Emergency department use and length of stay by younger and older adults: Nottingham cohort study in the emergency department (NOCED).

BACKGROUND: Younger and older adults attending the Emergency Department (ED) are a heterogeneous population. Longer length of ED stay is associated with adverse outcomes and may vary by age. AIMS: To evaluate the associations between age and (1) clinical characteristics and (2) length of ED stay among adults attending ED. METHODS: The NOttingham Cohort study in the Emergency Department (NOCED)-a retrospective cohort study-comprises new consecutive ED attendances by adults ≥ 18 years, at a secondary/tertiary care hospital, in 2019. Length of ED stay was dichotomised as < 4 and ≥ 4 h. The associations between age and length of ED stay were analysed by binary logistic regression and adjusted for socio-demographic and clinical factors including triage acuity. RESULTS: 146,636 attendances were analysed; 75,636 (51.6%) resulted in a length of ED stay ≥ 4 h. Attendances of adults aged 65 to 74 years, 75 to 84 years and ≥ 85 years, respectively, had an increased risk (odds ratio (95% confidence interval) of length of ED stay ≥ 4 h of 1.52 (1.45-1.58), 1.65 (1.58-1.72), and 1.84 (1.75-1.93), compared to those of adults 18 to 64 years (all p < 0.001). These findings remained consistent in the subsets of attendances leading to hospital admission and those leading to discharge from ED. DISCUSSION AND CONCLUSION: In this real-world cohort study, older adults were more likely to have a length of ED stay ≥ 4 h, with the oldest old having the highest risk. ED target times should take into account age of attendees.

Association of frailty with mortality in older inpatients with Covid-19: a cohort study.

BACKGROUND: COVID-19 has disproportionately affected older people. OBJECTIVE: The objective of this paper to investigate whether frailty is associated with all-cause mortality in older hospital inpatients, with COVID-19. DESIGN: Cohort study. SETTING: Secondary care acute hospital. PARTICIPANTS: Participants included are 677 consecutive inpatients aged 65 years and over. METHODS: Cox proportional hazards models were used to examine the association of frailty with mortality. Frailty was assessed at baseline, according to the Clinical Frailty Scale (CFS), where higher categories indicate worse frailty. Analyses were adjusted for age, sex, deprivation, ethnicity, previous admissions and acute illness severity. RESULTS: Six hundred and sixty-four patients were classified according to CFS. Two hundred and seventy-one died, during a mean follow-up of 34.3 days. Worse frailty at baseline was associated with increased mortality risk, even after full adjustment (P = 0.004). Patients with CFS 4 and CFS 5 had non-significant increased mortality risks, compared to those with CFS 1-3. Patients with CFS 6 had a 2.13-fold (95% CI 1.34-3.38) and those with CFS 7-9 had a 1.79-fold (95% CI 1.12-2.88) increased mortality risk, compared to those with CFS 1-3 (P = 0.001 and 0.016, respectively). Older age, male sex and acute illness severity were also associated with increased mortality risk. CONCLUSIONS: Frailty is associated with all-cause mortality risk in older inpatients with COVID-19.

Predicting fracture risk in osteoporosis: the use of fracture prediction tools in an osteoporosis clinic population.

BACKGROUND: In the UK, the National Institute for Health and Care Excellence recommends either fracture risk assessment tool (FRAX) or QFracture to estimate the 10 year fracture risk of individuals. However, it is not known how these tools compare in determining risk and subsequent treatment using set intervention thresholds or guidelines. METHODS: The 10 year major osteoporotic (MO) and hip (HI) fracture risks were calculated for 100 women attending osteoporosis clinic in 2010 using FRAX and QFracture, and subsequent agreement to treatment between the tools was looked at using National Osteoporosis Foundation and National Bone Health Alliance thresholds (FRAX-20/3 and QFracture 20/3). We also looked at using these thresholds for QFracture and comparing them with the National Osteoporosis Guideline Group (NOGG) guidelines for FRAX (FRAX-NOGG). RESULTS: The 10 year risk for MO fracture for FRAX was 17.0% (IQR 10.8-24.0) and that of QFracture was 15.8% (IQR 9.5-27.7) (p=0.732). The 10 year risk for HI fracture for FRAX was 5.0% (IQR 2.1-8.9) and that of QFracture was 8.1% (IQR 2.5-21.6) (p<0.001). The agreement between FRAX-20/3 and QFracture-20/3 was greater than the agreement between FRAX-20/3 and FRAX-NOGG or QFracture-20/3 and FRAX-NOGG. CONCLUSIONS: The calculated 10 year risk for MO fracture between FRAX and QFracture was similar, whereas that of HI fracture was significantly different. The agreement to treatment between QFracture-20/3 and FRAX-NOGG was only 45%. Treatment decisions can differ depending on the fracture calculation tool used when coupled with certain intervention thresholds or guidelines.

Autoimmune haemolytic anaemia emerging during Campath treatment in a patient with CD5 negative chronic lymphocytic leukaemia.

Campath is being employed for the treatment of autoimmune haemolytic anemia (AIHA) whether or not associated to B cell chronic lymphoid leukaemia (CLL). CD5 negative CLL is relatively uncommon and runs an indolent course. We report a CD5 negative CLL patient who developed AIHA associated with cytomegalovirus infection reactivation whilst on treatment with Campath for progressive disease.

Orthogeriatrics moving forward.

The role of the orthogeriatrician has grown over the last few years. Orthogeriatrics was primarily involved in the care and management of fragility hip fractures, but has recently been expanded to provide specialist care to patients admitted with other various fractures, the spine, pelvis, appendicular, and those suffered from major trauma. There is also an increasing role for the orthogeriatrician to optimise the pre-operative care of patients undergoing elective joint and spine surgery. Much of what we do incorporates comprehensive geriatric assessment of the frail older person, and research into new and innovative ways of managing various types of fragility fractures such as the use of enhanced recovery after surgery (ERAS) pathways, regional anaesthesia, vertebral augmentation in spinal fractures, sacral augmentation and anabolic treatment in pelvic fractures. Ultimately, this reduces post-operative complication rates, improves outcomes and leads to better patient care and recovery.

Antiplatelets in secondary stroke prevention: should clopidogrel be the first choice?

Antiplatelet therapy has proven efficacy in the secondary prevention of recurrent non-cardioembolic ischaemic stroke. Recent evidence suggests clopidogrel is as effective as combined therapy with aspirin and extended-release dipyridamole for the prevention of recurrent stroke. As cerebrovascular and ischaemic heart disease are closely related, it would be sensible to use a drug shown to prevent vascular events in both territories. Clopidogrel meets these criteria, is superior to aspirin monotherapy, and has fewer side effects compared with extended-release dipyridamole. While there is no direct evidence supporting the use of clopidogrel in transient ischaemic attacks, it is likely that clopidogrel is effective because transient ischaemic attacks and stroke are part of the same disease spectrum. Clopidogrel could thus be useful as first line secondary prevention therapy in all non-cardioembolic stroke subtypes and transient ischaemic attacks, to prevent recurrent ischaemic events in all vascular territories.

Multi-organ failure in adult onset Still's disease: a septic disguise.

The diagnosis of adult onset Still's disease is difficult in the absence of definite clinical and laboratory criteria. A delayed diagnosis of adult onset Still's disease was made in a 23-year-old female who developed multi-organ failure and disseminated intravascular coagulation with fingertip auto-amputation during a febrile illness considered septic due to the persistence of elevated serum procalcitonin concentration.