Introduction Delirium is associated with a wide range of adverse patient safety outcomes, yet it remains consistently under-diagnosed. We undertook a systematic review of studies describing delirium in adult medical patients in secondary care. We investigated if changes in healthcare complexity were associated with trends in reported delirium over the last four decades. Methods We used identical criteria to a previous systematic review, only including studies using internationally accepted diagnostic criteria for delirium (the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases). Estimates were pooled across studies using random effects meta-analysis, and we estimated temporal changes using meta-regression. We investigated publication bias with funnel plots. Results We identified 15 further studies to add to 18 studies from the original review. Overall delirium occurrence was 23% (95% CI 19–26%) (33 studies) though this varied according to diagnostic criteria used (highest in DSM-IV, lowest in DSM-5). There was no change from 1980 to 2019, nor was case-mix (average age of sample, proportion with dementia) different. Overall, risk of bias was moderate or low, though there was evidence of increasing publication bias over time. Discussion The incidence and prevalence of delirium in hospitals appears to be stable, though publication bias may have masked true changes. Nonetheless, delirium remains a challenging and urgent priority for clinical diagnosis and care pathways.
Background: The highest burden of hypertension is found in Sub-Saharan Africa (SSA) with a threefold greater mortality from stroke and other associated diseases. Ethnicity is known to influence the response to antihypertensives, especially in black populations living in North America and Europe. We sought to outline the impact of all commonly used pharmacological agents on both blood pressure reduction and cardiovascular morbidity and mortality in SSA. Methods: We used similar criteria to previous large meta-analyses of blood pressure agents but restricted results to populations in SSA. Quality of evidence was assessed using a risk of bias tool. Network meta-analysis with random effects was used to compare the effects across interventions and meta-regression to explore participant heterogeneity.Results: Thirty-two studies of 2860 participants were identified. Most were small studies from single, urban centres. Compared with placebo, any pharmacotherapy lowered SBP/DBP by 8.51/8.04 mmHg, and calcium channel blockers (CCBs) were the most efficacious first-line agent with 18.46/11.6 mmHg reduction. Fewer studies assessing combination therapy were available, but there was a trend towards superiority for CCBs plus ACE inhibitors or diuretics compared to other combinations. No studies examined the effect of antihypertensive therapy on morbidity or mortality outcomes.Conclusion: Evidence broadly supports current guidelines and provides a clear rationale for promoting CCBs as first-line agents and early initiation of combination therapy. However, there is a clear requirement for more evidence to provide a nuanced understanding of stroke and other cardiovascular disease prevention amongst diverse populations on the continent.
Background The epidemiology of acute kidney injury (AKI) in children in sub-Sahara Africa (SSA) is poorly described. The aim of this study was to establish the incidence, etiology, and outcomes of community-acquired AKI in pediatric admissions in Southern Malawi. Methods We conducted a prospective observational study of pediatric admissions to a tertiary hospital in Blantyre between 5 February and 30 April 2016. Children were screened for kidney disease on admission with measurement of serum creatinine and assessment of urine output. The clinical presentation, etiology, and management of children with AKI were documented. Results A total of 412 patients (median age 4 years, 52.6% male, and 7.5% human immunodeficiency virus [HIV] infected) were included in the study. Forty-five patients (10.9%) had AKI (Kidney Disease: Improving Global Outcomes [KDIGO] criteria), which was stage 3 in 16 (35.6%) patients. Sepsis and hypoperfusion, most commonly due to malaria ( n = 19; 42.2%), were the causes of AKI in 38 cases (84.4%). Three patients (6.7%) underwent peritoneal dialysis (PD) for AKI: 2 of them recovered kidney function, and the other one died. In-hospital mortality was 20.5% in AKI and 2.9% if no kidney disease was present ( p < 0.0001). Seventeen (47.2%) patients with kidney disease had persistent kidney injury on hospital discharge. Conclusion Acute kidney injury occurs in 10.9% of pediatric admissions in Malawi and is primarily due to infections, particularly malaria. Acute kidney injury results in significantly increased in-hospital mortality. Urgent interventions are required to eliminate preventable causes of death in this region.
BackgroundNontyphoidal Salmonellae frequently cause life-threatening bacteremia in sub-Saharan Africa. Young children and HIV-infected adults are particularly susceptible. High case-fatality rates and increasing antibiotic resistance require new approaches to the management of this disease. Impaired cellular immunity caused by defects in the T helper 1 pathway lead to intracellular disease with Salmonella that can be countered by IFNγ administration. This report identifies the lymphocyte subsets that produce IFNγ early in Salmonella infection.MethodologyIntracellular cytokine staining was used to identify IFNγ production in blood lymphocyte subsets of ten healthy adults with antibodies to Salmonella (as evidence of immunity to Salmonella), in response to stimulation with live and heat-killed preparations of the D23580 invasive African isolate of Salmonella Typhimurium. The absolute number of IFNγ-producing cells in innate, innate-like and adaptive lymphocyte subpopulations was determined.Principal FindingsEarly IFNγ production was found in the innate/innate-like lymphocyte subsets: γδ-T cells, NK cells and NK-like T cells. Significantly higher percentages of such cells produced IFNγ compared to adaptive αβ-T cells (Student's t test, P<0.001 and ≤0.02 for each innate subset compared, respectively, with CD4+- and CD8+-T cells). The absolute numbers of IFNγ-producing cells showed similar differences. The proportion of IFNγ-producing γδ-T cells, but not other lymphocytes, was significantly higher when stimulated with live compared with heat-killed bacteria (P<0.0001).Conclusion/SignificanceOur findings indicate an inherent capacity of innate/innate-like lymphocyte subsets to produce IFNγ early in the response to Salmonella infection. This may serve to control intracellular infection and reduce the threat of extracellular spread of disease with bacteremia which becomes life-threatening in the absence of protective antibody. These innate cells may also help mitigate against the effect on IFNγ production of depletion of Salmonella-specific CD4+-T lymphocytes in HIV infection.
Introduction In 2017, NHS England introduced proactive identification of frailty into the General Practitioners (GP) contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty and impact of recognition on patient care. We aimed to explore the conceptualisation and identification of frailty by multidisciplinary primary care clinicians in England. Methods Qualitative semi-structured interviews were conducted with primary care staff across England including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 12). Results Totally, 31 clinicians participated. Frailty was seen as difficult to define, with uncertainty about its value as a medical diagnosis. Clinicians conceptualised frailty differently, dependant on job-role, experience and training. Identification of frailty was most commonly informal and opportunistic, through pattern recognition of a frailty phenotype. Some practices had embedded population screening and structured reviews. Visual assessment and continuity of care were important factors in recognition. Most clinicians were familiar with the electronic frailty index, but described poor accuracy and uncertainty as to how to interpret and use this tool. There were different perspectives amongst professional groups as to whether frailty should be more routinely identified, with concerns of capacity and feasibility in the current climate of primary care workload. Conclusions Concepts of frailty in primary care differ. Identification is predominantly ad hoc and opportunistic. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools and resource allocation, may encourage wider recognition.
BackgroundSore throat is a common and self-limiting condition. There remains ambiguity in stratifying patients to immediate, delayed or no antibiotic prescriptions. NICE recommends two clinical prediction rules (CPRs), FeverPAIN and CENTOR, to guide decision-making.AimDescribe the diagnostic accuracy of CPRs in identifying streptococcal throat infections.Design and SettingAdults presenting to UK primary care with sore throat, who did not require immediate antibiotics.MethodsAs part of the Treatment Options without Antibiotics for Sore Throat (TOAST) trial, 565 participants, aged ≥18, were recruited on day of presentation to general practice. Physicians could opt to give delayed prescriptions. CPR scores were not part of the trial protocol but calculated post-hoc from baseline assessments. Diagnostic accuracy was calculated by comparing scores to throat swab cultures.Results81/502 (16.1%) of patients had Group A, C or G streptococcus cultured on throat swab. Overall diagnostic accuracy of both CPRs was poor: area under receiver-operating-characteristics curve 0.62 for Centor; 0.59 for FeverPAIN. Post-test probability of a positive or negative test was 27.3% (95% confidence intervals: 6.0%–61.0%) and 84.1% (80.6%–87.2%) for FeverPAIN ≥4, vs 25.7% (16.2%–37.2%) and 85.5% (81.8%–88.7%) for Centor ≥3. Higher CPR scores were associated with increased delayed antibiotic prescriptions (χ2=8.42, P=0.004 for FeverPAIN ≥4; χ2=32.0, P<0.001 for Centor ≥3).ConclusionsIn those that do not require immediate antibiotics in primary care, neither CPR provide a reliable way of diagnosing streptococcal throat infection. However, clinicians were more likely to give delayed prescriptions to those with higher scores.
Introduction In 2017 NHS England introduced proactive identification of frailty into the General Practitioners (GPs) Contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty, or perceptions of impact on patient care. Evidence from international settings suggests primary care clinicians may have mixed interpretations of frailty, with important implications for their willingness to support different frailty interventions. We aimed to explore the conceptualisation of frailty, and how community-dwelling frail older adults are identified in primary care. Methods Semi-structured interviews were conducted with primary care staff across England, including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 13). Results 31 practitioners participated (12 GPs, 19 non-GPs). Frailty was seen as difficult to define, with uncertainty in its value as a medical diagnosis. The most common working model was the frailty phenotype, associated with deterioration at end of life. There was a mixture of formal and informal processes for identifying frailty. A few practices had embedded population screening and structured reviews. Informal processes included use of ‘housebound’ as a proxy for frailty, identification through chronic disease and medication reviews, and holistic assessment through good continuity of care. Many clinicians described poor accuracy of the electronic Frailty Index, yet it was commonly used to grade frailty during protocolised chronic disease reviews. The Clinical Frailty Score, in contrast, was felt to be easy to use and interpret, but inconsistently recorded within electronic health records. Most clinicians favoured better tools for identifying frailty, alongside resources to support these individuals. Conclusions Concepts of frailty in primary care differ. Identification is predominantly ad-hoc, opportunistic and associated with terminal illness. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools, may encourage wider recognition.
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