward round duration. Patient factors, namely hearing and cognitive impairment, limited the interaction that patients were able to have with the clinician via video link.ConclusionVideo inpatient ward round consultations offer an effective opportunity for physicians to continue clinical patient-facing roles whilst working remotely. Furthermore, this minimises the impact of COVID-19 on specialty trainees, by providing continued training and assessment opportunities for individuals required to shield. This novel method affords a framework transferrable to clinicians from other hospital specialties who may be required to work remotely. Future reviews of patient and relative satisfaction with this process are required.

Effects of an Integrated Palliative Care Pathway: More Proactive GPs, Well Timed, and Less Acute Care: A Clustered, Partially Controlled Before-After Study

ObjectivesThis study presents the design of an integrated, proactive palliative care pathway covering the full care cycle and evaluates its effects using 3 types of outcomes: (1) physician-reported outcomes, (2) outcomes reported by family, and (3) (utilization of) health care outcomes. DesignA clustered, partially controlled before-after study with a multidisciplinary integrated palliative care pathway as its main intervention. Setting and Participantsafter assessment in hospital departments of oncology, and geriatrics, and in 13 primary care facilities, terminally ill patients were proactively included into the pathway. Patients' relatives and patients’ general practitioners (GPs) participated in a before/after survey and in interviews and focus groups. InterventionA multidisciplinary, integrated palliative care pathway encompassing (among others) early identification of the palliative phase, multidisciplinary consultation and coordination, and continuous monitoring of outcomes. MeasuresMeasures included GP questionnaire: perceived quality of palliative care; questionnaires by family members: FAMCARE, QOD-LTC, EDIZ; and 3 types of health care outcomes: (1) utilization of primary care: consultations, intensive care, communication, palliative home visits, consultations and home visits during weekends and out-of-office-hours, ambulance, admission to hospital; (2) utilization of hospital care: outpatient ward consultations, day care, emergency room visits, inpatient care, (radio) diagnostics, surgical procedures, other therapeutic activities, intensive care unit activities; (3) pharmaceutical care utilization. ResultsGPs reported that palliative patients die more often at their preferred place of death, and that they now act more proactively toward palliative patients. Relatives of included, deceased patients reported clinically relevant improved quality of dying, and more timely palliative care. Patients in the pathway received more (intensive) primary care, less unexpected care during out-of-office hours, and more often received hospital care in the form of day care. Conclusions and ImplicationsAn integrated palliative care pathway improves a variety of clinical outcomes important to patients, their families, physicians, and the health care system. The integration of palliative care into multidisciplinary, proactive palliative care pathways, is therefore a desirable future development.

Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019.

Coronavirus disease-2019 (COVID-19) is a highly infectious respiratory disease that leads to respiratory, physical, and psychological dysfunction in patients. Respiratory rehabilitation is an important intervention as well as cure for clinical patients. With increased understanding of COVID-19 and the accumulation of clinical experience, we proposed recommendations for respiratory rehabilitation in adults with COVID-19 based on the opinions of frontline clinical experts involved in the management of this epidemic and a review of the relevant literature and evidence. Our recommendations are as follows: 1. for inpatients with COVID-19, respiratory rehabilitation would relieve the symptoms of dyspnea, anxiety, and depression and eventually improve physical functions and the quality of life; 2. for severe/critical inpatients, early respiratory rehabilitation is not suggested; 3. for patients in isolation, respiratory rehabilitation guidance should be conducted through educational videos, instruction manuals, or remote consultation; 4. assessment and monitoring should be performed throughout the respiratory rehabilitation process; 5. proper grade protection should be used following the present guidelines. These recommendations can guide clinical practice and form the basis for respiratory rehabilitation in COVID-19 patients.

Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine

Point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. It has many uses in daily clinical practice, including improved diagnostic timeliness and accuracy, and providing information about a patient's prognosis and follow-up. It has been integrated into numerous specialities, but remains relatively undefined in internal medicine training programs. Ultrasonography is a useful tool in the standard clinical practice of internists in numerous clinical scenarios (Emergency Department, hospital ward, general and specific consultations, and home care). Although POCUS has been recently included in the European curriculum of internal medicine, there are differences between European internists in its use, ranging from not at all to well structured educational programs. The use of POCUS needs to be widespread in internal medicine departments, and to accomplish this we must encourage structured training. This document details the consensus-based recommendations by the European Federation of Internal Medicine (EFIM) Ultrasound working group. We establish POCUS core competencies and clinical settings for internists in a symptom-based approach. We also propose training requirements, providing a framework for training programs at a national level.

WED 031 Neuro hot clinics: direct access clinic for acute medical patients

20% of acute medical patients present with neurological symptoms, yet are often managed by non-specialist acute physicians. This district general hospital (DGH) introduced a direct access neurology clinic, to reduce hospital admissions and improve access to neurological expertise for vulnerable patients. Patients would otherwise have been admitted to await ward consultation. 20 ‘Hot’ clinic appointments each week were allocated by administration prior to discharge from the medical admissions unit. All appointments were within 48 hours. Common diagnoses were migraine, first seizure, and non-epileptic attack disorder and rarer presentations included 5 with transverse myelitis, 1 with cerebral vasculitis, and 1 with Hepatitis E related encephalomyelopathy.243 patients were seen by a Consultant Neurologist in 9 months in this hot clinic, thus saving at least 243 bed days and £73 000. Only 4 of these patients were readmitted. The hot clinic required 4PAs of consultant time split across weekdays, at an estimated cost of £30 000 per annum.This neurology acute clinic successfully provided front door neurological input, a vital service for GPs and patients, and made approximate annual saving of £70 000. Evidently, every DGH should consider implementing neurology ‘hot’ clinics.

WED 028 One person can make a difference: our experience in a busy london dgh

Our Neurology unit is in a busy district general hospital; serving a deprived inner London community, providing a ward consultation service 5 days a week. The unit consists of 5 consultant Neurologists, a consultant Neuroradiologist and 2 specialist nurses. In 2016, a junior doctor was appointed. By analysing data from 10 months in 2015 and 2017; we assessed the impact on the delivery of Neurological care, before and after the appointment. The unit saw a 157% increase in number of patients seen, including a significant proportion now seen in ED and ambulatory care. This is equivalent to a minimum of 2 more patients each working day (n=872 vs. 1317). The percentage of patients seen on same day of referral (<12 hours) increased from 47% to 77%. The proportion of inpatients reviewed who were then followed up on the ward during their stay, increased from 13.9% to 35.5%, representing increased availability of continuing Neurology advice. The percentage of patients who waited more than 24 hours for Neurology input decreased from 14.9% to 5.83%. Our results support the appointment of a full time junior colleague to allow rapid, safe and ongoing Neurological input to patients and to support ED and admitting colleagues.

Positioning document on incorporating point-of-care ultrasound in Internal Medicine departments

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine.

Documento de posicionamiento sobre la incorporación de la ecografía clínica en los servicios de Medicina Interna

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine.

Characteristics of inpatients with heart failure selected for cardiologist-directed care at North Shore Hospital

Background: Waitemata DHB provides comprehensive cardiology inpatient services, with 35 dedicated beds, and 24/7 ward consultation at two acute hospitals. Patients admitted with congestive heart failure (CHF) are cared for by both Cardiology and General Medicine. Cardiologists select patients for admission to the cardiology beds. We investigated differences in the patients selected by Cardiology and those managed by General Medicine at North Shore Hospital. Methods:Audit of admissions in 2013 identified 46 patients with a primary diagnosis of CHF (DRGs = ‘CHF’, ‘left ventricular failure’ or ‘cardiomyopathy’) admittedunderCardiology. We randomly selected 46 out of 748 CHF patients admitted under General Medicine in 2013 as a comparison group. Results: Cardiology patients were more likely to be male (87% vs 43%), younger (<70 years = 64% vs 11%), Maori (20% vs 4%), and have severe systolic dysfunction: EF% <35% = 63% vs 36%. HFPEF was more common in General Medicine patients (3% vs 38%). Myocardial infarction (26% vs 4%) and valvular disease (26% vs 17%) were more common in Cardiology patients. Cardiology patients had far greater outpatient follow-up (72% vs 16%), and lower readmission rates (22% vs 59%). All-cause mortality at 12 months was high in the General Medicine group (15% vs 48%). Conclusion: There are significant clinical differences in patients selected for cardiologist-directed inpatient care. Further work is needed to assess whether this is the best use of specialist resources, and whether there are opportunities for improvement in the care of CHF patients remaining under the General Medicine service.

Widespread circulation of a new echovirus 30 variant causing aseptic meningitis and non-specific viral illness, South-East France, 2013

BackgroundHuman enteroviruses (HEVs) are major cause of aseptic meningitis. A new outbreak of E-30 occurred between April and September 2013 in Marseille, South-East France. ObjectivesBetter understand what happen locally when an E-30 outbreak occurs. Study designLaboratory data (identification and characterization of circulating E-30 strains by partial/complete genome sequencing) were analyzed together with clinical data from emergency ward of the public hospital of Marseille. ResultsCompared with data from previous years, we observed an excess of HEV infections between April and September 2013. A total of 202 patients were tested positive of which 79% (160/202) had a cerebrospinal fluid tested positive. Because we performed genotyping using clinical specimens, we obtained representative molecular data related to patients tested positive and found a majority (105/119) of echoviruses 30 (E-30). Phylogenetic analysis revealed that E-30 circulating in Europe since 2000 belong to a unique lineage and showed at the intra-genogroup level the temporal circulation of E-30. Molecular data also indicated that majority of E-30 detected (92%) were almost identical. Compared with data from previous years, this outbreak was finally associated with an excess of patients admitted to an emergency ward for meningitis but also for non-specific viral illness. ConclusionsOur data provide new insights into microevolution of E-30: almost all E-30 emerged from local circulation of one parental virus. Moreover, our findings showed that HEV outbreaks cause an excess of emergency ward consultations but probably also an excess of consultations to general practitioners who receive majority of the non-specific viral illness.

¿Se abusa de las técnicas de neuroimagen en pacientes con migraña crónica? Estudio en un área de salud del Principado de Asturias

There is a general perception of neuroimaging procedures overuse, mainly of CT scan, in patients with headache in Spain. To analyze the use of neuroimaging techniques, mainly CT scan as it is of free access in our region, in routine clinical practice in patients with chronic migraine (CM). We reviewed the medical records of a consecutive series of women diagnosed as CM in our headache clinic. The data on consumption of neuroimaging procedures were collected at all levels (emergency department, inpatient ward and neurologic outpatient consultation). We included 139 women with CM. A total of 106 patients (76%) had at least one CT brain scan. Twenty-eight patients (20%) had 2 or more CT scans. In 6 of these patients (21%) there was a clinical reason for repeating the studies, while there was no reason in the remaining 22 (79%). MRI had been carried out in our headache clinic in 59 patients (42%). In 43 (73%) MRI was normal, in 9 (15%) the MRI showed nonspecific lesions in the white matter and in 7 patients (11%) MRI studies were abnormal. There was no direct relationship between MRI lesion and CM. There were 15 patients with CM (11%) without any neuroimaging study. We could not find a real overuse of neuroimaging techniques in patients with CM in our health area.

Cambridge Breathlessness Intervention Service (CBIS)

Breathlessness is a common disabling symptom of advanced cardiorespiratory disease both malignant and non-malignant in nature. It is profoundly distressing for both patient and those who care for them, and often leads to disability, social isolation, and depression. It is extremely difficult to palliate successfully and interventions that help breathlessness are still poorly understood. Breathlessness occurs in 90% of patients with advanced chronic obstructive pulmonary disease and lung cancer and is also common in heart failure. The Cambridge Breathlessness Intervention Service was set up to deliver an evidence-based complex intervention for breathlessness and to carry out research to improve its management. The team consists of a palliative care consultant, specialist physiotherapists, a lead occupational therapist: it is part of a palliative care department at an acute hospital but sees patients in the community and carries out ward consultations. The evaluation and modelling of the service (using the Medical Research Council (MRC) methodology for research in complex interventions) has taken 10 years and has shown the value of the fan, using pacing techniques, an individualized exercise programme, breathing exercises, learning anxiety reduction techniques, and support for carers delivered with a rehabilitative approach. Recently, the Phase III evaluation of the service has demonstrated its effectiveness in reducing distress due to breathlessness in patients with lung cancer. The qualitative data also demonstrated the importance not only of the interventions themselves but also the manner in which they were delivered, i.e. that empathy; kindness and active listening were central to effective management.

Do we need an SBIRT program?

Drug use has an impact on physical and mental health. Quite often, patients attend accident and emergency (A&E) departments due to drug-use-related disorders, and this is why screening and brief intervention for substance use disorders are relevant in emergency room settings. Studies have shown that screening, brief intervention, and referral to treatment (SBIRT) programmes are effective in several medical settings, including A&E departments. Since most of the evidence has been gathered in the US, this study tries to identify the relevance of substance use disorders in a large Spanish A&E Department and the possible need to implement a SBIRT programme. All medical doctors on duty in a given day were asked prospectively about ward consultations attended during their 16 hours-shift. The questionnaire included information on patients’ substance use and if this was related to the medical visit, whether or not they thought the patient needed referral to an addiction specialist and their opinion on what may help them to improve the management of those patients. 194 patients were attended. 22 patients (11.3%) were reported as substance users. Only 2 were visited by the psychiatrist (1%). Alcohol (n=10), cannabis (n=3) and benzodiazepines (n=4) were the most reported drugs (n=10). Practitioners considered that support from an addiction specialist (8, 7/10) and specific training in the management of substance users (8, 2/10) as the most valuable aids. Availability of screening tools was somewhat less valued (7, 2/10). The number of patients who present to the A&E department with a drug related-problem is large, yet these patients are scarcely seen by the psychiatrist. Practitioners see training opportunities in the management of substance users and the availability of addiction specialists as the most valued aids. Regardless, the rate of patients presenting with substance use related disorders warrants further research and suggests the convenience to implement SBIRT programmes in A&E department settings.

The lived experience of breathlessness and its implications for care: a qualitative comparison in cancer, COPD, heart failure and MND.

BackgroundBreathlessness is one of the core symptoms, particularly persistent and frequent, towards the end of life. There is no evidence of how the experience of breathlessness differs across conditions. This paper compares the experience of breathlessness in cancer, COPD, heart failure and MND, four conditions sharing heavy symptom burdens, poor prognoses, high breathlessness rates and palliative care needs.MethodsFor this qualitative study a purposive sample of 48 patients was included with a diagnosis of cancer (10), COPD (18), heart failure (10) or MND (10) and experiencing daily problems of breathlessness. Patients were recruited from the respective clinics at the hospital; specialist nurses' ward rounds and consultations, and "Breathe Easy" service users meetings in the community. Data were collected through semi-structured, in-depth interviews and participant observation. Breathlessness was compared according to six components derived from explanatory models and symptom schemata, first within groups and then across groups. Frequency counts were conducted to check the qualitative findings.ResultsAll conditions shared the disabling effects of breathlessness. However there were differences between the four conditions, in the specific constraints of the illness and patients' experiences with the health care context and social environment. In cancer, breathlessness signalled the (possible) presence of cancer, and functioned as a reminder of patients' mortality despite the hopes they put in surgery, therapies and new drugs. For COPD patients, breathlessness was perceived as a self-inflicted symptom. Its insidious nature and response from services disaffirmed their experience and gradually led to greater disability in the course of illness. Patients with heart failure perceived breathlessness as a contributing factor to the negative effects of other symptoms. In MND breathlessness meant that the illness was a dangerous threat to patients' lives. COPD and heart failure had similar experiences.ConclusionIntegrated palliative care is needed, that makes use of all appropriate therapeutic options, collaborative efforts from health, social care professionals, patients and caregivers, and therapies that acknowledge the dynamic interrelation of the body, mind and spirit.

The inpatient neurology consultation service: value and cost

Neurological conditions comprise a significant proportion of patient admissions to hospital but, in the majority of cases, are admitted under the care of non-neurological physicians. As a consequence, neurological ward consultations are commonly requested by the admitting medical teams to review diagnoses and management plans. The outcomes of neurological ward consultations were examined and the time required for the referral process recorded by performing a detailed prospective three-month audit of inpatient referrals to the neurology service. The consultations of 120 patients were recorded, categorised and analysed. These consultations were beneficial in the vast majority of cases, with a clear impact on patient diagnoses or management plans. The consultation process was time consuming, however, both in respect of the initial review, but also with follow-up visits. This audit highlights the importance of neurological input in the diagnosis and management of hospital inpatients. The time taken for this process should be resourced appropriately.