Factors associated with older people's emergency department attendance towards the end of life: a systematic review.

BACKGROUND: Emergency department (ED) attendance for older people towards the end of life is common and increasing, despite most preferring home-based care. We aimed to review the factors associated with older people's ED attendance towards the end of life. METHODS: Systematic review using Medline, Embase, PsychINFO, CINAHL and Web of Science from inception to March 2017. Included studies quantitatively examined factors associated with ED attendance for people aged ≥65 years within the last year of life. We assessed study quality using the QualSyst tool and determined evidence strength based on quality, quantity and consistency. We narratively synthesized the quantitative findings. RESULTS: Of 3824 publications identified, 21 were included, combining data from 1 565 187 participants. 17/21 studies were from the USA and 19/21 used routinely collected data. We identified 47 factors and 21 were included in the final model. We found high strength evidence for associations between ED attendance and palliative/hospice care (adjusted effect estimate range: 0.1-0.94); non-white ethnicity (1.03-2.16); male gender (1.04-1.83, except 0.70 in one sub-sample) and rural areas (0.98-1.79). The final model included socio-demographic, illness and service factors, with largest effect sizes for service factors. CONCLUSIONS: In this synthesis, receiving palliative care was associated with lower ED attendance in the last year of life for older adults. This has implications for service models for older people nearing the end of life. However, there is limited evidence from European countries and none from low or middle-income countries, which warrants further research

Early and empirical high-dose cryoprecipitate for hemorrhage after traumatic injury: The CRYOSTAT-2 randomized clinical trial

Critical bleeding is associated with a high mortality rate in patients with trauma. Hemorrhage is exacerbated by a complex derangement of coagulation, including an acute fibrinogen deficiency. Management is fibrinogen replacement with cryoprecipitate transfusions or fibrinogen concentrate, usually administered relatively late during hemorrhage. To assess whether survival could be improved by administering an early and empirical high dose of cryoprecipitate to all patients with trauma and bleeding that required activation of a major hemorrhage protocol. CRYOSTAT-2 was an interventional, randomized, open-label, parallel-group controlled, international, multicenter study. Patients were enrolled at 26 UK and US major trauma centers from August 2017 to November 2021. Eligible patients were injured adults requiring activation of the hospital's major hemorrhage protocol with evidence of active hemorrhage, systolic blood pressure less than 90 mm Hg at any time, and receiving at least 1 U of a blood component transfusion. Patients were randomly assigned (in a 1:1 ratio) to receive standard care, which was the local major hemorrhage protocol (reviewed for guideline adherence), or cryoprecipitate, in which 3 pools of cryoprecipitate (6-g fibrinogen equivalent) were to be administered in addition to standard care within 90 minutes of randomization and 3 hours of injury. The primary outcome was all-cause mortality at 28 days in the intention-to-treat population. Among 1604 eligible patients, 799 were randomized to the cryoprecipitate group and 805 to the standard care group. Missing primary outcome data occurred in 73 patients (principally due to withdrawal of consent) and 1531 (95%) were included in the primary analysis population. The median (IQR) age of participants was 39 (26-55) years, 1251 (79%) were men, median (IQR) Injury Severity Score was 29 (18-43), 36% had penetrating injury, and 33% had systolic blood pressure less than 90 mm Hg at hospital arrival. All-cause 28-day mortality in the intention-to-treat population was 26.1% in the standard care group vs 25.3% in the cryoprecipitate group (odds ratio, 0.96 [95% CI, 0.75-1.23]; P = .74). There was no difference in safety outcomes or incidence of thrombotic events in the standard care vs cryoprecipitate group (12.9% vs 12.7%). Among patients with trauma and bleeding who required activation of a major hemorrhage protocol, the addition of early and empirical high-dose cryoprecipitate to standard care did not improve all cause 28-day mortality. ClinicalTrials.gov Identifier: NCT04704869; ISRCTN Identifier: ISRCTN14998314

An unusual case of stroke in a young patient

The patent foramen ovale (PFO) has been increasingly implicated in the aetiology of stroke, particularly in young patients with no other identifiable cause (cryptogenic stroke). A case of Parinaud's syndrome secondary to thromboembolism from a PFO is reported here

Abstract W P65: Determinants of Favourable Response to Thrombolysis in Wake-Up Ischaemic Stroke

Background and Purpose: Wake up Ischaemic Stroke (WUIS) patients may have the potential to benefit from thrombolysis. As the duration between stroke onset and treatment, the main determinant of response to thrombolysis, is unknown in these patients, a major consideration is to identify other clinical markers predictive of a favourable response. Methods: Subjects were selected by consecutive sampling of a prospective register a tertiary stroke centre between January 2009 and December 2010. The inclusion criteria were last seen normal &lt;12 hours but &gt;4.5 hours from symptom onset and met thrombolysis criteria apart from time. Data on baseline clinical characteristics, imaging and treatment were extracted from the register. Mortality and modified Rankin Scale (mRS) were assessed at 90 days. Symptomatic intracerebral haemorrhage (sICH) was assessed at 24 hours. Logistic regression was undertaken to identify independent determinants of these outcomes, and those significant at p&lt;0.1 were stratified and assessed using Peto’s fixed odds ratio for thrombolysis versus no thrombolysis. Results: Of the 122 WUIS patients fulfilling inclusion criteria 68 were thrombolysed and 54 (44%) were not thrombolysed. There were no differences in the baseline characteristics between the two groups. Logistic regression showed an independent relationship of age and NIHSS score with 90 day mortality and mRS 0-2 (p&lt;0.01 for all) and with stroke subtype (p&lt;0.1). There were no independent predictors of sICH. Thrombolysis had the best outcomes in WUIS patients aged 80-89 years with cardio-embolic stroke and NIHSS scores of 10-19 (Fig 1). Conclusions: Older WUIS patients and those with embolic stroke appear to benefit most from thrombolysis. </jats:p

Influence of Age on Thrombolysis Outcome in Wake-Up Stroke

Background and Purpose— Thrombolysis in patients &gt;80 years remains controversial; we hypothesized that &gt;80-year-old patients with wake-up ischemic stroke (WUIS) will benefit from thrombolysis despite risks because of poor outcomes with no treatment. Methods— The study included 68 thrombolysed patients with WUIS (33 [48%] &gt;80 years), 54 nonthrombolysed patients with WUIS (21 [39%] &gt;80 years), and 117 patients (&gt;80 years old) thrombolysed within 4.5 hours of symptom onset (reference group). Mortality and modified Rankin Scale (mRS) were assessed at 90 days. Results— Baseline characteristics of thrombolysed and nonthrombolysed &gt;80 and ≤80-year-old patients with WUIS were comparable. Thrombolysis outcomes in &gt;80-year-old patients with WUIS were better than in nonthrombolysed &gt;80-year-old patients with WUIS (90-day mortality: 24% versus 47%, P =0.034; mRS 0–2: 30% versus 5%, P =0.023; mRS 0–1: 15% versus 5%, P =0.24) and comparable with thrombolysed ≤80-year-old patients with WUIS. Thrombolysis was associated with odds ratio 0.27 (95% confidence interval, 0.05–0.97) for mortality and odds ratio 28.6 (95% confidence interval, 1.8–448) for mRS 0 to 2 at 90 days in &gt;80-year-old patients with WUIS after adjusting for stroke severity and risk factors. Conclusions— Thrombolysis may be associated with greater benefit in &gt;80-year-old patients with WUIS but a selection bias favoring thrombolysis in those most likely to benefit may significantly reduce interpretability of these findings. </jats:sec

National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock:a retrospective observational study

Introduction Severe sepsis and septic shock (SS) are time-critical medical emergencies that affect millions of people in the world. Earlier administration of antibiotics has been shown to reduce mortality from SS; however, the initiation of early resuscitation requires recognition that a patient may have sepsis. Early warning scores (EWS) are broadly used to detect patient deterioration, but to date have not been evaluated to detect patients at risk for SS. The purpose of our study was to look at the relationship between the initial national EWS (NEWS) in the emergency department (ED) and the diagnosis of SS.Methods We performed a retrospective, single-centre, observational study in the ED of an urban university hospital with an annual attendance of 140 000 patients. We aimed to include 500 consecutive non-trauma adult patients presenting to the ED with Manchester Triage System (MTS) category 1–3. The final diagnosis was taken from either the ED medical records or the hospital discharge summary. For all NEWS, the sensitivity and specificity to detect patients with SS was calculated.Results A total of 500 patients were included, 27 patients (5.4%) met the criteria for SS. The area under the curve (AUC) for NEWS to identify patient at risk for SS is 0.89 (95% CI 0.84 to 0.94). A NEWS of 3 or more at ED triage has a sensitivity of 92.6% (95% CI 74.2% to 98.7%) and a specificity of 77% (95% CI 72.8% to 80.6%) to detect patients at risk for SS at ED triage.Conclusions A NEWS of 3 or more at ED triage may be the trigger to systematically screen the patient for SS, which may ultimately lead to early recognition and treatment

A Case-Controlled Comparison of Thrombolysis Outcomes Between Wake-Up and Known Time of Onset Ischemic Stroke Patients

Background and Purpose— Wake-up ischemic stroke (WUIS) patients are not thrombolysed even if they meet other criteria for treatment. We hypothesized that patients with WUIS showing no or early ischemic changes on brain imaging will have thrombolysis outcomes comparable with those with known time of symptom onset. Methods— Consecutive sampling of a prospective registry of patients with stroke between January 2009 and December 2010 identified 394 thrombolysed patients meeting predefined inclusion criteria, 326 presenting within 0 to 4.5 hours of symptom onset (Reference Group) and 68 WUIS patients. Inclusion criteria were last seen normal &lt;12 hours or &gt;4.5 hours (WUIS) or presented &lt;4.5 hours (Reference Group), had National Institutes of Health Stroke Scale score ≥5, and no or early ischemic changes on imaging at presentation. The primary outcome measure was the modified Rankin Scale of 0 to 2 at 90 days measured by trained assessors blinded to patient grouping. Other outcome measures were symptomatic intracerebral hemorrhage, modified Rankin Scale 0 to 1, and mortality at 90 days. Results— The groups were comparable for mean age (72.8 versus 73.9 years; P =0.58) and baseline median National Institutes of Health Stroke Scale score (median 13 versus 12; P =0.34). The proportions of patients with modified Rankin Scale 0 to 2 (38% versus 37%; P =0.89) and modified Rankin Scale 0 to 1 (24% versus 16%; P =0.18) at 90 days, any ICH (20% versus 22%; P =0.42) and symptomatic intracerebral hemorrhage (3.4% versus 2.9%; P =1.0) were comparable after adjusting for age, stroke severity, and imaging changes. Only 9/394 (2%) patients were lost to follow-up. Conclusions— Thrombolysis in selected patients with WUIS is feasible, and its outcomes are comparable with those thrombolysed with 0 to 4.5 hours. </jats:sec