Camilla L. Wong

Does This Patient Have Bacterial Peritonitis or Portal Hypertension?How Do I Perform a Paracentesis and Analyze the Results?

CONTEXT Abdominal paracenteses are performed in patients with ascites, most commonly to assess for infection or portal hypertension and to manage refractory ascites. OBJECTIVES To systematically review evidence for paracentesis methods that may decrease risk of adverse events or improve diagnostic yield and to determine the accuracy of ascitic fluid analysis for spontaneous bacterial peritonitis or portal hypertension. DATA SOURCES Relevant English-language studies from Medline (1966-April 2007) and EMBASE (1980-April 2007). STUDY SELECTION Paracentesis studies evaluating interventions (use of preprocedure coagulation parameters, needle type, insertion location, ultrasound guidance, bedside inoculation into blood culture bottles, and use of plasma expanders in therapeutic taps) for reducing adverse events or improving the diagnostic yield, and studies assessing the accuracy of ascitic fluid biochemical analyses for spontaneous bacterial peritonitis or portal hypertension. DATA EXTRACTION For technique studies, data on intervention and outcome; and for diagnostic studies, data on parameters for diagnosing spontaneous bacterial peritonitis and portal hypertension (ie, ascitic fluid white blood cell and polymorphonuclear leukocyte [PMN] count, ascitic fluid pH, blood-ascitic fluid pH gradient, and serum-ascites albumin gradient). DATA SYNTHESIS Thirty-seven studies met inclusion criteria: 2 showed that obtaining preprocedure coagulation was likely unnecessary prior to paracentesis; 1 showed the 15-gauge, 3.25-inch needle-cannula results in less multiple peritoneal punctures [P = .05] and termination due to poor fluid return [P = .02] vs a 14-gauge needle in therapeutic paracentesis; 1 showed immediate inoculation of culture bottles improves diagnostic yield vs delayed (from 77% to 100% [95% CI for the difference, 5.3%-40.0%]); 9 evaluated therapeutic paracentesis, performed with or without albumin or nonalbumin plasma expanders, and found no consistent effect on morbidity or mortality; 16 showed the accuracy of biochemical analysis of ascitic fluid in patients suspected of having spontaneous bacterial peritonitis to increase the likelihood of spontaneous bacterial peritonitis (PMN count >250 cells/microL [summary likelihood ratio {LR}, 6.4] 95% CI, 4.6-8.8; ascitic fluid leukocyte count >1000 cells/microL [summary LR, 9.1] 95% CI, 5.5-15.1; pH < 7.35 [summary LR, 9.0] 95% CI, 2.0-40.6; or a blood-ascitic fluid pH gradient > or = 0.10 [LR, 11.3] 95% CI, 4.3-29.9) and other levels lowered the likelihood (PMN count < or = 250 cells/microL [summary LR, 0.2] 95% CI, 0.11-0.37; or a blood-ascitic fluid pH gradient < 0.10 [summary LR, 0.12] 95% CI, 0.02-0.77); and 4 showed the diagnostic accuracy of the serum-ascites albumin gradient lowers the likelihood of portal hypertension (< 1.1 g/dL [summary LR, 0.06] 95% CI, 0.02-0.20). CONCLUSIONS Ascitic fluid should be inoculated into blood culture bottles at the bedside. Spontaneous bacterial peritonitis is more likely at predescribed parameters of ascitic PMN count or blood-ascitic fluid pH, and portal hypertension is less likely below a predescribed serum-ascites albumin gradient.

An evaluation of a proactive geriatric trauma consultation service.

Objective:To describe and evaluate an inpatient geriatric trauma consultation service (GTCS). Background:Delays in recognizing the special needs of older trauma patients may result in suboptimal care. The GTCS is a proactive geriatric consultation model aimed at preventing and managing age-specific complications and discharge planning for all patients 60 years or older admitted to the St Michaels Hospital Trauma Service. Methods:This was a before and after case series of patients admitted pre-GTCS (March 2005–August 2007) and post-GTCS (September 2007–March 2010). Study data were derived from a review of the medical records and from the St Michaels Hospital trauma registry. Abstracted data included demographics, type of geriatric issues addressed, rate of adherence to recommendations made by the GTCS, geriatric-specific clinical outcomes, trauma quality indicators, consultation requests, and discharge destinations. Results:A total of 238 pre-GTCS patients and 248 post-GTCS patients were identified. The rate of adherence to recommendations made by the GTCS team was 93.2%. There were fewer consultation requests made to Internal Medicine and Psychiatry in the post-GTCS group (N = 31 vs N = 18, P = 0.04; and N = 33 vs N = 18, P = 0.02; respectively). There were no differences in any of the prespecified complications except delirium (50.5% pre-GTCS vs 40.9% post- GTCS, P = 0.05). Among patients admitted from home, fewer were discharged to long-term care facilities among the post-GTCS group (6.5% pre-GTCS vs 1.7% post-GTCS, P = 0.03). Conclusions:A proactive geriatric consultation model for elderly trauma patients may decrease delirium and discharges to long-term care facilities. Future studies should include a multicenter randomized trial of this model of care.

Does This Patient Have a Pleural Effusion

CONTEXT Pleural effusion is a common finding among patients presenting with respiratory symptoms. The value of the bedside examination to detect pleural effusion is unclear. OBJECTIVE To systematically review the evidence regarding the accuracy of the physical examination in assessing the probability of a pleural effusion. DATA SOURCES We searched MEDLINE (1950-October 2008) and EMBASE (1980-October 2008) using Ovid to identify English-language studies conducted in a clinical setting. Additional studies were identified by searching the bibliographies of retrieved articles and contacting experts in the field. STUDY SELECTION We included prospective studies of diagnostic accuracy that compared at least 1 physical examination maneuver with radiographic confirmation of pleural effusion. DATA EXTRACTION Three authors independently appraised study quality and extracted relevant data. Data regarding participant recruitment, reference standard, diagnostic test(s), and test accuracy were extracted. Disagreements were resolved by consensus. DATA SYNTHESIS We identified 310 unique citations, but only 5 prospectively conducted studies met inclusion criteria (N = 934 patients). A random-effects model was used for quantitative synthesis. Of the 8 physical examination maneuvers evaluated in the included studies (conventional percussion, auscultatory percussion, breath sounds, chest expansion, tactile vocal fremitus, vocal resonance, crackles, and pleural friction rub), dullness to conventional percussion was most accurate for diagnosing pleural effusion (summary positive likelihood ratio, 8.7; 95% confidence interval, 2.2-33.8), while the absence of reduced tactile vocal fremitus made pleural effusion less likely (negative likelihood ratio, 0.21; 95% confidence interval, 0.12-0.37). CONCLUSIONS Based on the limited number of studies, dullness to percussion and tactile fremitus are the most useful findings for pleural effusion. Dull chest percussion makes the probability of a pleural effusion much more likely but requires a chest radiograph to confirm the diagnosis. When the pretest probability of pleural effusion is low, the absence of reduced tactile vocal fremitus makes pleural effusion less likely so that a chest radiograph might not be necessary depending on the overall clinical situation.

Does This Patient Have an Exudative Pleural Effusion?: The Rational Clinical Examination Systematic Review

IMPORTANCE Thoracentesis is performed to identify the cause of a pleural effusion. Although generally safe, thoracentesis may be complicated by transient hypoxemia, bleeding, patient discomfort, reexpansion pulmonary edema, and pneumothorax. OBJECTIVE To identify the best means for differentiating between transudative and exudative effusions and also to identify thoracentesis techniques for minimizing the risk of complications by performing a systematic review the evidence. DATA SOURCES We searched The Cochrane Library, MEDLINE, and Embase from inception to February 2014 to identify relevant studies. STUDY SELECTION We included randomized and observational studies of adult patients undergoing thoracentesis that examined diagnostic tests for differentiating exudates from transudates and evaluated thoracentesis techniques associated with a successful procedure with minimal complications. DATA EXTRACTION AND SYNTHESIS Two investigators independently appraised study quality and extracted data from studies of laboratory diagnosis of pleural effusion for calculation of likelihood ratios (LRs; n = 48 studies) and factors affecting adverse event rates (n = 37 studies). RESULTS The diagnosis of an exudate was most accurate if cholesterol in the pleural fluid was greater than 55 mg/dL (LR range, 7.1-250), lactate dehydrogenase (LDH) was greater than 200 U/L (LR, 18; 95% CI, 6.8-46), or the ratio of pleural fluid cholesterol to serum cholesterol was greater than 0.3 (LR, 14; 95% CI, 5.5-38). A diagnosis of exudate was less likely when all Lights criteria (a ratio of pleural fluid protein to serum protein >0.5, a ratio of pleural fluid LDH to serum LDH >0.6, or pleural fluid LDH >two-thirds the upper limit of normal for serum LDH) were absent (LR, 0.04; 95% CI, 0.02-0.11). The most common complication of thoracentesis was pneumothorax, which occurred in 6.0% of cases (95% CI, 4.0%-7.0%). Chest tube placement was required in 2.0% of procedures (95% CI, 0.99%-2.9%) in which a patient was determined to have radiographic evidence of a pneumothorax. With ultrasound, a radiologists marking the needle insertion site was not associated with decreased pneumothorax events (skin marking vs no skin marking odds ratio [OR], 0.37; 95% CI, 0.08-1.7). Use of ultrasound by any experienced practitioner also was not associated with decreased pneumothorax events (OR, 0.55; 95% CI, 0.06-5.3). CONCLUSIONS AND RELEVANCE Lights criteria, cholesterol and pleural fluid LDH levels, and the pleural fluid cholesterol-to-serum ratio are the most accurate diagnostic indicators for pleural exudates. Ultrasound skin marking by a radiologist or ultrasound-guided thoracentesis were not associated with a decrease in pneumothorax events.

Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis

BackgroundElective surgeries can be associated with significant harm to older adults. The present study aimed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery.MethodsMedline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. Prospective studies reporting prognostic factors associated with postoperative complications (composite outcome of medical and surgical complications), functional decline, mortality, post-hospitalization discharge destination, and prolonged hospitalization among older adults undergoing elective surgery were included. Study characteristics and prognostic factors associated with the outcomes of interest were extracted independently by two reviewers. Random effects meta-analysis models were used to derive pooled effect estimates for prognostic factors and incidences of adverse outcomes.ResultsOf the 5692 titles and abstracts that were screened for inclusion, 44 studies (12,281 patients) reported on the following adverse postoperative outcomes: postoperative complications (n =28), postoperative mortality (n = 11), length of hospitalization (n = 21), functional decline (n = 6), and destination at discharge from hospital (n = 13). The pooled incidence of postoperative complications was 25.17% (95% confidence interval (CI) 18.03–33.98%, number needed to follow = 4). The geriatric syndromes of frailty (odds ratio (OR) 2.16, 95% CI 1.29–3.62) and cognitive impairment (OR 2.01, 95% CI 1.44–2.81) were associated with developing postoperative complications; however, there was no association with traditionally assessed prognostic factors such as age (OR 1.07, 95% CI 1.00–1.14) or American Society of Anesthesiologists status (OR 2.62, 95% CI 0.78–8.79). Besides frailty, other potentially modifiable prognostic factors, including depressive symptoms (OR 1.77, 95% CI 1.22–2.56) and smoking (OR 2.43, 95% CI 1.32–4.46), were also associated with developing postoperative complications.ConclusionGeriatric syndromes are important prognostic factors for postoperative complications. We identified potentially modifiable prognostic factors (e.g., frailty, depressive symptoms, and smoking) associated with developing postoperative complications that can be targeted preoperatively to optimize care.

Perioperative gabapentin and delirium following total knee arthroplasty: a post-hoc analysis of a double-blind randomized placebo-controlled trial

To the Editor, Delirium is characterized by a new onset of fluctuating attention and confusion and is often linked to various triggering factors. Developing delirium is associated with an increased risk of post-discharge mortality, functional decline, longer hospitalization, hospital-acquired complications, persistent cognitive deficits, increased costs, and long-term institutionalization. Postoperative delirium is associated with pain severity as well as the effects of opioids on the central nervous system. Although gabapentin has opioid-sparing effects and reduces postoperative pain, it is uncertain whether its opioid-sparing properties and reduction in pain scores translate into less postoperative delirium. We report an analysis of a double-blinded randomized placebo-controlled trial that was designed primarily to compare gabapentin with placebo with respect to postoperative pain and in-hospital rehabilitation after total knee arthroplasty (TKA). This report addresses the post-hoc analysis of postoperative delirium in the two groups. A separate Sunnybrook Health Sciences Centre Research Ethics Board approval was obtained for this post-hoc analysis. Details on enrolment criteria, participant recruitment, and study duration are in the primary publication. A computerized list of random numbers was generated for block randomization, treatment allocation was concealed, and gabapentin and placebo medications were identical and identically packaged. Physicians, nurses, patients, and data abstractors were blinded to treatment allocation. The sample size was based on the estimate for the primary outcome of the original trial. Gabapentin 600 mg or placebo was administered two hours before surgery along with celecoxib 400 mg. Patients received femoral and sciatic nerve blocks along with spinal anesthesia. Postoperatively, patients received placebo or gabapentin 200 mg tid for four days, as per randomization. All patients received celecoxib 200 mg every 12 hr for 72 hr and morphine intravenous patient-controlled analgesia for 24 hr. OxyContin 5 mg q8hr was started the morning after surgery. Incident postoperative delirium was identified via a validated medical chart abstraction tool. The first episode of delirium was included for each given patient. Duration of delirium was also identified by the validated medical chart abstraction tool or by discharge date, whichever occurred first. Potential risk factors for delirium were abstracted (cognitive impairment, APACHE II score, visual impairment, and preoperative dehydration). A subset of 27 records was abstracted independently by a second investigator for inter-rater reliability of incidents of delirium. K. Dighe, MD Mackenzie Health, Richmond Hill, ON, Canada

A young man with deep vein thrombosis, hyperhomocysteinemia and cobalamin deficiency

The case: A 21-year-old university student presented to hospital with a 1-week history of swelling and discomfort in his right calf. Compression ultrasonography revealed occlusive thrombi in the right superficial femoral and popliteal veins. Investigations, including complete blood count,

Assessing the Impact of a Geriatric Clinical Skills Day on Medical Students' Attitudes Toward Geriatrics

Background The aging population requires an improvement in physicians’ attitudes, knowledge, and skills, regardless of their specialty. This study aimed to identify attitude changes of University of Toronto pre-clerkship medical students towards geriatrics after participation in a Geriatric Clinical Skills Day (GCSD). Methods This was a before and after study. The GCSD consisted of one large and four small interactive, inter-professional geriatric medicine workshops facilitated by various health professionals. A questionnaire, including the validated UCLA Geriatrics Attitudes Scale, was administered to participating pre-clerkship medical students before and after the GCSD. A one-sample t-test and signed rank parametric test were used to determine attitude changes. Results 42.1% indicated an interest in Geriatric Medicine, 26.3% in Geriatric Psychiatry, and 63.2% in working with elderly patients. Both pre- and post-mean scores were greater than 3 (neutral), indicating a positive attitude before and after the intervention (p < .001). There was no significant difference in the change in mean total scores (signed rank test p ≥ .12, Student’s t-test p > .11). Conclusions The GCSD did not alter pre-clerkship students’ attitudes towards geriatrics. This study adds to geriatric medical education research and warrants further investigation in a larger, multi-centred trial.

Canadian Study of Health and Aging Clinical Frailty Scale: Does It Predict Adverse Outcomes among Geriatric Trauma Patients?

BACKGROUND The Canadian Study of Health and Aging Clinical Frailty Scale (CFS) and the laboratory Frailty Index (FI-lab) are validated tools based on clinical and laboratory data, respectively. Their utility as predictors of geriatric trauma outcomes is unknown. Our primary objective was to determine whether pre-admission CFS is associated with adverse discharge destination. Secondary objectives were to evaluate the relationships between CFS and in-hospital complications and between admission FI-lab and discharge destination. STUDY DESIGN We performed a 4-year (2011 to 2014) retrospective cohort study with patients 65 years and older admitted to a level I trauma center. Admission FI-lab was calculated using 23 variables collected within 48 hours of presentation. The primary outcome was discharge destination, either adverse (death or discharge to a long-term, chronic, or acute care facility) or favorable (home or rehabilitation). The secondary outcome was in-hospital complications. Multivariable logistic regression was used to evaluate the relationship between CFS or FI-lab and outcomes. RESULTS There were 266 patients included. Mean age was 76.5 ± 7.8 years and median Injury Severity Score was 17 (interquartile range 13 to 24). There were 260 patients and 221 patients who had sufficient data to determine CFS and FI-lab scores, respectively. Pre-admission frailty as per the CFS (CFS 6 or 7) was independently associated with adverse discharge destination (odds ratio 5.1; 95% CI 2.0 to 13.2; p < 0.001). Severe frailty on admission, as determined by the FI-lab (FI-lab > 0.4), was not associated with adverse outcomes. CONCLUSIONS Pre-admission clinical frailty independently predicts adverse discharge destination in geriatric trauma patients. The CFS may be used to triage resources to mitigate adverse outcomes in this population. The FI-lab determined on admission for trauma may not be useful.

Hospital-acquired delirium in older adults

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) classifies delirium as a syndrome of disturbed attention and awareness that has an acute onset, fluctuating course and is associated with an additional disturbance in cognition.1 Delirium may be hypoactive (lethargy and