Profiling frequent attenders at an inner city emergency department.

BACKGROUND: Emergency department (ED) frequent attenders (FAs) have a higher rate of adverse outcomes compared to infrequent attenders. AIMS: The primary aim was to describe the prevalence of FAs at an inner city ED. A subgroup analysis was undertaken for high and very high FAs to establish demographics and other factors which might cause them to attend frequently. METHODS: A retrospective review of all patients who attended the ED at Mercy University Hospital (MUH), Cork, during 2016 was undertaken. Patients were classified as either infrequent attenders (1-2 attendances/year), frequent attenders (3-12 attendances/year), high frequent attenders (HFA, 13-29 attendances/year), or very high frequent attenders (VHFA, > 30 attendances/year). RESULTS: During 2016, a total of 21,920 patients presented 33,152 times. Overall, 90.2% (n = 19,761) were infrequent attenders, whilst 9.6% (n = 2115) were FAs. A further 36 patients (0.16%) were HFAs and eight patients (0.04%) were classified as VHFAs. Almost 10% of patients attended the ED three or more times, accounting for 29% of overall ED attendances. The HFA and VHFA cohorts were predominantly male (79.5%, n = 35) with an average age of 49.6 years. They were found to have multiple medical comorbidities, complex psychosocial problems, and a mortality rate of 11.3% over a 2-year period. CONCLUSIONS: This retrospective review is the most detailed assessment of Irish FAs undertaken to date. Further studies are required to examine the Irish hospitals most at need of Case Management Strategy Programmes which we postulate could minimise the risk of adverse outcomes for these patients and improve overall ED efficiency.

Diagnostic Accuracy of Tests for Polyuria in Lithium-Treated Patients.

In lithium-treated patients, polyuria increases the risk of dehydration and lithium toxicity. If detected early, it is reversible. Despite its prevalence and associated morbidity in clinical practice, it remains underrecognized and therefore undertreated. The 24-hour urine collection is limited by its convenience and practicality. This study explores the diagnostic accuracy of alternative tests such as questionnaires on subjective polyuria, polydipsia, nocturia (dichotomous and ordinal responses), early morning urine sample osmolality (EMUO), and fluid intake record (FIR). This is a cross-sectional study of 179 lithium-treated patients attending a general adult and an old age psychiatry service. Participants completed the tests after completing an accurate 24-hour urine collection. The diagnostic accuracy of the individual tests was explored using the appropriate statistical techniques. Seventy-nine participants completed all of the tests. Polydipsia severity, EMUO, and FIR significantly differentiated the participants with polyuria (area under the receiver operating characteristic curve of 0.646, 0.760, and 0.846, respectively). Of the tests investigated, the FIR made the largest significant change in the probability that a patient experiences polyuria (<2000 mL/24 hours; interval likelihood ratio, 0.18 and >3500 mL/24 hours; interval likelihood ratio, 14). Symptomatic questioning, EMUO, and an FIR could be used in clinical practice to inform the prescriber of the probability that a lithium-treated patient is experiencing polyuria.

Risk factors for polyuria in a cross-section of community psychiatric lithium-treated patients.

OBJECTIVES: Polyuria increases the risk of dehydration and lithium toxicity in lithium-treated patients. Risk factors have been inconsistently described and the variance of this adverse effect remains poorly understood. This study aimed to establish independent risk factors for polyuria in a community, secondary-level lithium-treated sample of patients. METHODS: This was a cross-sectional study of the lithium-treated patients attending a general adult and an old age psychiatry service. Participants completed a 24-hour urine collection. Urine volume and the presence of polyuria were the outcomes of interest. The relationship between outcome and the participant's demographic and clinical characteristics was explored with univariable and multivariable analysis. RESULTS: A total of 122 participants were included in the analysis, with 38% being diagnosed with polyuria. Female gender and increased body weight independently predicted the presence of polyuria (standardized regression coefficient 1.01 and 0.94, respectively; p = 0.002 and p = 0.003, respectively). Female gender and increased body weight, lithium dose, and duration of lithium treatment independently predicted higher 24-hour urine volumes (standardized regression coefficients 0.693, p < 0.0005; 0.791, p < 0.0005; 0.276, p = 0.043; 0.181, p = 0.034, respectively). Of three different weight metrics, lean body weight was the most predictive. CONCLUSIONS: Female gender and increased body weight explain part of the variance of this adverse effect. Both risk factors offer fresh insights into the pathophysiology of this potentially reversible and dangerous adverse effect of lithium treatment. Future research should focus on understanding the differences between the genders and between different body compositions in terms of lithium pharmacokinetics and pharmacodynamics.

The surgeon and self-harm: at the cutting edge.

Surgeons frequently treat the consequences of self-harm. Self-harm is a common problem and presentations to Irish hospitals are increasing. It increases the risk of suicide and is associated with long term morbidity. Appropriate management can improve the prognosis. Surgeons require a number of skills to appropriately manage patients who self-harm. In this review we outline those skills including diagnosis, communication, capacity and risk assessment.