Textbook of Adult Emergency Medicine

Now fully revised and updated, Textbook of Adult Emergency Medicine provides clear and consistent coverage of this rapidly evolving specialty. Building on the success of previous editions, it covers all the major topics that present to the trainee doctor in the emergency department. It will also prove invaluable to the range of other professionals working in this setting - including nurse specialists and paramedics - who require concise, highly practical guidance, incorporating latest best practice and current guidelines. For the first time this edition now comes with a complete and enhanced electronic version, providing a richer learning experience and making rapid reference easier than ever before, anytime, anywhere

Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial

Background Trials of fluoxetine for recovery after stroke report conflicting results. The Assessment oF FluoxetINe In sTroke recoverY (AFFINITY) trial aimed to show if daily oral fluoxetine for 6 months after stroke improves functional outcome in an ethnically diverse population. Methods AFFINITY was a randomised, parallel-group, double-blind, placebo-controlled trial done in 43 hospital stroke units in Australia (n=29), New Zealand (four), and Vietnam (ten). Eligible patients were adults (aged ≥18 years) with a clinical diagnosis of acute stroke in the previous 2–15 days, brain imaging consistent with ischaemic or haemorrhagic stroke, and a persisting neurological deficit that produced a modified Rankin Scale (mRS) score of 1 or more. Patients were randomly assigned 1:1 via a web-based system using a minimisation algorithm to once daily, oral fluoxetine 20 mg capsules or matching placebo for 6 months. Patients, carers, investigators, and outcome assessors were masked to the treatment allocation. The primary outcome was functional status, measured by the mRS, at 6 months. The primary analysis was an ordinal logistic regression of the mRS at 6 months, adjusted for minimisation variables. Primary and safety analyses were done according to the patient's treatment allocation. The trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12611000774921. Findings Between Jan 11, 2013, and June 30, 2019, 1280 patients were recruited in Australia (n=532), New Zealand (n=42), and Vietnam (n=706), of whom 642 were randomly assigned to fluoxetine and 638 were randomly assigned to placebo. Mean duration of trial treatment was 167 days (SD 48·1). At 6 months, mRS data were available in 624 (97%) patients in the fluoxetine group and 632 (99%) in the placebo group. The distribution of mRS categories was similar in the fluoxetine and placebo groups (adjusted common odds ratio 0·94, 95% CI 0·76–1·15; p=0·53). Compared with patients in the placebo group, patients in the fluoxetine group had more falls (20 [3%] vs seven [1%]; p=0·018), bone fractures (19 [3%] vs six [1%]; p=0·014), and epileptic seizures (ten [2%] vs two [<1%]; p=0·038) at 6 months. Interpretation Oral fluoxetine 20 mg daily for 6 months after acute stroke did not improve functional outcome and increased the risk of falls, bone fractures, and epileptic seizures. These results do not support the use of fluoxetine to improve functional outcome after stroke

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

CKD.QLD Haem Report

A report on the haematologic profiles of patients with chronic kidney disease at a leading Queensland metropolitan kidney health service.The presence and severity of anaemia are strongly correlated with heightened hospital resource consumption, death and terminal renal failure in these CKD patients. Potential benefits of expanded use of preventative and therapeutic interventions might be assessed against such data

Validation of a tool to safely triage selected patients with chest pain to unmonitored beds

Objective: To externally validate a chest pain protocol that triages low risk patients with chest pain to an unmonitored bed

Inhibition of ammonia oxidisers to control nitrification rate under simulated winter dairy forage grazing conditions: An incubation study

The microbial process of nitrification plays a key role within the soil nitrogen cycle. Nitrification is the process where ammonia is oxidised to nitrite and then to nitrate and this process can have major negative environmental effects. It has previously been determined that both ammonia oxidising bacteria (AOB) and ammonia oxidising archaea (AOA) mediate the first step of the nitrification process, i.e. the ammonia oxidation process in soil, but it is unclear which group is important under wet winter forage grazing conditions. The reduction of nitrification rates is an important factor in reducing NO₃⁻ leaching from winter forage systems and a key mitigation tool is the use of the nitrification inhibitor dicyandiamide (DCD). The aim of this study was to investigate the effect of cow urine and dicyandiamide (DCD), on AOA and AOB population abundance in dairy winter forage grazed soils. While this study indicated that AOA were present within the soil, it was AOB that played the dominant role in ammonia oxidation in the urine treated soil. In the urine only treatment (applied at 500 kg N ha⁻¹), the AOB amoA gene copy numbers were 11.7 times that of the control on day 21. The urine plus DCD treatment applied at 10 kg DCD ha-1 and urine plus DCD treatment applied at 20 kg DCD ha⁻¹, respectively, showed a 91.3 % and 96.6 % reduction in AOB amoA gene copy numbers at the same point in time. By day 112, the nitrate concentration for the urine only treatment was 8.4 times the control. Whereas, the urine plus DCD (10 kg ha⁻¹) and urine plus DCD (20 kg ha⁻¹) treatments had an 84.4 % and an 88.5 % reduction in nitrate concentration, respectively, compared to the urine only treatment. These results illustrate that while both AOA and AOB were present within the soil only one group of microbes was actively involved in the ammonia oxidation process. The results also show that using the nitrification inhibitor DCD is a highly effective way to inhibit the growth of AOB, leading to a reduction in NO₃⁻ concentration in the soil under a winter forage grazing system

Spectrum (characteristics) of patients with chronic kidney disease (CKD) with increasing age in a major metropolitan renal service

Aim of our study is to describe, in people with CKD, the demographic and clinical characteristics and outcomes with increasing age. The prevalence of CKD in Western populations, where longevity is the norm, is about 10-15%, but how age influence different characteristics of patients with CKD is largely not known. One thousand two hundred sixty-five patients enrolled in the CKD.QLD registry at the Royal Brisbane and Women's Hospital were grouped according to age at consent i.e