Recovery from delirium and psychotic manifestations following treatment of anaemia with off-label rituximab in active cold haemagglutinin disease.

Anaemia is an independent, commonly under-recognised risk factor for delirium. Prompt management of anaemia and its underlying aetiology could result in recovery from delirium and associated psychotic manifestations. We report this unprecedented case of complete recovery from delirium and challenging behaviour, following treatment of autoimmune haemolytic anaemia with rituximab.

Recognition and management of acute kidney injury in hospitalised patients can be partially improved with the use of a care bundle.

Acute kidney injury (AKI) is common in hospitalised patients but is known be suboptimally managed; the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report in 2009 identified significant failings in AKI care. An audit, using standards suggested by the NCEPOD report, of all adult inpatients with AKI in a large central-London NHS hospital in a 7-day period in 2011 showed poor recognition and management of AKI. In response, an AKI 'care bundle' was developed and deployed throughout the hospital along with a programme of enhanced education. Re-audit in 2013 showed that AKI was significantly more likely to have been recognised by the clinical team than in 2011, and patients with AKI were significantly more likely to have had fluid status clinically assessed and nephrotoxic medication stopped in 2013 than in 2011. There was no significant improvement in fluid administration if assessed as hypovolaemic and compliance with the guideline for prevention of contrast nephropathy. In 2011, all audit measures were met in 3.7% of patient-days versus 8.4% in 2013. More in-depth work is necessary to better understand the factors which limit optimal care.

WWW. Do not forget older people.

BACKGROUND: internet use continues to grow. It is often assumed that most users are younger or middle aged. We set out to establish how access to and use of the Internet varied with age. METHODS: we surveyed a sample of patients attending urology outpatient clinics in a one week period. RESULTS: use of the internet decreases with increasing age. However 75% of ages 65-69 and 55% of over 80's access the internet, with most doing so at least weekly. Whilst health-related information is very relevant, only 20% of patients had looked at the hospital departmental website prior to a visit. CONCLUSION: as health professionals we must ensure that we have relevant up-to-date information on our websites for patients to access of all age ranges. Departments should give consideration to courses or other novel methods (e.g. computers in GP surgeries, text to speech software, etc) to improve internet access in older people.

Effective quality improvement of thromboprophylaxis in acute medicine.

INTRODUCTION: The Health Select Committee Report on the prevalence of venous thromboembolism (VTE) in 2005 suggested that poor awareness of the risks of VTE contributed significantly to mortality and morbidity in hospitalised patients. It recommended that all hospitalised patients should undergo a VTE risk assessment. In 2006, an audit in medical patients at Guy's and St Thomas' NHS Foundation Trust (GSTFT) revealed a lack of documentation of VTE risk assessment and poor use of thromboprophylaxis in 'at risk' patients. In 2007, the GSTFT 'Venous Thromboembolism in Adult Medical Inpatients' guideline was approved. The aim was to achieve a thromboprophylaxis culture within Acute Medicine and, in doing so, achieve a high adherence rate. METHODS: The guideline was launched and implemented using a multidisciplinary and multiple intervention approach involving education and feedback, IT intervention, verbal and written reminders, regular audit and process redesign. RESULTS: An audit in 2008 showed that the rate of adherence had increased from 56% preguideline to 96%. However, a repeat audit in 2009 suggested that even though the majority of patients were receiving appropriate thromboprophylaxis, risk assessment documentation was poor. This resulted in treatment being provided to some low-risk patients when it was not required. CONCLUSION: In conclusion, the most effective means of achieving VTE guideline adherence is to establish a thromboprophylaxis culture. This can be accomplished through a multiple intervention and continuous feedback approach. However, it is essential to ensure that a comprehensive VTE risk assessment is carried out to ensure that those not requiring treatment do not receive it unnecessarily.

An emerging infectious cause of renal impairment in the UK.

Hantaviruses are endemic in many central European countries, particularly the Balkans, infection causing non-specific 'flu-like symptoms and renal dysfunction which is self-limiting in the majority of cases. In this case, there was a diagnostic delay, resulting in numerous unnecessary investigations, prolonged hospital stay and almost an invasive renal biopsy. A travel history is therefore essential, to establish travel to an endemic region within the previous 2-6 weeks. With increasing travel and immigration, hantavirus is likely to be seen more frequently as an imported infection into the UK. However, further research is required to establish the potential for acquisition of infection here, as the animal host, the bank vole, is part of local wildlife. Therefore, the authors urge physicians to be alert to this possibility when faced with acute renal failure in association with an undiagnosed febrile illness, particularly when there is a history of an appropriate environmental or animal exposure.

Tongue swelling in association with oseltamivir (Tamiflu).

A 29-year-old lady presented with an increasingly swollen tongue 3 days after commencing oseltamivir (Tamiflu) for flu-like symptoms. Once identified as the cause, her symptoms rapidly improved with antihistamines and discontinuing the Tamiflu. The authors find only one other case in the literature reporting this very rare side effect.

Modernising morning report: innovation in teaching and learning.

BACKGROUND: Over recent years there has been a shift in undergraduate medical education, from predominantly passive, didactic teaching methods to facilitating learning by focusing on the management of common scenarios, through the means of problem- and case-based learning. CONTEXT: Case-based learning and peer-led teaching are often overlooked at postgraduate level, despite the continuing demonstrated success of these methods in fostering independent reasoning and problem-solving skills that are vital for newly qualified doctors to develop. When trying to strike a balance between educational needs and service provision, it is essential to identify and implement efficient, effective approaches to optimise learning opportunities. INNOVATION: We have adapted the pre-existing framework of the American 'Morning Report' to suit the needs of today's junior doctors, creating a system of providing case-based learning paired with peer-led teaching. IMPLICATIONS: We evaluated the educational model through a focus group session, and found that our Morning Report was a unique environment where junior doctors feel comfortable engaging with group case-based teaching, with the support and encouragement of senior consultants, reinforced with online case summaries and blog resources.

Provision of palliative care for chronic heart failure inpatients: how much do we need?

BACKGROUND: Clinical guidance recommends early CHF palliative care intervention, but the magnitude of need is unknown and evidence-based referral criteria absent.This study aimed to: 1) Measure point prevalence of inpatients appropriate for palliative care. 2) Identify patient characteristics associated with palliative care appropriateness. 3) Propose evidence-based clinical referral criteria. METHODS: Census: all adult medical inpatient files in a UK tertiary teaching hospital were reviewed, identifying patients with CHF as a reason for current admission, using NYHA stage 3/4 classification, cross referenced with existing ECHO data. Each CHF patient was classified according to appropriateness for palliative care against a definition of unresolved pain and/or symptoms and/or psychosocial problems 7 days post admission. RESULTS: Three hundred and sixty-five patient files were reviewed, and 28 clinically identified as having CHF. Of these, 11 had confirmed unpreserved ejection fraction,16 of the 28 patients were appropriate for palliative care. Of the total inpatient population reviewed, 10 (2.7%) had both confirmed ejection fraction 45% also require palliative care. Our conservative criteria suggest a point prevalence of 2.7% of patients having both ejection fraction

CAALYX: a new generation of location-based services in healthcare.

Recent advances in mobile positioning systems and telecommunications are providing the technology needed for the development of location-aware tele-care applications. This paper introduces CAALYX--Complete Ambient Assisted Living Experiment, an EU-funded project that aims at increasing older people's autonomy and self-confidence by developing a wearable light device capable of measuring specific vital signs of the elderly, detecting falls and location, and communicating automatically in real-time with his/her care provider in case of an emergency, wherever the older person happens to be, at home or outside.

Impact of age on QT interval and QT dispersion in healthy subjects: a regression analysis.

OBJECTIVE: although the isolated effects of age on QT interval and QT dispersion (QTd) have been previously investigated, no data are available on the simultaneous effects of age and other physiological or lifestyle factors on QT interval and QTd in healthy subjects. We studied the effects of age, gender, body mass index, smoking status, and blood pressure on these electrocardiographic parameters. DESIGN: observational study. SETTING: academic medical centre. PARTICIPANTS AND MEASUREMENTS: age, gender, body mass index, smoking status, and blood pressure were obtained from 191 consecutive healthy subjects (101 males and 90 females, age range 19-89 years). The subjects were divided into three groups according to their age: <30 (n=56), 30-65 (n=49), and >65 years (n=86). RESULTS: heart-rate corrected QT interval (QTc, Bazett's formula) progressively increased with advancing age (389+/-3 vs. 411+/-4 vs. 418+/-3 ms, means+/-SEM; P<0.01). By contrast, no differences in QTd were observed across the three groups (36+/-2 vs. 35+/-3 vs. 40+/-2 ms, P=NS). A multivariate regression analysis showed that age (P<0.01) and body mass index (P=0.04) independently predicted QT interval while gender was a weak (P=0.09) predictor of QTd. CONCLUSIONS: after adjusting for gender, smoking status, and blood pressure, age and body mass index independently predicted QT interval in healthy subjects. By contrast, age is not a predictor of QTd. The increase of QT interval associated with ageing and body mass index might be secondary to cardiac hypertrophy and myocardial action potential prolongation.