Objectives
To characterise the risk factors for chronic idiopathic normocytic anaemia (CINA) in older people, particularly the role of age-associated renal impairment.
Methods
Patients aged ≥65 years ...admitted to a medical unit over 12 months were assessed. Those with secondary causes of anaemia including chronic kidney disease (CKD) were excluded. CINA was defined as a haemoglobin <130 g/l for men and <120 g/l for women for at least 6 months without any apparent cause. Renal function was determined by estimating creatinine clearance (CrCl) using Cockcroft–Gault formula, and glomerular filtration rate (GFR) using modification of diet in renal disease (MDRD) and chronic kidney disease epidemiology collaboration (CKD-EPI) formulas.
Results
116 had CINA. Controls were 572. The mean estimates of renal function were significantly lower in cases as compared with controls (
P
< 0.001). The risk of CINA increased by 12.6, 10.4 and 12 %, respectively, for each unit decrease in CrCl, MDRD-eGFR and CKD-EPI-eGFR, independent of age and other covariates. The adjusted odds ratios for CINA in those with CrCl, MDRD or CKD-EPI eGFR <60 ml/min/1.73 m
2
were 2.68 (CI 1.53–4.70); 2.70 (CI 1.57–4.62) and 2.12 (CI 1.46–3.74), respectively. Other covariates in the model that were independently associated with CINA included advanced age, diabetes mellitus (DM), use of angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), history of dementia and living in a residential care facility.
Conclusions
Age-associated renal impairment independently contributes to CINA. Other potential risk factors for CINA include advanced age, DM and ACEI or ARB use.
OBJECTIVE: To determine the prevalence of syndrome of inappropriate antidiuretic hormone secretion (SIADH) among older hyponatremic patients in a subacute geriatric facility, to identify patients ...with no apparent cause for the SIADH (idiopathic SIADH), and to determine their clinical characteristics.
DESIGN: Prospective analysis of a cohort of older patients over a period of 3 months.
SETTING: Two wards in a geriatric rehabilitation hospital.
PARTICIPANTS: Patients aged 65 and older.
MEASUREMENTS: All patients with hyponatremia (serum sodium <135 mmols/l) were clinically examined and relevant investigations were performed to determine the etiology of hyponatremia. Patients were observed for symptoms of hyponatremia. Hyponatremia was classified into possible SIADH and non‐SIADH types. Patients with SIADH type hyponatremia were screened for possible causes. Past medical histories were obtained from the general practitioners.
RESULTS: Of the 172 patients studied, 43 (25%) had hyponatremia. It was symptomatic in only four patients. Twenty‐two (51%) had SIADH etiology. In nine (mean age 84 ± 4), no cause for the SIADH was evident (presumed idiopathic SIADH) and in seven, hyponatremia (128–135 mmols/l) was chronic (12 to 72 months). Further reduction in serum sodium, which was symptomatic, was noted in two of these patients with the onset of pneumonia.
CONCLUSION: Most older hyponatremic patients in a rehabilitation setting seem to have SIADH etiology. This study confirms the presence of a group of older individuals with chronic idiopathic hyponatremia in whom the underlying mechanism may be SIADH related to aging. Hyponatremia is modest in these patients and has little clinical significance. However, they may be at increased risk of developing symptomatic hyponatremia with intercurrent illnesses.
Both hypertension and orthostatic hypotension (OH) are strongly age-associated and are common management problems in older people. However, unlike hypertension, management of OH has unique challenges ...with few well-established treatments. Not infrequently, they both coexist, further compounding the management. This review provides comprehensive information on OH, including pathophysiology, diagnostic workup and treatment, with a view to provide a practical guide to its management. Special references are made to patients with supine hypertension and postprandial hypotension and older hypertensive patients.
Ambulatory blood pressure (ABP) monitoring in type 2 diabetes (T2DM) is not yet routine in clinical practice.
To quantify abnormal ABP patterns and their associations with diabetic complications, and ...to assess the reliability of office blood pressure (OBP) for assessing BP in T2DM.
In a cross-sectional study, eligible patients with T2DM underwent OBP and 24- hour ABP measurements under standardized conditions and screening for diabetic complications.
56 patients (mean age 67 ± 10 years, males 50%) completed assessment. 43(73%) had a known history of hypertension. Non-dipping and nocturnal systolic hypertension (SHT) were prevalent in 31(55%) and 32(57%) patients, respectively. 16(29%) demonstrated masked phenomenon, but only three (7%) demonstrated white coat effect. Nocturnal SHT had a significant association with composite microvascular complications independent of daytime systolic BP control (adjusted odds ratio (OR) 1.72(CI 1.41-4.25). There was no association between other abnormal ABP patterns and diabetic complications. The sensitivity and specificity of OBP for diagnosing HT or assessing BP control was 59% and 68% respectively. The positive and negative predictive values were 74% and 52% respectively.
Non-dipping, reverse dipping, nocturnal SHT and masked phenomenon are highly prevalent in patients with T2DM with or without a known history of hypertension. Compared with non-dipping, nocturnal SHT may be a stronger predictor of end organ damage. The reliability of OBP for assessing BP in T2DM is only modest. Patients with T2DM are likely to benefit from routine ABP monitoring.
To determine the important risk factors for hip fracture and the discriminability of hip fracture risk in different age cohorts (≤80 years, >80 years).
Consecutive admissions of hip fracture over 24 ...months in those aged >60 years, and an age- and sex-matched control derived from admissions under a medical unit were prospectively assessed. The risk factors and the discriminabilty of hip fracture risk by age were investigated for each sex in univariate and multivariate models. The area under the curve (AUC) statistics from the receiver operating characteristic curve analysis was used to estimate the ability of the independent risk factors to discriminate hip fracture risk.
The important risk factors in women aged ≤80 years were lower bodyweight, previous osteoporotic fracture, hip fracture in first-degree relatives and lower plasma 25OHD, and their discriminative effect was (AUC) 0.69. Previous osteoporotic fracture and lower plasma 25OHD were the important risk factors in men aged ≤80 years, with a discriminative effect of 0.83. In the >80-year age cohorts, only falls was independently associated with hip fracture in both sexes, with discriminative effects of 0.60 and 0.62 in females and males, respectively.
The overall discrimination of hip fracture risk appears less adequate in those aged >80 years when compared with those aged ≤80 years. Although skeletal factors have a greater risk association with hip fracture in patients aged ≤80 years, it is falls that is important in those aged >80 years. The relative importance of risk factors also appears to vary between the sexes in those aged ≤80 years.
The predictors of clinically significant bleeding events (CSBE) associated with direct oral anticoagulants (DOAC) are poorly characterised in the literature.
To determine the incidence and predictors ...of CSBE in patients receiving DOAC.
Patients who received DOAC during admission to a general medical unit over a 2-year period were retrospectively studied. Following the index admission, patients were followed for 12 months or for the duration of treatment (if the latter was less than 12 months). The relevant data were obtained by review of medical records.
A total of 203 patients was studied over a mean follow-up period of 293 (±81) days. The incidence of CSBE was 13.7 (95% confidence interval (CI): 9.5-21.1) per 100 person-years. Age ≥ 75 years (P = 0.01), concurrent use of antiplatelet medications (P = 0.02) and lower estimated creatinine clearance (CrCl) (P = 0.03) had a significant univariate association with CSBE. However, in the multivariate logistic regression, only concurrent use of antiplatelet medications remained significantly associated with CSBE (adjusted odds ratio (OR) 3.6; 95% CI: 1.4-9.6; P = 0.01). Concurrent use of antiplatelet medications was also independently associated with major bleeding events (MBE) (adjusted OR 4.9; 95% CI: 1.1-21.4; P = 0.04). Although 39 (19.2%) patients received antiplatelet medications, the indications for concurrent antiplatelet use complied with current guidelines in only 3 (7.7%) patients.
Caution should be exercised when prescribing antiplatelet medications with DOAC as this combination is a potential risk factor for both major and non-major clinically significant bleeding events. In most patients, the concurrent use of antiplatelet medications was discordant with the current consensus guidelines.
The current evidence suggests that ambulatory blood pressure monitoring (ABPM) should be an integral part of the diagnosis and management of hypertension. However, its uptake in routine clinical ...practice has been variable. This paper reviews the current evidence for the role of ABPM in clinical practice, including in hypotensive disorders and in specific comorbidities. It further discusses the clinical significance of abnormal ambulatory blood pressure patterns and hypertensive syndromes such as white coat, masked and resistant hypertension.
Normocalcaemic primary hyperparathyroidism (NPHPT) is often under-recognised in clinical practice.
To determine the prevalence and clinical significance of NPHPT in an unselected sample in an acute ...hospital setting.
Patients aged >18 years who had measurement of an elevated serum parathyroid hormone (PTH ≥ 7 pmol/L) during 12 months from 1 January 2017 to 31 December 2017 were retrospectively studied. NPHPT was defined by the presence of elevated serum PTH with normal albumin-corrected serum calcium on two or more occasions after excluding secondary causes. Patients were followed up for 2 years. Relevant data were collected by review of electronic medical records.
Of the 2593 patients who had PTH measured during the study period, 1278 had serum PTH ≥ 7 pmol/L. Hypercalcaemic primary hyperparathyroidism (PHPT) was diagnosed in 174 patients. Secondary causes for elevated serum PTH were identified in 993 patients: 815 (chronic kidney disease - estimated glomerular filtration rate < 60 mL/min/1.73 m
or renal transplant), 98 (vitamin D deficiency - 25(OH)D < 50 nmol/L), 28 (gastric bypass surgery), 38 (medications), 13 (malabsorption or post-thyroidectomy) and 1 (hypercalciuria). Data were incomplete for 80 patients. The prevalence of NPHPT with and without the exclusion of hypercalciuria was 0.19% (5) and 0.39% (10) respectively. The prevalence of nephrolithiasis in NPHPT was higher than PHPT (100% vs 15% among five patients (P < 0.001) and 50% vs 15% among 10 patients (P = 0.014)). The prevalence of osteoporosis was not significantly different between NPHPT and PHPT (20% vs 45% among five patients (P = 0.389) and 30% vs 45% among 10 patients (P = 0.518)).
These findings give further credence to the diagnosis of NPHPT as a clinical entity. Nephrolithiasis may be a greater problem than osteoporosis in NPHPT compared with PHPT. This needs prospective evaluation.
Summary
Background
Community‐acquired pneumonia (CAP) is a common condition and a number of guidelines have been developed for its assessment and treatment. Adherence to guidelines by clinicians ...varies and particularly the prescribing of antibiotics often remains suboptimal.
Objective
The aim of this study was to elucidate potential barriers and enablers to the adherence to antibiotic guidelines by clinicians treating CAP in an Australian hospital.
Methods
Semi‐structured interviews were conducted with purposively recruited senior prescribers who regularly treat CAP in an Australian hospital. Thematic analysis identified a number of themes and subthemes related to their knowledge, attitudes and behaviours associated with the use of CAP guidelines.
Results
Thematic saturation was reached after 10 in‐depth interviews. Although similar barriers to the use of guidelines as previously described in the literature were confirmed, a number of novel, potential enablers were drawn from the interviews. Clinicians’ acceptance and accessibility of guidelines emerged as enabling factors. Generally positive attitudes towards antimicrobial stewardship services invite leveraging what was described as the relationship‐based and hierarchical nature of medical practice to provide personalised feedback and updates to clinicians.
Conclusions
Adding a social and personalised approach of antimicrobial stewardship to policy‐ and systems‐based strategies may lead to incremental improvements in guideline adherent practice when assessing and treating CAP.
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