Doctors Are Inconsistent in Estimating Survival after CPR and Are Not Using Such Predictions Consistently in Determining DNACPR Decisions.

Background: It is unclear whether doctors base their resuscitation decisions solely on their perceived outcome. Through the use of theoretical scenarios, we aimed to examine the 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision-making. Methods: A questionnaire survey was sent to consultants and specialty trainees across two Norfolk (UK) hospitals during December 2013. The survey included demographic questions and six clinical scenarios with varying prognosis. Participants were asked if they would resuscitate the patient or not. Identical scenarios were then shown in a different order and doctors were asked to quantify patients' estimated chance of survival. Results: A total of 137 individuals (mean age 41 years (SD 7.9%)) responded. The response rate was 69%. Approximately 60% were consultants. We found considerable variation in clinician estimates of median chance of survival. In three out of six of our scenarios, the survival estimated varied from <1% to 95%. There was a statistically significant difference identified in the estimated median survival between those clinicians who would or would not resuscitate in four of the six scenarios presented. Conclusion: This study has highlighted the wide variation between clinicians in their estimates of likely survival and little concordance between clinicians over their resuscitation decisions. The diversity in clinician decision-making should be explored further.

Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke: Analysis of UK Regional Registry Data, Systematic Review, and Meta-Analysis.

BACKGROUND: The impact of hemoglobin levels and anemia on stroke mortality remains controversial. We aimed to systematically assess this association and quantify the evidence. METHODS AND RESULTS: We analyzed data from a cohort of 8013 stroke patients (mean±SD, 77.81±11.83 years) consecutively admitted over 11 years (January 2003 to May 2015) using a UK Regional Stroke Register. The impact of hemoglobin levels and anemia on mortality was assessed by sex-specific values at different time points (7 and 14 days; 1, 3, and 6 months; 1 year) using multiple regression models controlling for confounders. Anemia was present in 24.5% of the cohort on admission and was associated with increased odds of mortality at most of the time points examined up to 1 year following stroke. The association was less consistent for men with hemorrhagic stroke. Elevated hemoglobin was also associated with increased mortality, mainly within the first month. We then conducted a systematic review using the Embase and Medline databases. Twenty studies met the inclusion criteria. When combined with the cohort from the current study, the pooled population had 29 943 patients with stroke. The evidence base was quantified in a meta-analysis. Anemia on admission was found to be associated with an increased risk of mortality in both ischemic stroke (8 studies; odds ratio 1.97 [95% CI 1.57-2.47]) and hemorrhagic stroke (4 studies; odds ratio 1.46 [95% CI 1.23-1.74]). CONCLUSIONS: Strong evidence suggests that patients with anemia have increased mortality with stroke. Targeted interventions in this patient population may improve outcomes and require further evaluation.

Incidentally Raised Cardiac Troponin I Has a Worse Prognosis in Older Patients Compared to Those with Normal Cardiac Troponin I and Patients with Acute Coronary Syndrome: A Cohort Study.

BACKGROUND: Incidentally elevated cardiac troponin I (cTnI) levels are common in acutely unwell older patients. However, little is known about how this impacts on the prognosis of these patients. OBJECTIVE: We aimed to investigate whether incidentally elevated cTnI levels (group 1) are associated with poorer outcome when compared to age- and sex-matched patients without an elevated cTnI level (group 2), and to patients diagnosed with acute coronary syndrome (group 3). PATIENTS AND METHODS: This prospective, matched cohort study placed patients ≥75 years old who were admitted to a University teaching hospital into groups 1-3, based on the cTnI levels and underlying diagnosis. Outcomes were compared between the groups using mixed-effects regression models and adjusted for renal function and C-reactive protein. All-cause mortality at discharge, at 1 month and 3 months, alongside the length of hospital stay (LOS), were recorded. RESULTS: In total, 315 patients were included, with 105 patients in each of the 3 groups. The mean age was 84.8 ± 5.5 years, with 41.9% males. All patients were followed up for 3 months. The percent all-cause mortality at discharge and the LOS for groups 1, 2 and 3 were 12.4, 3.8 and 8.6% and 11.2, 8.5 and 7.7 days, respectively. Group 1 had significantly increased mortality at 3 months [odds ratio (OR) 2.80, 95% confidence interval (CI) 1.12-6.96; p = 0.040] and LOS (OR 1.39, 95% CI 1.08-1.79; p = 0.008) compared to group 2 and did not differ significantly when compared to 3-month mortality (OR 2.39, 95% CI 0.91-6.29; p = 0.079) or LOS (OR 1.26, 95% CI 0.96-1.66; p = 0.097) in group 3. CONCLUSION: There is a significant association between an incidental rise in cTnI level with mortality and LOS in older patients. Further research is required to evaluate whether a more systematic management of these patients would improve the prognosis.

Characteristics and determinants of survival in oldest old nursing home residents admitted to hospital with an acute illness compared to their younger counterparts.

BACKGROUND AND OBJECTIVES: The clinical problems and needs of our oldest old (≥85 years) are often substantially different from those of younger patients, and are arguably different from younger elderly patients (age 65-84). With the increasing number of frail oldest olds residing in Nursing Homes (NH), we aim to identify differences in prognostic indicators and outcomes in this age group compared to younger NH residents. METHODS: We retrospectively identified all consecutive admissions from NHs to an Acute Medical Assessment Unit between January 2005 and December 2007. Admission prognostic indicators and outcomes at follow-up were compared between younger (<85) and older (≥85) age groups. Using multiple regression methods controlling for potential confounders, we compared in-hospital mortality and long-term survival after discharge between the groups. RESULTS: Three hundred and sixteen patients (mean age 84.3, SD 8.34 years) were included (68 % females). Admission characteristics were mostly similar between age groups. In-hospital mortality rates were not significantly different between groups, even after adjusting for possible confounders. Oldest old patients had a significantly greater hazard of dying after discharge (HR 1.37; 1.03-1.83) compared to the younger group after removing explanatory variables with more than 5 % missing data. CONCLUSION: Whilst the admission characteristics are similar between younger and older patients from NHs, there is evidence to suggest worse long-term survival prospects for oldest old patients.

Comparison of levels of depression in medical and non-medical students.

BACKGROUND: High levels of depression in junior doctors prompted this research into the prevalence of depression in medical students, compared with other non-medical university students. We also explored potential vulnerability factors that may be associated with student depression. METHODS: A comparative cross-sectional internet-based questionnaire design was used. This self-administered questionnaire, consisting of demographic details and questions about potential vulnerability factors, was disseminated to both medical and non-medical life-sciences students via their university e-mail accounts. The Patient Health Questionnaire 9 (PHQ-9), a self-completed depression-specific questionnaire, was included. RESULTS: Non-medical students showed a higher prevalence of moderate and severe depressive symptoms than their medical student peers, although medical students reported more symptoms of mild depression. Multivariable logistic regression analysis indicated that belonging to an ethnic minority (p = 0.021), and having a personal (p < 0.001) or family history of depression (p < 0.001) were associated with a higher risk of depression. Having studied for a previous degree appeared to be protective against depression (p = 0.029). Around half (50% of medical and 54% of non-medical) students indicated that they would not feel able to consult their university tutors if depressed. DISCUSSION: Significant levels of depression were reported by both medical and non-medical students. Potential vulnerability factors included: a personal or family history of depression, point of degree entry and belonging to an ethnic minority. The reluctance of students to consult their tutors about such problems highlights the potentially stigmatising nature of depression, and reinforces the need for higher education institutions to address these issues.