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General medicine

Infectious diseases Letters 3 February 2020 Free

The impact of rapid molecular diagnostic testing for respiratory viruses on outcomes for emergency department patients

To the Editor: Uncontrolled before‐and‐after studies are highly prone to bias. Wabe and colleagues report on the impact of rapid influenza testing on outcomes for emergency department (ED) patients.1 They compared outcomes across four hospitals between the 2016 influenza season, when standard testing was used, and 2017, when rapid testing was used. Rapid testing was associated with shorter test turnaround times, more patients receiving results, and lower admission rates. Before‐and‐after studies use historical controls, in this case the prior influenza season, to evaluate the impact of interventions. This may be adequate for comparing simple indicators, such as test turnaround time, or for generating hypotheses. However, uncontrolled before‐and‐after studies are not useful for assessing more complex outcomes, such as admission rates, which are highly vulnerable to bias from other factors that may impact the observed results. For this reason, they are discouraged by some publishing groups.2 Frequent genetic drift in influenza virus strains causes variations in the burden and severity of illness each year, which influences ED presentations, testing and admission rates. The 2017 influenza season saw unprecedented numbers of influenza cases and ED presentations in NSW,3 which likely influenced admission practices. Teasing out the effect of rapid testing on admission rates is therefore not possible using an uncontrolled comparison between two disparate influenza seasons, in the manner of Wabe and colleagues. The steps taken to attempt to reduce seasonal effects cannot address this. It is also not possible to determine the net direction of biases in this study. Given the higher cost of rapid tests, it is important to have good estimates of their impact to inform economic evaluations. There are stronger methodologies that still allow timely evaluation using routinely collected data. At minimum, a comparison could be made to hospitals that did not implement rapid testing. When data from more seasons are available, an interrupted time series analysis may be appropriate.4 Interventions that mitigate the burden of seasonal influenza on health services are critical. Rapid testing is likely one such intervention, and therefore warrants careful evaluation with robust methodologies to inform its use.

Anthea L Katelaris · Ross M Andrews · Jeremy McAnulty

Mja2 50443
Endocrinology Letters 13 January 2020 Free

Euglycaemic ketoacidosis from an SGLT2 inhibitor exacerbated by a ketogenic diet

To the Editor: A 64‐year‐old woman presented to our emergency department with progressively reduced consciousness over 3 days. This was preceded by 2 days of vomiting and diarrhoea. She had been systemically well before this, with no acute medical issues. She had type 2 diabetes and had been commenced on combination 10 mg empagliflozin and 5 mg linagliptin a year ago after having experienced diarrhoea with metformin. Her most recent glycated haemoglobin level was 58 mmol/mol (reference interval [RI], 20–42 mmol/mol). She had also been trialling the Atkins diet for about 2 months before presentation. Her initial blood tests demonstrated high anion gap metabolic acidosis, an initial blood sugar level of 10.3 mmol/L (RI, 3.2–5.4 mmol/L] and a serum ketone level of 4.7 mmol/L (RI, < 0.6 mmol/L). She was diagnosed as having euglycaemic ketoacidosis secondary to using a sodium–glucose cotransporter type 2 (SGLT2) inhibitor (empagliflozin) and precipitated by her diarrhoeal illness and her Atkins diet. After a dextrose and insulin infusion, the anion gap normalised within 4 hours of presentation. She became progressively more alert within 24 hours of presentation. She was discharged 2 days after presentation with directions never to recommence empagliflozin. This case highlights the risks of combining ketogenic diets such as the Atkins diet with SGLT2 inhibitors, as outlined by Grammatiki and colleagues.1 SGLT2 inhibitors have a diuretic effect as they block the reabsorption of sodium as well as glucose.2 Hypovolaemia stimulates release of counter‐regulatory hormones such as glucagon, cortisol and adrenaline, which further increase insulin resistance, lipolysis and ketogenesis. Our patient's diarrhoeal illness preceding presentation likely exacerbated this hypovolaemia and therefore ketogenesis. High protein, low carbohydrate ketogenic diets such as Atkins in isolation usually only result in a mild, temporary ketosis.3 In the setting of an SGLT2 inhibitor and infective illness, however, it increased our patient's susceptibility to ketosis.

Shampa Sinha · Daniel Gavaghan · Steven Yew

Endocrinology Research 18 November 2019 Free

Routine glucose assessment in the emergency department for detecting unrecognised diabetes: a cluster randomised trial

Glucose and HbA1c screening alone does not increase detection of previously unidentified diabetes in patients admitted from EDs

N Wah Cheung · Lesley V Campbell · Gregory R Fulcher · Patrick McElduff · Barbara Depczynski · Shamasunder Acharya · John Carter · Bernard Champion · Roger Chen · David Chipps · Jeff Flack · Jen Kinsella · Margaret Layton · Mark McLean · Robert G Moses · Kris Park · Ann M Poynten · Carol Pollock · Debbie Scadden · Katherine T Tonks · Mary Webber · Chris White · Vincent Wong · Sandy Middleton

Mja2 50394
General medicine Letters 18 November 2019 Free

Management of pregabalin and gabapentin prescribing and use in NSW prisons

To the Editor: The editorial by Murnion and Conigrave1 and the article by Crossin and colleagues2 on the dangers of misuse of pregabalin are a timely warning to all prescribers. The black market utility (based on testimonies) and frequent misuse of pregabalin is well known both academically and to prescribers in prison environments.3,4 Harm relating to gabapentinoid use is noted to be increasing globally. A 2017 case–control study showed a dramatic increase in relative risk of death with opioid and gabapentinoid versus opioid alone.5 People leaving prison are at a higher risk of opioid overdose death, partly because of loss of tolerance.6,7 This will likely be compounded by inappropriate gabapentinoid prescribing. In New South Wales prisons, the Justice Health and Forensic Mental Health Network sees many patients who present seeking pregabalin and other prescription drugs in our health clinics. Patients often enter custody using high doses of medications prescribed in the community, including gabapentinoids, benzodiazepines and opiates. The Network applies a multidisciplinary team approach between primary care, pharmacy, and drug, alcohol and mental health services for these complex patients. Furthermore, clinicians undertake regular medication reviews of patients; medications that are not indicated are deprescribed to reduce potential harm to patients.8,9 The Network has developed management guidelines around gabapentinoid use, including regular review of prescriptions by general practitioners and the clinical director. Off‐label use is discouraged. Pregabalin is always a supervised medication, and dose limits and deprescribing programs are in place to limit availability if not indicated. Alternate medications for the management of diagnosed neuropathic pain are effective and may pose less risk in prison environments.8,9 Gabapentinoid drugs are not used as an alternative to opiate pain medications in NSW prisons. Patients are assessed and given appropriate medications according to the quality and safe use of medicines approach, and medication charts are regularly audited to ensure safe prescription of medications. There has been an overall reduction in actual gabapentinoid prescribing in NSW prisons in recent years. We encourage all Australian prescribers to ensure care around prescribing of gabapentinoid and other medications, especially for complex patients with drug and alcohol misuse and polypharmacy issues.

Gary Nicholls · Peter Samios · Stephen Hampton

Mja2 50398
Emergency medicine Letters 19 August 2019 Free

Getting smart with smartphones: emergency medical information storage among adult emergency department patients

To the Editor: Patients presenting to an emergency department (ED) may be unable to communicate with treating clinicians. Immediate access to emergency medical information is essential to providing optimal care and avoiding harm. Smartphone medical alert apps, such as those pre‐installed on the two major operating systems (iOS [Apple], Android [Google]), allow patients to store emergency medical information that is accessible to clinicians when a patient is incapacitated and the smartphone is locked. Similar to medical alert bracelets, these apps are designed to store basic emergency medical information. Via a self‐administered app, patients can record as much emergency medical information as they feel comfortable sharing. This information can be rapidly accessed from the smartphone's locked screen, bypassing default security features. We recently asked a convenience sample of 250 adult ED patients, well enough to complete a survey, to complete a questionnaire assessing their smartphone usage, familiarity, attitudes and barriers towards storing emergency medical information on smartphone apps. Ethics approval was obtained through the St Vincent's Hospital Melbourne Human Research Ethics Committee. Two hundred patients completed the survey. The mean age of respondents was 39 years (95% CI, 37–41 years). Most owned a smartphone and had it with them in the ED. Only 15% (31/200) currently used an emergency medical information app, with most using the default pre‐installed app. The commonest barrier to use was a lack of awareness or familiarity with the app. Once informed, most patients (97%; 194/200) were willing to use such an app in the future (Box). Patients who have privacy and security concerns about the government‐controlled My Health Record may view storing emergency medical information on smartphones as a safer option. The depth of information on a smartphone would be considerably less than that accessible via My Health Record, but in an emergency, some information is better than none. Using smartphones to store emergency medical information may lead to better emergency care for incapacitated patients. There is enthusiasm from patients to embrace this technology. General practitioners and other clinicians are well placed to inform patients and facilitate its adoption. ED clinicians should be encouraged to check the phones of incapacitated patients in the initial assessment and triage phase for the presence of potentially lifesaving information. Box – Number of patients currently storing or prepared to store emergency medical information on a smartphone app, by type of information Currently storing (n = 31) Prepared to store (n = 194) Number 95% CI Number 95% CI Name 27 (87%) 74–97% 171 (88%) 84–93% Date of birth 26 (84%) 71–94% 148 (76%) 70–82% Emergency contact 21 (68%) 48–84% 179 (92%) 88–96% Medical conditions 16 (52%) 36–68% 168 (87%) 81–91% Medications 11 (36%) 19–52% 162 (84%) 78–89% Allergies 9 (29%) 14–48% 177 (91%) 87–95% Organ donor status 11 (36%) 19–52% 173 (89%) 85–94% Blood type 13 (42%) 26–58% 184 (95%) 92–98%

Weiyu Fang · Rachel Zordan · Stuart J Dilley

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