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Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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T, Tamori Y, Tamura R, Tamura Y, Tan CHH, Tan EZZ, Tanabe A, Tanabe K, Tanaka A, Tanaka A, Tanaka N, Tang S, Tang Z, Tanigaki K, Tarlac M, Tatsuzawa A, Tay JF, Tay LL, Taylor J, Taylor K, Taylor K, Te A, Tenbusch L, Teng KS, Terakawa A, Terry J, Tham ZD, Tholl S, Thomas G, Thong KM, Tietjen D, Timadjer A, Tindall H, Tipper S, Tobin K, Toda N, Tokuyama A, Tolibas M, Tomita A, Tomita T, Tomlinson J, Tonks L, Topf J, Topping S, Torp A, Torres A, Totaro F, Toth P, Toyonaga Y, Tripodi F, Trivedi K, Tropman E, Tschope D, Tse J, Tsuji K, Tsunekawa S, Tsunoda R, Tucky B, Tufail S, Tuffaha A, Turan E, Turner H, Turner J, Turner M, Tuttle KR, Tye YL, Tyler A, Tyler J, Uchi H, Uchida H, Uchida T, Uchida T, Udagawa T, Ueda S, Ueda Y, Ueki K, Ugni S, Ugwu E, Umeno R, Unekawa C, Uozumi K, Urquia K, Valleteau A, Valletta C, van Erp R, Vanhoy C, Varad V, Varma R, Varughese A, Vasquez P, Vasseur A, Veelken R, Velagapudi C, Verdel K, Vettoretti S, Vezzoli G, Vielhauer V, Viera R, Vilar E, Villaruel S, 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Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial. Lancet Diabetes Endocrinol 2024; 12:51-60. [PMID: 38061372 DOI: 10.1016/s2213-8587(23)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). INTERPRETATION In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. FUNDING Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.
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Riedel HB, Espejo T, Bingisser R, Kellett J, Nickel CH. A fast emergency department triage score based on mobility, mental status and oxygen saturation compared with the emergency severity index: a prospective cohort study. QJM 2023; 116:774-780. [PMID: 37399089 PMCID: PMC10559338 DOI: 10.1093/qjmed/hcad160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/27/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Waiting for triage in overburdened emergency departments (ED) has become an increasing problem, which endangers patients. A fast triage system to rapidly identify low-acuity patients should divert care and resources to more urgent cases. AIM The objective of this study was to compare the performance of the Kitovu Hospital fast triage (KFT) score with the Emergency Severity Index (ESI), using mortality and hospital admission as proxies for the patients' acuity. DESIGN This is a prospective observational study of consecutive patients presenting to a Swiss academic ED. METHODS Patients were prospectively triaged into one of five ESI strata and retrospectively assessed by the KFT score, which awards one point each for altered mental status, impaired mobility and oxygen saturation <94%. RESULTS The KFT score had a lower discrimination than the ESI for hospital admission, but a higher discrimination for mortality from 24 h to 1 year after ED presentation. A total of 5544 (67%) patients were assigned to the lowest acuity by the KFT score compared with 2374 (28.7%) by the ESI; there was no significant difference in the 24-h mortality of patients who were deemed low acuity by either score. CONCLUSION Compared to the ESI, the KFT score identifies more than twice as many patients at low risk of early death. Therefore, this score might help to identify patients who could be managed through alternative pathways. This may be particularly helpful in situations of ED crowding and access block.
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Affiliation(s)
- H B Riedel
- Emergency Department, University Hospital Basel, Petersgraben 2, 4031 Basel, Schweiz
| | - T Espejo
- Emergency Department, University Hospital Basel, Petersgraben 2, 4031 Basel, Schweiz
| | - R Bingisser
- Emergency Department, University Hospital Basel, Petersgraben 2, 4031 Basel, Schweiz
| | - J Kellett
- Department of Emergency Medicine, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Petersgraben 2, 4031 Basel, Schweiz
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Holland M, Dannatt A, Kellett J, Green D. Emergency admissions' diagnoses and risk of in-hospital death according to the primary ICD-10 chapter assigned at discharge and the National Early Warning Score on admission. Acute Med 2023; 22:113-119. [PMID: 37746679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND The relationship between diagnosis, illness severity, and mortality risk for unselected emergency admissions is poorly defined. AIM To define primary ICD-10 diagnostic chapters at discharge, admission illness severity by the National Early Warning Score, and in-hospital mortality for all unselected emergency admissions. METHOD Retrospective, observational, cohort study of 122,259 unselected, adult emergency admissions to Salford Royal Hospital between 2014 and 2022. RESULTS In-hospital mortality was 4.3% but most patients had an ICD-10 chapter associated with a lower risk of death. 60% of in-hospital deaths were in four chapters, infections, circulatory and respiratory diseases, or neoplasms. An admission NEWS ≥3 was associated with earlier mortality and an eight-fold increased risk of in-hospital mortality. 45% of all in-hospital deaths occurred in patients with an admission NEWS <3. CONCLUSION Mortality in emergency hospital admissions is associated with illness severity and four diagnostic chapters. NEWS should not be the only arbiter of hospital admission, as for certain diagnostic chapters the risk of death is high even if vital signs on presentation are normal.
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Affiliation(s)
- M Holland
- School of Clinical and Biomedical Sciences, University of Bolton, UK
| | - A Dannatt
- School of Medical Sciences, University of Manchester, UK
| | - J Kellett
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - D Green
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, UK
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Kellett J, Bogh SB, Ekelund U, Brabrand M. Can the ECG be used to estimate age-related survival? QJM 2022; 115:298-303. [PMID: 33970281 DOI: 10.1093/qjmed/hcab134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/19/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There are few reports of the relationship between electrocardiogram (ECG) findings and the age-related survival of acutely ill patients. AIM This study compared the 1-year survival curves of patients attending two Danish emergency departments (EDs) with normal and abnormal ECGs. Patients were divided into age groups from 20 to 90 years of age, and an abnormal ECG was defined as low QRS voltage (i.e. lead I + II <1.4 mV) or QTc interval prolongation >434 ms. METHODS A retrospective register-based observational study on 35 496 patients attending two Danish EDs, with 100% follow-up for 1 year. RESULTS ECG abnormality increases linearly with age, and between 30 and 70 years of age. Patients aged 20-29 years with ECG abnormalities are more than four times more likely to die within a year than patients of the same age with a normal ECG. An individual with an abnormal ECG has the same risk of dying within a year as an individual with a normal ECG who is 10 years older. After 70 years of age this tight relationship ends, but for younger individuals with an abnormal ECG the increase in mortality is even higher. CONCLUSION An ECG may be a simple practical estimate of age-related survival. For a patient under 70 years, an abnormal QRS voltage or a prolonged QTc interval may increase 1-year mortality to that of a patient ∼10 years older.
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Affiliation(s)
- J Kellett
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - S B Bogh
- Odense Patient Data Explorative Network, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - U Ekelund
- Department of Emergency and Internal Medicine, Skåne University Hospital at Lund, Lund, Sweden
| | - M Brabrand
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
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Kennedy A, Holland M, Sullivan P, Gebril A, Arora N, Vijayakumar V, Hoole A, Nickel C, Hodcroft C, Harrington L, Wheble M, Soong J, Scriven N, Kellett J, Slinger K, Price V, Alsma J, Astbury S, Varia R, Rigby A, Subbe C. Developing priorities for quality improvement in acute medicine using a modified Delphi method A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI). Acute Med 2022; 21:74-79. [PMID: 35681180 DOI: 10.52964/amja.0901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The SAM Quality Improvement Committee (SAM-QI), set up in 2016, has worked over the last year to determine the priority Acute Medicine QI topics. They have also discussed and put forward proposals to improve QI training for Acute Medicine professionals. METHODS A modified Delphi process was completed over four rounds to determine priority QI topics. Online meetings were also used to develop proposals for QI training. RESULTS Same Day Emergency Care (SDEC) was chosen as the priority topic for QI work within Acute Medicine. CONCLUSION The SAM-QI group settled on SDEC being the priority topic for Acute Medicine QI development. Throughout the Delphi process SAM-QI has also developed proposals for QI training that will help Acute Medicine professionals deliver coordinated meaningful improvements in care.
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Affiliation(s)
- A Kennedy
- Department of Acute Medicine, Airedale Hospital NHS Foundation Trust, Keighley, West Yorkshire, BD20 6TD
| | - M Holland
- Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, BL3 5AB, UK. ORCID iD: 0000-0001-8336-5336
| | | | - A Gebril
- Department of Acute Medicine, Salford Royal, Manchester, M6 8HD
| | - N Arora
- Department of Acute Medicine, Watford General Hospital Vicarage Rd, Watford WD18 0HB
| | - V Vijayakumar
- Department of Acute Medicine, Torbay and South Devon Foundation Trust, TQ2 7AA
| | - A Hoole
- Department of Acute Medicine, University Hospital of Wales, Cardiff, CF14 4XW
| | - C Nickel
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - C Hodcroft
- Department of Acute Medicine, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun CF72 8XR
| | - L Harrington
- Department of Acute Medicine, University College London Hospitals NHS Foundation Trust, London
| | - M Wheble
- Department of Acute Medicine, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW
| | - J Soong
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore
| | - N Scriven
- Department of Acute Medicine, Calderdale Hospital, Dryclough Ln, Halifax HX3 0NH
| | - J Kellett
- Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland
| | - K Slinger
- Department of Acute Medicine, Castle Lane East , Bournemouth, Dorset, BH7 7DW
| | - V Price
- Department of Acute Medicine, Royal Liverpool Hospital, Prescot St, Liverpool L7 8XP
| | - J Alsma
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - S Astbury
- Society for Acute Medicine, 9 Queen Street, Edinburgh, EH2 1JQ
| | - R Varia
- Department of Acute Medicine, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, L35 5DR
| | - A Rigby
- Senior Service Improvement Manager, St Helens & Knowsley Teaching Hospitals NHS Trust
| | - C Subbe
- School of Medical Sciences, Bangor University & Consultant Acute, Respiratory & Critical Care Medicine, Ysbyty Gwynedd, Bangor, LL57 2PW, UK. ORCID iD: 0000-0002-3110-8888
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Kellett J, Sikakulya FK, Nickel CH. The prediction of early mortality by the ROX index of oxygenation and respiratory rate in diverse Canadian and Ugandan cohorts of unselected patient: a post-hoc retrospective analysis of 80,558 patient observations. Acute Med 2022; 21:68-73. [PMID: 35681179 DOI: 10.52964/amja.0900] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIM To investigate the association between in-hospital mortality and the ROX index of respiratory rate and oxygenation in diverse cohorts of unselected patient at different prediction windows. METHODS A retrospective post-hoc analysis of data from a major regional referral Canadian hospital and a low-resource hospital in sub-Saharan Africa. RESULTS Four patient cohorts were examined: Canadian medical, surgical and intensive care unit (ICU) patients, and all patients admitted to an African hospital. In all patients in-hospital mortality rose as ROX declined. Apart from ICU patients, ROX had a high discrimination for death within 72 hours. For non-ICU patients the negative predictive value of death within 72 hours for a ROX value <22 ranged from 0.994 to 1.000 Conclusion: In diverse cohorts of unselected patients, the ROX index has a high discrimination for death within 72 hours. However, the index has little or no prognostic value for patient admitted to ICU.
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Affiliation(s)
- J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - F K Sikakulya
- Department of General Surgery, Kampala International University, Western Campus, Bushenyi, Uganda, Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo
| | - C H Nickel
- Emergency Department, University Hospital Basel
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Wasingya-Kasereka L, Nakitende I, Nabiryo J, Namujwiga T, Kellett J. Presenting symptoms, diagnoses and in-hospital mortality in a low resource hospital environment. QJM 2021; 114:25-31. [PMID: 32415975 DOI: 10.1093/qjmed/hcaa169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/08/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The relationship between symptoms, signs and discharge diagnoses with in-hospital mortality is poorly defined in low-resource settings. AIM To explore the prevalence of presenting symptoms, signs and discharge diagnoses of medical patients admitted to a low-resource sub-Saharan hospital and their association with in-hospital mortality. METHODS In this prospective observational study, the presenting symptoms and signs of all medical patients admitted to a low-resource hospital in sub-Saharan Africa, their discharge diagnoses and in-hospital mortality were recorded. RESULTS Pain, gastro-intestinal complaints and feverishness were the commonest presenting symptoms, but none were associated with in-hospital mortality. Only headache was associated with decreased mortality, and no symptom was associated with increased in-hospital mortality. Malaria was the commonest diagnosis. Vital signs, mobility, mental alertness and mid-upper arm circumference (MUAC) had the strongest association with in-hospital mortality. Tuberculosis and cancer were the only diagnoses associated with in-hospital mortality after adjustment for these signs. CONCLUSION Vital signs, mobility, mental alertness and MUAC had the strongest association with in-hospital mortality. All these signs can easily be determined at the bedside at no additional cost and, after adjustment for them by logistic regression the only diagnoses that remain statistically associated with in-hospital mortality are tuberculosis and cancer.
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Affiliation(s)
| | - I Nakitende
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - J Nabiryo
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - T Namujwiga
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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Jauslin AS, Kellett J, Brabrand M, Simon NR, Rueegg M, Twerenbold R, Osswald S, Bassetti S, Tschudin-Sutter S, Siegemund M, Rentsch K, Bingisser R, Nickel CH. D-dimer levels for Risk Stratification in Patients with Suspected COVID-19 - A Prospective Observational Study. Acute Med 2021; 20:193-203. [PMID: 34679137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Elevated D-dimer levels have been observed in COVID-19 and are of prognostic value, but have not been compared to an appropriate control group. METHODS Observational cohort study including emergency patients with suspected or confirmed COVID-19. Logistic regression defined the association of D-dimer levels, COVID-19 positivity, age, and gender with 30-day-mortality. RESULTS 953 consecutive patients (median age 58, 43% women) presented with suspected COVID-19: 12 (7.4%) patients with confirmed SARS-CoV-2-infection died, compared with 28 (3.5%) patients without SARS-CoV-2-infection. Overall, most (56%) patients had elevated D-dimer levels (≥0.5mg/l). Age (OR 1.07, CI 1.05-1.10), D-dimer levels ≥0.5mg/l (OR 2.44, CI 0.98-7.39), and COVID-19 (OR 2.79, CI 1.28-5.80) were associated with 30-day-mortality. CONCLUSION D-dimer levels are effective prognosticators in both patient groups.
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Affiliation(s)
- A S Jauslin
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| | - J Kellett
- MD, Department of Emergency Medicine, Hospital of South West Jutland, 6700 Esbjerg, Denmark
| | - M Brabrand
- MD, PhD, Department of Emergency Medicine, Hospital of South West Jutland, 6700 Esbjerg, Denmark
| | - N R Simon
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| | - M Rueegg
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| | - R Twerenbold
- MD, Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland
| | - S Osswald
- MD, Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland
| | - S Bassetti
- MD, Department of Internal Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - S Tschudin-Sutter
- MD, Division of Infectious Disease & Hospital Epidemiology, University Hospital Basel, 4031 Basel, Switzerland
| | - M Siegemund
- MD, Department of Intensive Care, University Hospital Basel, 4031 Basel, Switzerland
| | - K Rentsch
- PhD, Department of Laboratory Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - R Bingisser
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| | - C H Nickel
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
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Jensen NH, Sze-Long Lo R, Hung K, Lorentzen M, Laugesen S, Posth S, Hansen S, Jensen K, Kellett J, Graham CA, Brabrand M. Thermographic visualization of facial vasoconstriction is associated with 30-day all-cause mortality in medical patients; prospective observational two-site cohort study. Acute Med 2021; 20:101-109. [PMID: 34190736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Quick and reliable assessment of acute patients is required for accurate triage. The temperature gradient between core and peripheral temperature could possibly instantly provide information on circulatory status. METHODS Adult medical patients, who did not receive supplementary oxygen, attending two emergency departments, had a thermographic image taken on arrival. The association between 30-day mortality and gradients was tested using logistic regression. RESULTS 726 patients were studied, median age was 64 years and 14 (1.9%) died within 30 days. There was a significant association between mortality and temperature gradient, comparable to vital signs, age, and clinical intuition. CONCLUSION Temperature gradient between nose and eye had an acceptable discriminatory power for 30-day all-cause mortality.
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Affiliation(s)
- N H Jensen
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - R Sze-Long Lo
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | - Kkc Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | - M Lorentzen
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - S Laugesen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - S Posth
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - S Hansen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - K Jensen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - C A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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De Bie Dekker AJR, Dijkmans JJ, Todorovac N, Hibbs R, Boe Krarup K, Bouwman AR, Barach P, Fløjstrup M, Cooksley T, Kellett J, Bindels AJGH, Korsten HHM, Brabrand M, Subbe CP. Testing the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation. Resuscitation 2020; 157:3-12. [PMID: 33027620 DOI: 10.1016/j.resuscitation.2020.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Clinical teams struggle on general wards with acute management of deteriorating patients. We hypothesized that the Crisis Checklist App, a mobile application containing checklists tailored to crisis-management, can improve teamwork and acute care management. METHODS A before-and-after study was undertaken in high-fidelity simulation centres in the Netherlands, Denmark and United Kingdom. Clinical teams completed three scenarios with a deteriorating patient without checklists followed by three scenarios using the Crisis Checklist App. Teamwork performance as the primary outcome was assessed by the Mayo High Performance Teamwork scale. The secondary outcomes were the time required to complete all predefined safety-critical steps, percentage of omitted safety-critical steps, effects on other non-technical skills, and users' self-assessments. Linear mixed models and a non-parametric survival test were conducted to assess these outcomes. RESULTS 32 teams completed 188 scenarios. The Mayo High Performance Teamwork scale mean scores improved to 23.4 out of 32 (95% CI: 22.4-24.3) with the Crisis Checklist App compared to 21.4 (20.4-22.3) with local standard of care. The mean difference was 1.97 (1.34-2.6; p < 0.001). Teams that used the checklists were able to complete all safety-critical steps of a scenario in more simulations (40/95 vs 21/93 scenarios) and these steps were completed faster (stratified log-rank test χ2 = 8.0; p = 0.005). The self-assessments of the observers and users showed favourable effects after checklist usage for other non-technical skills including situational awareness, decision making, task management and communication. CONCLUSIONS Implementation of a novel mobile crisis checklist application among clinical teams was associated in a simulated general ward setting with improved teamwork performance, and a higher and faster completion rate of predetermined safety-critical steps.
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Affiliation(s)
- A J R De Bie Dekker
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
| | - J J Dijkmans
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - N Todorovac
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark; Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - R Hibbs
- Integral Business Support Ltd, Wrexham, United Kingdom
| | - K Boe Krarup
- Department of Anesthesiology, Odense University Hospital, Odense, Denmark
| | - A R Bouwman
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - P Barach
- Department of Anesthesiology and Critical care, Wayne State University School of Medicine, Detroit; Jefferson College of Population Health, PA, USA
| | - M Fløjstrup
- Institute of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - T Cooksley
- Department of Acute and Internal Medicine, The Christie Hospital, Manchester, United Kingdom
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - A J G H Bindels
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - H H M Korsten
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - M Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark; Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark; Institute of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - C P Subbe
- Department of Acute Medicine, Ysbyty Gwynedd and Bangor University, Bangor, United Kingdom
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12
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Kellett J. Response to: Respiratory rate and pulmonary embolus. QJM 2020; 113:144-145. [PMID: 30989205 DOI: 10.1093/qjmed/hcz085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J Kellett
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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13
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Lyngholm L, Nickel CH, Kellett J, Chang S, Cooksley T, Brabrand M. Normal gait, albumin and d-dimer levels identify low risk emergency department patients: a prospective observational cohort study with 365-day 100% follow-up. QJM 2020; 113:86-92. [PMID: 31504931 DOI: 10.1093/qjmed/hcz226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/12/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND If survival could be reliably predicted many patients could be safely managed outside of hospital in an ambulatory care setting. AIM Comparison of common laboratory findings, co-morbidities, mobility and vital signs as predictors of mortality of acutely ill emergency department (ED) attendees. DESIGN Prospective observational study. METHODS Secondary analysis of 1334 consenting acutely ill patients attending a Danish ED. RESULTS 67 (5%) out of 1334 patients died within 100 days. After logistic regression seven predictors of 100 days mortality remained significant: an albumin level ≤34 gm/l, D-dimer level >0.51 mg/l, an Asadollahi score (based on admission laboratory data and age) ≥12, a platelet count <159 X 1000/ml, impaired mobility on presentation, a respiratory rate ≥30 bpm and a Charlson co-morbidity index ≥3. Only 5 of the 442 without any of these variables died within 365 days. Only one of the 517 patients with a stable independent gait and normal d-dimer and albumin levels died within 100 days, none died within 30 days of assessment and 12 died within 365 days. Of the remaining 817 patients 66 (8%) died within 100 days. CONCLUSION These findings suggest that normal gait, albumin and d-dimer levels are the most parsimonious way of identifying low risk ED patients.
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Affiliation(s)
- L Lyngholm
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - J Kellett
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - S Chang
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
- Department of Clinical Biochemistry, Hospital of South West Jutland, Esbjerg, Denmark
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, Manchester, UK
| | - M Brabrand
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
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14
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Nakitende I, Namujwiga T, Dunsmuir D, Ansermino JM, Wasingya-Kasereka L, Kellett J. Respiratory rates observed over 15 seconds compared with rates measured using the RRate app. Practice-based evidence from an observational study of acutely ill adult medical patients during their hospital admission. Acute Med 2020; 19:15-20. [PMID: 32226952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND counting respiratory rate over 60 seconds can be impractical in a busy clinical setting. METHODS 870 respiratory rates of 272 acutely ill medical patients estimated from observations over 15 seconds and those calculated by a computer algorithm were compared. RESULTS The bias of 15 seconds of observations was 1.85 breaths per minute and 0.11 breaths per minute for the algorithm derived rate, which took 16.2 SD 8.1 seconds. The algorithm assigned 88% of respiratory rates their correct National Early Warning Score points, compared with 80% for rates from 15 seconds of observation. CONCLUSION The respiratory rates of acutely ill patients are measured nearly as quickly and more reliably by a computer algorithm than by observations over 15 seconds.
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Affiliation(s)
- I Nakitende
- Department of Medicine, Enrolled Nurse, Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - T Namujwiga
- Department of Medicine, Enrolled Midwife, Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - D Dunsmuir
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - J M Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | | | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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15
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Lyngholm LE, Nickel CH, Kellett J, Chang S, Cooksley T, Brabrand M. A negative D-dimer identifies patients at low risk of death within 30 days: a prospective observational emergency department cohort study. QJM 2019; 112:675-680. [PMID: 31179506 DOI: 10.1093/qjmed/hcz140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/27/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the ability of a normal D-dimer level (<0.5 mg/l) to identify emergency department (ED) patients at low risk of 30-day all-cause mortality. DESIGN In this prospective observational study, D-dimer levels of adult medical patients were assessed at arrival to the ED. Data on 30-day survival status were extracted from the Danish Civil Registration System with complete follow-up. SETTING The Hospital of South West Jutland. PATIENTS All patients aged 18 years or older who required any blood sample on a clinical indication on arrival to the ED. Participants were required to give written informed consent before enrollment. MAIN RESULTS The study population of 1 518 patients with median age 66 years of which 49.4% were female. Of the 791 (52.1%) patients with normal D-dimer levels, 3 (0.4%) died within 30 days; one death resulted from an unrelated traumatic accident. Of the 727 (47.9%) patients with abnormal D-dimer levels (≥0.50 mg/l), 32 (4.4%) died within 30 days. Patients with normal D-dimer levels had a significantly lower 30-day mortality compared to patients with abnormal D-dimer levels (odds ratio 0.08, 95% CI 0.02-0.28): of the 35 patients who died within 30 days, 19 (54.3%) had normal or near normal vital signs when first assessed. CONCLUSION Normal D-dimer levels identified patients at low risk of 30-day mortality. Since most patients who died within 30 days presented with normal or near normal vital signs, D-dimer levels appear to provide additional prognostic information.
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Affiliation(s)
- L E Lyngholm
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Switzerland
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
| | - S Chang
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark
- Department of Clinical Biochemistry, Hospital of South West Jutland, Denmark
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, UK
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
- Department of Emergency Medicine, Odense University Hospital, Denmark
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16
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Rimbi M, Dunsmuir D, Ansermino JM, Nakitende I, Namujwiga T, Kellett J. Respiratory rates observed over 15 and 30 s compared with rates measured over 60 s: practice-based evidence from an observational study of acutely ill adult medical patients during hospital admission. QJM 2019; 112:513-517. [PMID: 30888422 DOI: 10.1093/qjmed/hcz065] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/08/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Respiratory rate is often measured over a period shorter than 1 min and then multiplied to produce a rate per minute. There are few reports of the performance of such estimates compared with rates measured over a full minute. AIM Compare performance of respiratory rates calculated from 15 and 30 s of observations with measurements over 1 min. DESIGN A prospective single center observational study. METHODS The respiratory rates calculated from observations for 15 and 30 s were compared with simultaneous respiratory rates measured for a full minute on acutely ill medical patients during their admission to a resource poor hospital in sub-Saharan Africa using a novel respiratory rate tap counting software app. RESULTS There were 770 respiratory rates recorded on 321 patients while they were in the hospital. The bias (limits of agreement) between the rate derived from 15 s of observations and the full minute was -1.22 breaths per minute (bpm) (-7.16 to 4.72 bpm), and between the rate derived from 30 s and the full minute was -0.46 bpm (-3.89 to 2.97 bpm). Rates observed over 1 min that scored 3 National Early Warning Score points were not identified by half the rates derived from 15 s and a quarter of the rates derived from 30 s. CONCLUSION Practice-based evidence shows that abnormal respiratory rates are more reliably detected with measurements made over a full minute, and respiratory rate measurement 'short-cuts' often fail to identify sick patients.
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Affiliation(s)
- M Rimbi
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - D Dunsmuir
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - J M Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - I Nakitende
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - T Namujwiga
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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17
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Rimbi M, Nakitende I, Namujwiga T, Kellett J. How well are heart rates measured by pulse oximeters and electronic sphygmomanometers? Practice-based evidence from an observational study of acutely ill medical patients during hospital admission. Acute Med 2019; 18:144-147. [PMID: 31536051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND heart rates generated by pulse oximeters and electronic sphygmomanometers in acutely ill patients may not be the same as those recorded by ECG. METHODS heart rates recorded by an oximeter and an electronic sphygmomanometer were compared with electrocardiogram (ECG) heart rates measured on acutely ill medical patients. RESULTS 1010 ECGs were performed on 217 patients while they were in the hospital. The bias between the oximeter and the ECG measured heart rate was -1.37 beats per minute (limits of agreement -22.6 to 19.9 beats per minute), and the bias between the sphygmomanometer and the ECG measured heart rate was -0.14 beats per minute (limits of agreement -22.2 to 21.9 beats per minute). Both devices failed to identify more than half the ECG recordings that awarded 3 NEWS points for heart rate. CONCLUSION Heart rates of acutely ill patients are not reliably measured by pulse oximeter or electronic sphygmomanometers.
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Affiliation(s)
- M Rimbi
- Medical Officer, Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - I Nakitende
- Department of Medicine, Enrolled Nurse, Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - T Namujwiga
- Department of Medicine, Enrolled Midwife, Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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18
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Kellett J. Which patients should be monitored, how should they be monitored, and why should they be monitored? Acute Med 2019; 18:208-209. [PMID: 31912050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Intensively monitoring severely ill patients is like placing a smoke alarm in a burning building: it makes no sense. Smoke alarms only makes sense if they are placed in buildings before a fire starts, or after a fire has been extinguished in order to make sure it does not start again. Therefore, logic suggests that it is more important to monitor sick patients with normal vital signs in order to detect any deterioration as early as possible, or AFTER a severe illness in order to ensure they do not relapse, and it is safe for them to be discharged from hospital and return home.
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Affiliation(s)
- J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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19
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D’Cunha N, Naumovski N, Georgousopoulou E, Hunter M, Kellett J, Mellor D, McKune A, Isbel S. TEN-WEEK ADHERENCE TO A COMMERCIAL SMARTPHONE APPLICATION INTERVENTION IN A CLINICAL SAMPLE OF OLDER ADULTS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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20
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Brabrand M, Knudsen T, Hallas J, Graham CA, Kellett J. The PARIS score can reliably predict 7-day all-cause mortality for both acute medical and surgical patients: an international validation study. QJM 2018; 111:721-725. [PMID: 30124965 DOI: 10.1093/qjmed/hcy174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We believe errors in the risk assessment of acutely ill patients occur because only vital signs without concurrent functional capacity are considered. We, therefore, developed the PARIS risk score based on blood pressure, age, respiratory rate, loss of independence and oxygen saturation. AIM Validation of the PARIS score in four independent cohorts from three countries. METHODS Retrospective cohort study of acutely ill patients admitted to hospitals in Denmark, Ireland and Uganda. Vital signs and functional capacity (registered as ability to stand or walk or get into bed unaided) was recorded upon arrival. Patients were followed up for 7 days (Denmark and Ireland) or until discharge (Uganda) and mortality recorded. The discriminatory power (ability to identify patients at increased risk) was determined using area under the receiver operating characteristics curve (AUROC) and calibration (precision) using Hosmer-Lemeshow goodness of fit test. RESULTS Out of 14 447 patients, 327 (2.3%) died within 7 days: median age was 59 (39-75) years and 7458 (51.8%) were female. Seven-day mortality increased from 0.3% with a score of 0-26.7% with a score of 5. The score's AUROC as 0.833 [95% confidence interval (95% CI) 0.811-0.856], 0.817 (95% CI 0.792-0.842) and 0.894 (95% CI 0.813-0.974) for all patients, medical patients and surgical patients, respectively. However, except for surgical patients, calibration of the score was poor. CONCLUSION The PARIS score can identify both high and low risk acutely admitted medical and surgical patients, but calibration was poor for medical patients.
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Affiliation(s)
- M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
- Centre South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Sdr. Boulevard 29, Odense C, Denmark
| | - T Knudsen
- Centre South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, Esbjerg, Denmark
- Department of Medicine, Hospital of South West Jutland, Finsensgade 35, Esbjerg, Denmark
| | - J Hallas
- Department of Clinical Pharmacology, Odense University Hospital, J. B. Winsløws Vej 19, 2., Odense C, Denmark
| | - C A Graham
- Centre South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, Esbjerg, Denmark
- Emergency Medicine Academic Unit, Chinese University of Hong Kong, 2/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
- Centre South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, Esbjerg, Denmark
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21
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Nakitende I, Namujwiga T, Kellett J, Opio M, Lumala A. Patient reported symptoms, body temperature and hospital mortality: an observational study in a low resource healthcare environment. QJM 2018; 111:691-697. [PMID: 29986087 DOI: 10.1093/qjmed/hcy147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fever is a common presenting complaint of patients, especially in sub-Saharan Africa. Although most medical authorities consider fever to be synonymous with an elevated body temperature the relationship of the complaint of fever made by patients to temperature has not been well defined. AIM This study examined the relationship of the complaint of fever to temperature on and after admission and in-hospital mortality. METHOD Observational study in a low-resource Ugandan mission hospital. RESULTS Out of 2122 alert patients admitted between 9 August 2016 and 5 January 2018, 349 (16.4%) complained of fever: these patients were no more likely to have an abnormal temperature or die in-hospital than those not complaining of fever. Of the 707 alert patients admitted after 1 July 2017, 422 were interviewed in detail about their symptoms: only rigors, feeling intermittently hot and cold, and anorexia were statistically related to the complaint of fever, and only rigors to an admission temperature >38°C. No symptom or sign was associated with a temperature ≤36°C: cold and clammy skin was the only finding associated with in-hospital death. On logistic regression the only independent predictors of mortality were: the National Early Warning Score, impaired mobility on presentation and cold and clammy skin. CONCLUSION In this study, the term fever used by patients and raised body temperature were not synonymous. Although fever and related symptoms reported by patients are common presenting complaints only the finding of cold and clammy skin was associated with in-hospital mortality.
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Affiliation(s)
- I Nakitende
- Department of Medicine, Enrolled Midwife, Kitovu Hospital, Masaka, Uganda
| | - T Namujwiga
- Department of Medicine, Enrolled Nurse, Kitovu Hospital, Masaka, Uganda
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - M Opio
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - A Lumala
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
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22
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Brabrand M, Kellett J, Opio M, Cooksley T, Nickel CH. Should impaired mobility on presentation be a vital sign? Acta Anaesthesiol Scand 2018; 62:945-952. [PMID: 29512139 DOI: 10.1111/aas.13098] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/31/2018] [Accepted: 02/10/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Vital signs are routinely used to assess acutely ill patients, but they do not detect all patients at risk of death. This retrospective multicenter cohort study compares the prediction of death by impaired mobility with age, co-morbidities, and vital sign changes. METHODS On first assessment, patients from a combined cohort of 9684 Danish and Irish patients and a separate cohort of 1010 Ugandan patients were stratified by impaired mobility on presentation (IMOP), vital sign changes assessed by the National Early Warning Score (NEWS), the Charlson Co-morbidity Index, and age. RESULTS Fourteen percent of Danish and Irish patients had IMOP compared with 42% of Ugandan patients. The odds ratios of IMOP for 7-day mortality were similar for both cohorts (i.e. 11.8, 95% CI 5.8-24.0 for Ugandan patients versus 6.7, 95% CI 5.0-9.0 for Danish and Irish patients). Univariate analysis of Ugandan patients showed that none of the parameters tested (i.e. low blood pressure, pulse, elevated respiratory rate, hypothermia, low oxygen saturation, old age, and coma) had a statistically higher odds ratio for either 7-day mortality than IMOP. Multivariate logistic regression analysis of Danish and Irish patients also showed that none of these parameters or the Charlson Co-morbidity Index had a statistically higher odds ratio than IMOP for either 7-day or 30-day mortality. CONCLUSION Immobility on presentation is a vital sign and predicts mortality for acutely ill patients independently of the traditional vital signs, age, and co-morbidities.
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Affiliation(s)
- M. Brabrand
- Department of Emergency Medicine; Hospital of South West Jutland; Esbjerg Denmark
- Department of Emergency Medicine; Odense University Hospital; Odense Denmark
| | - J. Kellett
- Department of Emergency Medicine; Hospital of South West Jutland; Esbjerg Denmark
| | - M. Opio
- Department of Medicine; Kitovu Hospital; Kitovu Uganda
| | - T. Cooksley
- Department of Acute Medicine; University Hospital of South Manchester; Manchester UK
| | - C. H. Nickel
- Emergency Department; University Hospital Basel; Basel Switzerland
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Wachelder JJH, van Galen LS, Kellett J, Nickel CH, Haak HR. Unplanned readmissions among patients presenting with nonspecific complaints. Eur J Intern Med 2018; 54:e36-e37. [PMID: 29885755 DOI: 10.1016/j.ejim.2018.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 05/14/2018] [Indexed: 11/17/2022]
Affiliation(s)
- J J H Wachelder
- Department of Internal Medicine, Máxima Medical Centre, 5631 BM Eindhoven/Veldhoven, The Netherlands; Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands; Dept. of Internal Medicine, Division of General Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, the Netherlands.
| | - L S van Galen
- Section Acute Medicine, Department of Internal Medicine, VU Medical Centre, Amsterdam, The Netherlands; Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Switzerland
| | - H R Haak
- Department of Internal Medicine, Máxima Medical Centre, 5631 BM Eindhoven/Veldhoven, The Netherlands; Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands; Dept. of Internal Medicine, Division of General Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, the Netherlands
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Kellett J, Sampson M, Swords F, Murphy HR, Clark A, Howe A, Price C, Datta V, Myint KS. Young people's experiences of managing Type 1 diabetes at university: a national study of UK university students. Diabet Med 2018; 35:1063-1071. [PMID: 29687498 DOI: 10.1111/dme.13656] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 01/30/2023]
Abstract
AIM Little is known about the challenges of transitioning from school to university for young people with Type 1 diabetes. In a national survey, we investigated the impact of entering and attending university on diabetes self-care in students with Type 1 diabetes in all UK universities. METHODS Some 1865 current UK university students aged 18-24 years with Type 1 diabetes, were invited to complete a structured questionnaire. The association between demographic variables and diabetes variables was assessed using logistic regression models. RESULTS In total, 584 (31%) students from 64 hospitals and 37 university medical practices completed the questionnaire. Some 62% had maintained routine diabetes care with their home team, whereas 32% moved to the university provider. Since starting university, 63% reported harder diabetes management and 44% reported higher HbA1c levels than before university. At university, 52% had frequent hypoglycaemia, 9.6% reported one or more episodes of severe hypoglycaemia and 26% experienced diabetes-related hospital admissions. Female students and those who changed healthcare provider were approximately twice as likely to report poor glycaemic control, emergency hospital admissions and frequent hypoglycaemia. Females were more likely than males to report stress [odds ratio (OR) 4.78, 95% confidence interval (CI) 3.19-7.16], illness (OR 3.48, 95% CI 2.06-5.87) and weight management issues (OR 3.19, 95% CI 1.99-5.11) as barriers to self-care. Despite these difficulties, 91% of respondents never or rarely contacted university support services about their diabetes. CONCLUSION The study quantifies the high level of risk experienced by students with Type 1 diabetes during the transition to university, in particular, female students and those moving to a new university healthcare provider.
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Affiliation(s)
- J Kellett
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Clinical Research and Trials Unit, Norwich, UK
| | - M Sampson
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Clinical Research and Trials Unit, Norwich, UK
| | - F Swords
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Clinical Research and Trials Unit, Norwich, UK
| | - H R Murphy
- University Medical Centre, University of East Anglia, Norwich, UK
| | - A Clark
- Norwich Medical School, Faculty of Health and Medical Sciences, Norwich, UK
| | - A Howe
- Norwich Medical School, Faculty of Health and Medical Sciences, Norwich, UK
| | - C Price
- University Medical Centre, University of East Anglia, Norwich, UK
| | - V Datta
- Department of Paediatrics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - K S Myint
- Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Jones RP, Kellett J. The way healthcare is funded is wrong: it should be linked to deaths as well as age, gender and social deprivation. Acute Med 2018; 17:212-216. [PMID: 30882104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND most spending on health occurs in the last few months of life. This study explored the number of deaths in England and their relationship to healthcare funding. METHODS post hoc analysis Results: the number of deaths range from 3.3 to 15.1/1000/year, and the number of deaths per general practitioner from 5.2 to 27.3/year. Hospital deaths range from 12 to 52/1000 admissions. The correlation between the allocation index used for funding and deaths is not perfect and suggests that some regions may get up to17% less and others 14% more funding than is equitable. CONCLUSION there is considerable variation in the prevalence of death throughout England. If healthcare funding considered the local number of deaths it would be more equitable.
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Affiliation(s)
- R P Jones
- Statistical Advisor, Healthcare Analysis & Forecasting, Worcester, UK
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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Nannan Panday RS, Subbe CP, van Galen LS, Kellett J, Brabrand M, Nickel CH, Nanayakkara PWB. Changes in vital signs post discharge as a potential target for intervention to avoid readmission. Acute Med 2018; 17:77-82. [PMID: 29882557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Readmissions are treated as adverse events in many healthcare systems. Causes can be physiological deterioration or breakdown of social support systems. We investigated data from a European multi-centre study of readmissions for changes in vital signs between index admission and readmission. Data sets were graded according to the National Early Warning Score (NEWS). Of 487 patients in whom NEWS could be calculated on discharge and again on re-admission, 39.6% had worse vital signs with a NEWS score difference ≥ 2 points while only 7.6% had improved by ≤ 2 points. Changes in individual vital signs of 20% or more were most common in respiratory rate and heart rate. Monitoring of respiratory rate and pulse rate post-discharge might predict some deteriorations.
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Affiliation(s)
- R S Nannan Panday
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands, Amsterdam Cardiovascular Sciences, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - C P Subbe
- Department of Acute Medicine, Ysbyty Gwynedd Hospital, Bangor, Wales, United Kingdomn, School of Medical Sciences, Bangor University, Bangor, Wales, United Kingdom
| | - L S van Galen
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands, Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark, Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - P W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
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Opio MO, Mutiibwa G, Kellett J, Brabrand M. Does how the patient feels matter? A prospective observational study of the outcome of acutely ill medical patients who feel their condition has improved on their first re-assessment after admission to hospital. QJM 2017; 110:545-549. [PMID: 28402554 DOI: 10.1093/qjmed/hcx072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although asking how a patient feels is the first enquiry most clinicians make the value of the answer has never been examined in acutely ill patients. METHODS Prospective observational study that compared the predictive value of how well acutely ill medical patients felt after admission to a resource poor sub-Saharan hospital with their mental alertness, mobility and vital signs. RESULTS In total, 403 patients were studied. Patients who felt better when re-assessed 18.0 SD 9.1 h after admission to hospital were less likely to die in hospital (OR 0.18 95% CI 0.08-0.43, P = 0.00001) and more likely to be independent of others at discharge (OR 5.64 95% CI 3.04-10.47, P = 0.00001). Feeling better was an independent predictor of in-hospital death along with vital sign changes and gait stability, and an independent predictor of independence at discharge along with vital sign changes, gait stability and female gender. CONCLUSION In this patient cohort a subjective feeling of improvement at the first re-assessment after admission to hospital is a powerful independent predictor of reduced in-hospital mortality.
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Affiliation(s)
| | | | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
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Georgousopoulou EN, Naumovski N, Mellor DD, Tyrovolas S, Piscopo S, Valacchi G, Tsakountakis N, Zeimbekis A, Bountziouka V, Gotsis E, Metallinos G, Tyrovola D, Kellett J, Foscolou A, Tur JA, Matalas AL, Lionis C, Polychronopoulos E, Sidossis L, Panagiotakos D. Association between Siesta (Daytime Sleep), Dietary Patterns and the Presence of Metabolic Syndrome in Elderly Living in Mediterranean Area (Medis Study): The Moderating Effect of Gender. J Nutr Health Aging 2017; 21:1118-1124. [PMID: 29188870 DOI: 10.1007/s12603-016-0865-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Several lifestyle parameters including diet, physical activity and sleep were associated in isolation with the presence of Metabolic Syndrome (MetS) in adults, to date there is a paucity of studies which evaluated their combined role aging populations and especially with respect to gender. Therefore, the aim of the present study was to provide a global consideration of the lifestyle factors associated with MetS among elderly individuals. DESIGN Cross-sectional observational study. SETTING 21 Mediterranean islands and the rural Mani region (Peloponnesus) of Greece. PARTICIPANTS during 2005-2015, 2749 older (aged 65-100 years) from were voluntarily enrolled in the study. MEASUREMENTS Dietary habits, energy intake, physical activity status, socio-demographic characteristics, lifestyle parameters (sleeping and smoking habits) and clinical profile aspects were derived through standard procedures. The presence of MetS was defined using the definition provided by NCEP ATP III (revised) and cluster analysis was used to identify overall dietary habit patterns. RESULTS The overall prevalence of MetS in the study sample was 36.2%, but occurred more frequently in females (40.0% vs. 31.8%, respectively, p=0.03). Individuals with MetS were more likely to sleep during the day (89.4% vs. 76.8% respectively, p=0.039) and frequent 'siesta' was positively linked to the odds of MetS presence in females (Odds Ratio (OR) =3.43, 95% Confidence Intervals (CI): 1.08-10.9), but not for men (p=0.999). The lower carbohydrate (i.e., 45.2% of total daily energy, 120±16gr/day) dietary cluster was inversely associated with the odds for MetS presence, but only for men (OR=0.094, 95%CI: 0.010-0.883). CONCLUSIONS Lifestyle parameters including sleep and diet quality are strongly associated with the presence of MetS in elderly cohort, but different their level of influence appears to be different, depending on gender. Further research is needed to better consider the role of lifestyle characteristics in the management of MetS in clinical practice.
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Affiliation(s)
- E N Georgousopoulou
- Prof Demosthenes B Panagiotakos, 46 Paleon Polemiston St. Glyfada, Attica, 166 74, Greece, Tel. +30 210-9549332 - +30 210-9600719 (Fax),
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Acosta L, O'Kane G, Kellett J, Kowalewska A. Collaborations in Dietetics Education across Countries. J Acad Nutr Diet 2016. [DOI: 10.1016/j.jand.2016.06.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Cooksley T, Nanayakkara PWB, Nickel CH, Subbe CP, Kellett J, Kidney R, Merten H, Van Galen L, Henriksen DP, Lassen AT, Brabrand M. Readmissions of medical patients: an external validation of two existing prediction scores. QJM 2016; 109:245-8. [PMID: 26163662 DOI: 10.1093/qjmed/hcv130] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospital readmissions are increasingly used as a quality indicator with a belief that they are a marker of poor care and have led to financial penalties in UK and USA. Risk scoring systems, such as LACE and HOSPITAL, have been proposed as tools for identifying patients at high risk of readmission but have not been validated in international populations. AIM To perform an external independent validation of the HOSPITAL and LACE scores. DESIGN An unplanned secondary cohort study. METHODS Patients admitted to the medical admission unit at the Hospital of South West Jutland (10/2008-2/2009; 2/2010-5/2010) and the Odense University Hospital (6/2009-8/2011) were analysed. Validation of the scores using 30 day readmissions as the endpoint was performed. RESULTS A total of 19 277 patients fulfilled the inclusion criteria. Median age was 67 (range 18-107) years and 8977 (46.6%) were female. The LACE score had a discriminatory power of 0.648 with poor calibration and the HOSPITAL score had a discriminatory power of 0.661 with poor calibration. The HOSPITAL score was significantly better than the LACE score for identifying patients at risk of 30 day readmission (P < 0.001). The discriminatory power of both scores decreased with increasing age. CONCLUSION Readmissions are a complex phenomenon with not only medical conditions contributing but also system, cultural and environmental factors exerting a significant influence. It is possible that the heterogeneity of the population and health care systems may prohibit the creation of a simple prediction tool that can be used internationally.
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Affiliation(s)
- T Cooksley
- From the Department of Acute Medicine, University Hospital of South Manchester, Manchester, UK,
| | | | | | | | | | - R Kidney
- St. James' Hospital, Dublin, Ireland and
| | - H Merten
- VU University Medical Center, Amsterdam, Netherlands
| | - L Van Galen
- VU University Medical Center, Amsterdam, Netherlands
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Abstract
OBJECTIVES To determine the proportion of Residential Aged Care Facilities (RACFs) in Australia who use a nutrition screening tool on residents to identify those at risk of malnutrition, and to review practice following identification of residents as being at high risk of malnutrition. DESIGN Multi-center, cross sectional observational study. SETTING Residential Aged Care Facilities. PARTICIPANTS The Director of Nursing at each site was contacted by telephone and asked questions relating to current nutrition screening practices at their residential aged care facility. MEASUREMENTS Data was collected from a stratified sample of 229 residential aged care facilities in each state and territory in Australia. RESULTS 82% of RACFs (n = 188) use a nutrition screening tool on residents to identify those at risk of malnutrition, however only 52% of RACFs (n = 119) used a screening tool which is validated in the residential aged care setting. There was a significant association between facilities using a nutrition screening tool and the staff members being trained to conduct nutrition screening (p < 0.001). Facilities that employed a dietitian were more likely to use a validated nutrition screening tool (p < 0.005). The most frequently used nutrition screening tool was the 'Mini Nutritional Assessment - Short Form (MNA-SF)', which was used by 32% (n = 60) of the RACFs, followed by the 'Malnutrition Universal Screening Tool (MUST)' (15%, n = 29). CONCLUSION We found that the majority of RACFs in Australia use a nutrition screening tool, however many of these RACFs use a tool which has not been validated in the RACF setting. This study highlights the need for greater dietetic advocacy in using validated nutrition screening tools to ensure malnutrition is identified.
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Affiliation(s)
- J Kellett
- Jane Kellett, University of Canberra, Australia,
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Kellett J, Murray A, Woodworth S, Huang W. Trends in weighted vital signs and the clinical course of 44,531 acutely ill medical patients while in hospital. Acute Med 2015; 14:3-9. [PMID: 25745643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND little is known about the changes and trends of individual vital signs during the course of acute illness in hospital. METHODS the weighted points of the VitalPAC Early Warning Score (ViEWS) were assigned to each vital sign value measured on 44,531 acutely ill medical patients while they were hospitalized in the Thunder Bay Regional Health Sciences Centre, Ontario, Canada. These ViEWS weighted vital signs were averaged for every 24 hour period for five days after admission and five days before death or discharge and then combined to obtain an approximation of the trajectory of each vital sign while in hospital. RESULTS compared with the other vital signs, the ViEWS weighted points for respiratory rate increase the most in patients who died in hospital and decrease the most in survivors. Combining respiratory rate with the weighted points for any of the other vital signs reduced rather than increased their monitoring performance. CONCLUSION trends in respiratory rate, measured by observation at the bedside and given a ViEWS weighting is the best predictor of clinical outcome; minor changes predicted clinical outcome several days in advance.
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Affiliation(s)
- J Kellett
- Thunder Bay Regional Health Sciences Center, Thunder Bay, Ontario, Canada
| | - A Murray
- Dundalk Institute of Technology, Dundalk, Ireland
| | - S Woodworth
- Health Information Systems Research Center, University College Cork, Ireland
| | - W Huang
- Department of Mathematical Sciences, Lakehead University, Thunder Bay, Ontario, Canada
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Subbe CP, Kellett J, Whitaker CJ, Jishi F, White A, Price S, Ward-Jones J, Hubbard RE, Eeles E, Williams L. A pragmatic triage system to reduce length of stay in medical emergency admission: feasibility study and health economic analysis. Eur J Intern Med 2014; 25:815-20. [PMID: 25044094 DOI: 10.1016/j.ejim.2014.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 05/31/2014] [Accepted: 06/03/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Departments of Internal Medicine tend to treat patients on a first come first served basis. The effects of using triage systems are not known. METHODS We studied a cohort in an Acute Medical Unit (AMU). A computer-assisted triage system using acute physiology, pre-existing illness and mobility identified five distinct risk categories. Management of the category of very low risk patients was streamlined by a dedicated Navigator. Main outcome parameters were length of hospital stay (LOS) and overall costs. Results were adjusted for the degree of frailty as measured by the Clinical Frailty Scale (CFS). A six month baseline phase and intervention phase were compared. RESULTS 6764 patients were included: 3084 in the baseline and 3680 in the intervention phase. Patients with very low risk of death accounted for 40% of the cohort. The LOS of the 1489 patients with very low risk of death in the intervention group was reduced by a mean of 1.85days if compared with the 1276 patients with very low risk in the baseline cohort. This was true even after adjustment for frailty. Over the six month period the cost of care was reduced by £250,158 in very low patients with no increase in readmissions or 30day mortality. CONCLUSIONS Implementation of an advanced triage system had a measurable impact on cost of care for patients with very low risk of death. Patients were safely discharged earlier to their own home and the intervention was cost-effective.
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Affiliation(s)
- C P Subbe
- School of Medical Sciences, Bangor University, Bangor, United Kingdom
| | | | - C J Whitaker
- NWORTH, Clinical Trials Unit, Bangor University, Bangor. United Kingdom
| | - F Jishi
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
| | - A White
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
| | - S Price
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
| | - J Ward-Jones
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
| | - R E Hubbard
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Australia
| | - E Eeles
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Australia
| | - L Williams
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, United Kingdom
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Kellett J, Clifford M, Ridley A, Gleeson M. Validation of the VitalPACTM early warning score (ViEWS) in acutely ill medical patients admitted. Ir Med J 2013; 106:318. [PMID: 24579416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Opio MO, Nansubuga G, Kellett J, Clifford M, Murray A. Performance of TOTAL, in medical patients attending a resource-poor hospital in sub-Saharan Africa and a small Irish rural hospital. Acute Med 2013; 12:135-140. [PMID: 24098872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Recently a very simple, easy to remember early warning score (EWS) dubbed TOTAL has been reported. The score was derived from 309 acutely ill medical patients admitted to a Malawian hospital and awards one point for Tachypnea >30 breaths per minute, one point for Oxygen saturation <90%, two points for a Temperature <35°C, one point for Altered mental status, and one point for Loss of independence as indicated by the inability to stand or walk without help. TOTAL has an area under the receiver operator characteristic curve (AUROC) for death within 72 hours of 78%. METHODS We compared the performance of the TOTAL score in 849 medical patients attending a resource poor hospital in Uganda and 2935 patients admitted to a small rural hospital in Ireland. RESULTS TOTAL's AUROC for death within 24 hours was the same in both hospital populations: 85.1% (95% CI 78.6 - 91.6%) for Kitovu Hospital patients and 84.7% (95% CI 77.1 - 92.2%) for Nenagh Hospital patients. CONCLUSION The discrimination of TOTAL is exactly the same in elderly Irish patients as it is in young African patients. The score is easy to remember, easy to calculate, and works over a broad range of patients.
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Affiliation(s)
- M O Opio
- St. Joseph's Kitovu Health Care Complex, Masaka, Uganda
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Kellett J, O'Keeffe ST. The Model 2 hospital: role and challenges. Ir Med J 2012; 105:294. [PMID: 23240279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Abstract
OBJECTIVE Hospital admission, especially for the elderly, can be a seminal event as many patients die within a year. This study reports the prediction of death within a year of admission to hospital of the Simple Clinical Score (SCS) and ECG dispersion mapping (ECG-DM). ECG-DM is a novel technique that analyzes low-amplitude ECG oscillations and reports them as the myocardial micro-alternation index (MMI). METHODS a convenient sample of 430 acutely ill medical patients (mean age 67.9 ± 16.6 years) was followed up for 1 year after their last admission to hospital. RESULTS Seventy-four (16.3%) patients died within a year-all but seven had a SCS ≥5 and 40% of those with an MMI ≥50% died. Only six of variables were found by logistic regression to be independent predictors of mortality (i.e. age, MMI, SCS, a discharge diagnosis of cancer, hemoglobin <11 gm% and prior illness that required the patient to spend >50% of daytime in bed). The SCS and MMI plus age were comparable predictors of 1-year mortality: SCS ≥12 predicted 1-year mortality with the highest odds (16.1, chi square 79.09, p < 0.0001) and a score of age plus MMI >104 had an odds ratio of 9.4 (chi square 73.50, p < 0.0001), identified 69% of deaths, and 43% of the 119 patients who exceeded this score were dead within a year. CONCLUSION SCS and ECG-DM plus age are clinically useful for long-term prognostication. ECG-DM is inexpensive, only takes a few seconds to perform and requires no skill to interpret.
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Affiliation(s)
- J Kellett
- Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland.
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Kellett J, Emmanuel A, Rasool S. ECG dispersion mapping predicts clinical deterioration, measured by increase in the Simple Clinical Score. Acute Med 2012; 11:8-12. [PMID: 22423340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE ECG dispersion mapping (ECG-DM) is a novel technique that reports abnormal ECG microalternations. We report the ability of ECG-DM to predict clinical deterioration of acutely ill medical patients, as measured by an increase in the Simple Clinical Score (SCS) the day after admission to hospital. METHODS 453 acutely ill medical patients (mean age 69.7 +/- 14.0 years) had the SCS recorded and ECGDM performed immediately after admission to hospital. RESULTS 46 patients had an SCS increase 20.8 +/- 7.6 hours after admission. Abnormal micro-alternations during left ventricular re-polarization had the highest association with SCS increase (p=0.0005). Logistic regression showed that only nursing home residence and abnormal micro-alternations during re-polarization of the left ventricle were independent predictors of SCS increase with an odds ratio of 2.84 and 3.01, respectively. CONCLUSION ECG-DM changes during left ventricular re-polarization are independent predictors of clinical deterioration the day after hospital admission.
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Affiliation(s)
- J Kellett
- Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland.
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Emmanuel A, Ismail A, Kellett J. Assessing the need for hospital admission by the cape triage discriminator presentations and the simple clinical score. Emerg Med J 2010; 27:852-5. [DOI: 10.1136/emj.2009.086256] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Silke B, Kellett J, Rooney T, Bennett K, O'Riordan D. An improved medical admissions risk system using multivariable fractional polynomial logistic regression modelling. QJM 2010; 103:23-32. [PMID: 19846579 DOI: 10.1093/qjmed/hcp149] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIM To develop and validate an in-hospital mortality risk prediction tool for unselected acutely ill medical patients using routinely collected physiological and laboratory data. DESIGN Analysis of all emergency medical patients admitted to St James's Hospital (SJH), Dublin, between 1 January 2002 and 31 December 2007. Validation using a dataset of acute medical admissions from Nenagh Hospital 2000-04. METHODS Using routinely collected vital signs and laboratory findings, a composite 5-day in-hospital mortality risk score, designated medical admissions risk system (MARS), was developed using an iterative approach involving logistic regression and multivariable fractional polynomials. Results are presented as area under receiver operating characteristics curves (AUROC) as well as Hosmer and Lemeshow goodness-of-fit statistics. RESULTS A total of 10 712 and 3597 unique patients were admitted to SJH and Nenagh Hospital, respectively. The final score included nine variables [age, heart rate, mean arterial pressure, respiratory rate, temperature, urea, potassium (K), haematocrit and white cell count]. The AUROC for 5-day in-hospital mortality was 0.93 [95% confidence interval (CI) 0.92-0.94] for the SJH cohort (Hosmer and Lemeshow test, P = 0.32) and 0.92 (95% CI 0.90-0.94) for the external Nenagh hospital validation cohort (Hosmer and Lemeshow test, P = 0.28). CONCLUSION In-hospital mortality estimation using only routinely collected emergency department admission data is possible in unselected acute medical patients using the MARS system. Such a score applied to acute medical patients at the time of admission, could assist senior clinical decision makers in promptly and accurately focusing limited clinical resources. Further studies validating the impact of this model on clinical outcomes are warranted.
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Affiliation(s)
- B Silke
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland.
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Price HC, Thorne KI, Dukát A, Kellett J. European physicians overestimate life expectancy and the likely impact of interventions in individuals with Type 2 diabetes. Diabet Med 2009; 26:453-5. [PMID: 19388980 DOI: 10.1111/j.1464-5491.2009.02702.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
BACKGROUND Although thrombolytic therapy improves the outcome of myocardial infarction, it is associated with increased risks of stroke and bleeding; these risks may outweigh the benefits of therapy. The risks and benefits of thrombolysis, for any individual clinical situation, can be explicitly estimated by means of decision analysis. HYPOTHESIS The aim of this study was to compare the actual use of thrombolytic agents for suspected acute myocardial infarction (AMI) with the management preferred by a decision analysis model. METHODS Admission data prospectively obtained in 262 consecutive patients admitted to a rural community hospital's coronary care unit with suspected AMI, as well as clinical decisions and outcomes, were reviewed and analyzed. RESULTS Seventeen deaths from AMI and no major strokes were observed, compared with 18.30 deaths and 0.85 major strokes predicted by a decision analysis model. Forty-seven of 84 patients with confirmed AMI and 3 of 178 without AMI were given a thrombolytic agent, compared with 65 patients with and 7 without AMI who had decision analysis-guided therapy. Decision analysis-guided therapy could have saved 3.7 additional lives and gained 29.6 life years, but produced 0.4 extra strokes. Changing the quality adjustment for stroke or heart failure would not have altered the treatment preferred by decision analysis in any of the 262 cases studied. Some patients were predicted to benefit considerably from thrombolysis with little extra risk of stroke and vice versa: all cases must, therefore, be assessed individually. CONCLUSIONS A decision analysis model can guide thrombolytic therapy by promptly defining its risks and benefits.
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Affiliation(s)
- J Kellett
- Nenagh Hospital, County Tipperary, Ireland
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Abstract
BACKGROUND Predictive scores such as APACHE II and SAPS II have been used to assess patients in intensive care units, but only the modified early warning (MEW) score has been used to assess acutely ill general medical patients. DESIGN Observational study of predictors of mortality. SETTING Small Irish rural hospital. METHODS From 17 February 2000 to 29 January 2004, 9,964 consecutive patients admitted as acute medical emergencies were divided into a derivation cohort of 6,736 patients and a validation cohort of 3,228 patients. RESULTS In the derivation cohort, 316 patients (4.7%) died within 30 days of hospital admission. Under univariate analysis, age, vital signs and 18 categorical variables were associated with increased risk of death, and nine with reduced risk. Logistic regression identified 16 independent predictors of 30-day mortality, from which the Simple Clinical Score was derived, stratifying patients into five risk classes. In each class, mortality was not significantly different between the derivation and validation cohorts: 0-0.1% for very low risk, 1.5-1.6% for low risk, 3.8-3.9% for average risk, 9.0-10.3% for high risk, and 29.2-34.4% for very high risk. DISCUSSION The Simple Clinical Score quickly and accurately identifies patients at both a low and high risk of death from the first to the 30th day after admission, enabling prompt triage and placement within a health-care facility.
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Affiliation(s)
- J Kellett
- Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland.
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Kellett J. Prediction of mortality of patients with suspected heart failure by brain natriuretic peptide concentrations > 100 pg/ml: comparison of a clinical model with brain natriuretic peptide concentrations. Heart 2006; 92:1512-3. [PMID: 16973805 PMCID: PMC1861052 DOI: 10.1136/hrt.2005.069286] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Abstract
AIM Compare self- and physician-referred hospital admissions. METHODS Analysis of data prospectively collected on 3,076 consecutive acute medical admissions to a small hospital. RESULTS Self-referred patients were younger (50.6 vs. 63.7 years) and more likely to be smokers and drinkers. Conversely, physician-referred patients were more likely to present later, be ex-smokers, ex-drinkers and have poor prior health. More self-referred admissions were related to parasuicide and/or alcohol (27% vs. 4.5%). The physical, x-ray and laboratory findings of both types of patient were similar. Although self-referred patients had a shorter length of stay (3.8 days vs. 6.0 days) and a lower death rate (1.5% vs. 3.8%),they had higher 30-day readmission rates (14.6% vs. 8.5%). CONCLUSION Self-referred patients are less sick than those referred for hospital admission by a physician, have less psychosocial support, more alcohol-related illness and are nearly twice as likely to be readmitted within 30 days of discharge
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Affiliation(s)
- J Kellett
- Department of Medcine, Nenagh Hospital, Nenagh, Co. Tipperary.
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Flavin R, Finn S, McErlean A, Smyth P, Meaney J, O'Connell F, Kellett J, McGovern E, Gaffney E. Cannonball metastases with favourable prognosis. Ir J Med Sci 2005; 174:61-4. [PMID: 15868893 DOI: 10.1007/bf03168522] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Secondary 'cannonball' metastases to the lung are frequent and usually associated with disseminated malignancy and poor prognosis. AIM To report the case of a patient with metastatic pulmonary endometrial stromal sarcoma who had a previous hysterectomy for benign uterine fibroids and no past history of malignancy. RESULT A 70-year-old female presented with cannonball metastases in her lung. Four years previously she had a hysterectomy for 'fibroids'. Review of the original histology revealed endometrial stromal sarcoma, similar to the lung metastasis. She currently has a good prognosis. CONCLUSION A patient with 'cannonball' metastases can have a favourable prognosis. A female patient with a previous hysterectomy for uterine fibroids, should be considered to have metastatic sarcoma until proven otherwise.
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Affiliation(s)
- R Flavin
- Department of Histopathology, St. James's Hospital and Trinity College Medical School, Dublin
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Kellett J, Kokkinidis L. Extinction deficit and fear reinstatement after electrical stimulation of the amygdala: implications for kindling-associated fear and anxiety. Neuroscience 2004; 127:277-87. [PMID: 15262319 DOI: 10.1016/j.neuroscience.2004.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2004] [Indexed: 11/22/2022]
Abstract
Generalized seizures produced by electrical kindling of the amygdala in laboratory rats are a widely used animal model of temporal lobe epilepsy. In addition to seizure evolution amygdala kindling enhances emotionality. The relative roles of electrical stimulation and seizure induction in fear responding are unclear. Here we investigate this issue using extinction and reinstatement of fear-potentiated startle. After classical conditioning (light+footshock pairings) laboratory rats were fear extinguished with each light presentation followed by nonepileptogenic amygdala stimulation. In contrast to the normal extinction learning of control subjects, amygdala stimulated animals exhibited conditioned fear after 120 presentations of the nonreinforced conditioned stimulus (CS). In a second experiment electrical stimulation of the amygdala restored extinguished fear responding and the fear reinstatement was specific to extinction context. The reinstatement effect did not involve sensitized fear to the CS produced by amygdala stimulation. The possibility that electrical activation of the amygdala produces unconditioned fear was considered. Animals uniformly failed to demonstrate fear-potentiated startle using electrical stimulation of the amygdala as the unconditioned stimulus. This was the case with a subthreshold afterdischarge stimulus and a stimulation schedule that produced kindled seizures. The extinction deficit and fear reinstatement results were interpreted to suggest that amygdala stimulation activates acquired excitatory stimulus-affect neural connections formed during Pavlovian fear conditioning. Our data supports a model in which excitation of an amygdala-based memory-retrieval system reinforces the expression of learned fear behaviors.
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Affiliation(s)
- J Kellett
- Department of Psychology, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
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Kellett J. Decision support and the appropriate use of fibrinolysis in myocardial infarction. Eff Clin Pract 2001; 4:1-9. [PMID: 11234180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
CONTEXT For patients with suspected acute myocardial infarction, decisions about fibrinolytic therapy must account for trade-offs between risks and benefits, which vary according to the clinical characteristics of the patient. OBJECTIVE To assess whether use of a decision-support computer program (DSCP) improves the selection of appropriate candidates for fibrinolytic therapy among patients with suspected acute myocardial infarction. DESIGN Before-and-after trial at a small rural hospital in Ireland. INTERVENTION DSCP based on a previously published decision-analysis model. With input of patient characteristics (e.g., age, sex, duration of symptoms, findings on electrocardiography) at initial evaluation, the DSCP predicts the likelihood of different outcomes (e.g., mortality, stroke) and life expectancy with and without fibrinolysis. PATIENTS 894 consecutive patients (262 before DSCP was introduced, 632 after) admitted to the coronary care unit with suspected acute myocardial infarction between January 1993 and July 1999. OUTCOME MEASURES Proportion of appropriate candidates (ST-segment elevation > 2 mm on electrocardiogram, symptom duration < or = 6 hours) receiving fibrinolysis before and after implementation of DSCP. RESULTS In general, patients admitted before and after DSCP implementation had similar clinical characteristics. The preintervention group presented somewhat earlier after the onset of symptoms (5.4 hours for preintervention vs. 7.2 hours for postintervention; P < 0.01) but had fewer confirmed acute myocardial infarctions (32% vs. 38%; P = 0.13). The proportion of appropriate patients receiving fibrinolysis before and after DSCP was nearly identical (66.7% vs. 68.9%; P > 0.2). Patients who received fibrinolysis after implementation of DSCP tended to be older (66.7 years vs. 63.8 years; P = 0.11) and were more likely to be female (36% vs. 26%; P > 0.2) than those who received fibrinolysis before DSCP implementation. The door-to-needle time decreased significantly from 88 minutes to 67 minutes after implementation of DSCP (P < 0.01). CONCLUSION Although overall rates of fibrinolysis did not change after implementation of DSCP, fibrinolytics may have been more appropriately directed toward higher risk patients who may be more likely to benefit from them.
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Affiliation(s)
- J Kellett
- Nenagh General Hospital, Nenagh, Ireland.
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Mets T, Monsch AU, Kellett J, Ousset PJ, Kuntzman F, Pellerin J, Leuschner A, Meaume S, Mischlich D, Moulias R. Assessment of dementia in elderly outpatients: a comparative study of European centers and consensus statement. Arch Gerontol Geriatr 2000; 30:17-24. [PMID: 15374045 DOI: 10.1016/s0167-4943(99)00044-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/1999] [Revised: 09/27/1999] [Accepted: 09/29/1999] [Indexed: 10/18/2022]
Abstract
Large numbers of elderly patients, suspected of having dementia, need medical evaluation, often in early phases of their illness. A complete outpatient assessment clearly could be advantageous. Thirty-five centers from 15 European countries, known to their scientific gerontological and geriatric societies to have experience in outpatient care for elderly patients with dementia, participated in an effort to develop a consensus statement for the assessment needs of these patients. The comparison of the centers showed that a wide variety of approaches was currently in practice. Differences appeared to be mainly based on local facilities and organization. A consensus for diagnostic outpatient assessment was easily reached. Diagnosis should be based on DSM-IV criteria, which requires a standardized assessment (including neuropsychological, functional and technical evaluation) and should be multidisciplinary. An assessment of dementia of elderly outpatients appears to be very feasible - a consensus approach with minimum diagnostic requirements is presented.
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Affiliation(s)
- T Mets
- Academic Hospital, Free University of Brussels, (VUB), Laarbeeklaan 101, B-1090 Brussels, Belgium.
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