405
Letters
Table 1 Mortality in different subgroups
Euglycaemic and non-smokers
Euglycaemics and smokers
Dysglycaemic and non-smokers
Dysglycaemic and smokers
Sex
Total
Mortality
Per cent
Total
Mortality
Per cent
Total
Mortality
Per cent
Total
Mortality
Per cent
Female Male
41 79
5 6
12.2 7.6
1 99
1 10
100 10.1
43 15
4 1
9.3 6.7
5 81
2 9
40 11.1
long-term prognosis of the patients; however, their effect on short-term prognosis is not well assessed. Therefore, this study was planned to describe the potential effect of dysglycaemia and smoking on short-term mortality in patients with ACS. Short-term mortality data (during first week of acute coronary episode) of 364 patients with ACS were collected from the coronary care unit (CCU) of our hospital over a period of 7 months (January–July 2009). These cases were then analysed as regards to their smoking and dysglycaemic status. The fasting and 2 h postprandial blood glucose levels were used to assess the glycaemic status of the patients after the CCU admission. Out of 364 CAD patients, 144 (39.5%) patients were having dysglycaemia, and 86 (59.7%) of dysglycaemic patients were smokers. Mortality appears higher in the presence of both smoking and dysglycaemia, with potential gender differences in effects (see Table 1). Glycometabolic state at hospital admission is an important risk marker for mortality in patients with acute myocardial infarction, whether or not they have known diabetes mellitus. The presence of elevated blood glucose levels, diabetes mellitus or both contributes to more than 3 million cardiovascular deaths worldwide each year (5). Both acute phase hyperglycaemia (stress hyperglycaemia) and diabetes are associated with adverse outcomes in ACS (6,7).
Our descriptive data support the idea that dysglycaemia and smoking status potentially accounts for excess mortality. Both smoking and dysglycaemia are modifiable risk factors, which can be controlled by lifestyle modification in many patients. A. Aggarwal,1 A. Raoot,2 S. Srivastava,3 S. Dwivedi,4 1 Department of Medicine, University College of Medical Sciences, University of Delhi & GTB Hospital, Delhi, India 2 Directorate of Health Services, Government of NCT of Delhi, Delhi, India 3 School of Medical Sciences and Research, Sharda University, Noida, India 4 Hamdard Institute of Medical Sciences and Research, Associated HAH Centenary Hospital, Jamia Hamdard (Hamdard University), New Delhi, India E-mail: [email protected]
References 1 Xavier D, Pais P, Devereaux PJ et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet 2008; 371(9622): 1435–42. 2 Halkos ME, Lattouf OM, Puskas JD et al. Elevated pre-operative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg 2008; 86(5): 1431–7.
3 Medhi M, Marshall MC Jr, Burke HB et al. HbA1c predicts length of stay in patients admitted for coronary artery bypass surgery Heart Dis 2001; 3(2): 77– 9. 4 Alserius T, Anderson RE, Hammar N, Nordqvist T, Ivert T. Elevated glycosylated haemoglobin (HbA1c) is a risk marker in coronary artery bypass surgery. Scand Cardiovasc J 2008; 42(6): 392–8. 5 Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355: 773–778. 6 Malmberg K, Norhammar A, Wedel H, Ryden L. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation 1999; 99: 2626–2632. 7 Kosiborod M, Rathore SS, Inzucchi SE et al. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation 2005; 111: 3078– 3086.
Disclosure None. doi: 10.1111/ijcp.12303
LETTER
The complexity of managing an ageing population Linked Comment: Arendts. Int J Clin Pract 2014; 68: 406.
To the Editor: The paper by Arendts et al. examining the impact of allied health intervention in older patients highlights the complexity of managing an ageing population. Their robust study suggests that early multidisciplinary assessment does not shorten length of stay (1). However, using length of stay alone may not accurately represent the value of such ª 2014 John Wiley & Sons Ltd Int J Clin Pract, March 2014, 68, 3, 403–406
assessment: comprehensive, multidisciplinary assessment has been shown to have an impact on other indices such as mortality or institutionalisation (2). As Arendts notes, factors that contribute to inpatient length of stay include increasing age, disability and complexity. Indeed, as pressure mounts to deliver services efficiently, patients with less complex needs are increasingly managed in ambulatory
or day-care settings (3). This will have the unintended effect of increasing average inpatient length of stay as the proportion of inpatients with complex needs grows. P. McElwaine, D. Robinson, Medicine for the Elderly, St James’s Hospital, Dublin, Ireland E-mail: [email protected]
406
Letters
References 1 Arendts G, Fitzhardinge S, Pronk K, Hutton M. Front-loading allied health intervention in the emergency department does not reduce length of stay for admitted older patients. Int J Clin Pract 2013; 67(8): 807–10. 2 Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for
older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011; 27(343): d6553. 3 McD Taylor D, Bennett DM, Cameron PA. A paradigm shift in the nature of care provision in emergency departments. Emerg Med J 2004; 21(6): 681–4.
Disclosure None. doi: 10.1111/ijcp.12358
LETTER
Response to McElwaine and Robinson Linked Comment: McElwaine and Robinson. Int J Clin Pract 2014; 68: 405–6.
To the Editor: I thank McElwaine and Robinson for their letter, particularly for emphasising that as we become better at selecting patients suitable for management in ambulatory settings, the complexity of patients in the hospital environment increases. Allied health intervention has an important role in facilitating discharge from the emergency department for ambulatory care, yielding a positive, albeit modest, impact on discharge rates (1) with an acceptable risk profile (2). As the population burden of frailty and complex chronic illness in
older people increases, refining our knowledge of which groups benefit most from specialist geriatric allied health services will enable better targeting of this valuable resource. G. Arendts, CCREM, WAIMR, Perth, Australia E-mail: [email protected]
rates in older people: a non-randomized clinical study. BMC Geriatrics 2012; 12: 8. 2 Arendts G, Fitzhardinge S, Pronk K, Hutton M. Outcomes in older patients requiring comprehensive allied health care prior to discharge from the emergency department. Emerg Med Australas 2013; 25(2): 127–31.
Disclosure
References
None.
1 Arendts G, Fitzhardinghe S, Pronk K, Donaldson M, Hutton M, Nagree Y. The impact of early emergency department allied health intervention on admission
doi: 10.1111/ijcp.12357
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, March 2014, 68, 3, 403–406
Letters
Table 1 Mortality in different subgroups
Euglycaemic and non-smokers
Euglycaemics and smokers
Dysglycaemic and non-smokers
Dysglycaemic and smokers
Sex
Total
Mortality
Per cent
Total
Mortality
Per cent
Total
Mortality
Per cent
Total
Mortality
Per cent
Female Male
41 79
5 6
12.2 7.6
1 99
1 10
100 10.1
43 15
4 1
9.3 6.7
5 81
2 9
40 11.1
long-term prognosis of the patients; however, their effect on short-term prognosis is not well assessed. Therefore, this study was planned to describe the potential effect of dysglycaemia and smoking on short-term mortality in patients with ACS. Short-term mortality data (during first week of acute coronary episode) of 364 patients with ACS were collected from the coronary care unit (CCU) of our hospital over a period of 7 months (January–July 2009). These cases were then analysed as regards to their smoking and dysglycaemic status. The fasting and 2 h postprandial blood glucose levels were used to assess the glycaemic status of the patients after the CCU admission. Out of 364 CAD patients, 144 (39.5%) patients were having dysglycaemia, and 86 (59.7%) of dysglycaemic patients were smokers. Mortality appears higher in the presence of both smoking and dysglycaemia, with potential gender differences in effects (see Table 1). Glycometabolic state at hospital admission is an important risk marker for mortality in patients with acute myocardial infarction, whether or not they have known diabetes mellitus. The presence of elevated blood glucose levels, diabetes mellitus or both contributes to more than 3 million cardiovascular deaths worldwide each year (5). Both acute phase hyperglycaemia (stress hyperglycaemia) and diabetes are associated with adverse outcomes in ACS (6,7).
Our descriptive data support the idea that dysglycaemia and smoking status potentially accounts for excess mortality. Both smoking and dysglycaemia are modifiable risk factors, which can be controlled by lifestyle modification in many patients. A. Aggarwal,1 A. Raoot,2 S. Srivastava,3 S. Dwivedi,4 1 Department of Medicine, University College of Medical Sciences, University of Delhi & GTB Hospital, Delhi, India 2 Directorate of Health Services, Government of NCT of Delhi, Delhi, India 3 School of Medical Sciences and Research, Sharda University, Noida, India 4 Hamdard Institute of Medical Sciences and Research, Associated HAH Centenary Hospital, Jamia Hamdard (Hamdard University), New Delhi, India E-mail: [email protected]
References 1 Xavier D, Pais P, Devereaux PJ et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet 2008; 371(9622): 1435–42. 2 Halkos ME, Lattouf OM, Puskas JD et al. Elevated pre-operative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg 2008; 86(5): 1431–7.
3 Medhi M, Marshall MC Jr, Burke HB et al. HbA1c predicts length of stay in patients admitted for coronary artery bypass surgery Heart Dis 2001; 3(2): 77– 9. 4 Alserius T, Anderson RE, Hammar N, Nordqvist T, Ivert T. Elevated glycosylated haemoglobin (HbA1c) is a risk marker in coronary artery bypass surgery. Scand Cardiovasc J 2008; 42(6): 392–8. 5 Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355: 773–778. 6 Malmberg K, Norhammar A, Wedel H, Ryden L. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation 1999; 99: 2626–2632. 7 Kosiborod M, Rathore SS, Inzucchi SE et al. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation 2005; 111: 3078– 3086.
Disclosure None. doi: 10.1111/ijcp.12303
LETTER
The complexity of managing an ageing population Linked Comment: Arendts. Int J Clin Pract 2014; 68: 406.
To the Editor: The paper by Arendts et al. examining the impact of allied health intervention in older patients highlights the complexity of managing an ageing population. Their robust study suggests that early multidisciplinary assessment does not shorten length of stay (1). However, using length of stay alone may not accurately represent the value of such ª 2014 John Wiley & Sons Ltd Int J Clin Pract, March 2014, 68, 3, 403–406
assessment: comprehensive, multidisciplinary assessment has been shown to have an impact on other indices such as mortality or institutionalisation (2). As Arendts notes, factors that contribute to inpatient length of stay include increasing age, disability and complexity. Indeed, as pressure mounts to deliver services efficiently, patients with less complex needs are increasingly managed in ambulatory
or day-care settings (3). This will have the unintended effect of increasing average inpatient length of stay as the proportion of inpatients with complex needs grows. P. McElwaine, D. Robinson, Medicine for the Elderly, St James’s Hospital, Dublin, Ireland E-mail: [email protected]
406
Letters
References 1 Arendts G, Fitzhardinge S, Pronk K, Hutton M. Front-loading allied health intervention in the emergency department does not reduce length of stay for admitted older patients. Int J Clin Pract 2013; 67(8): 807–10. 2 Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for
older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011; 27(343): d6553. 3 McD Taylor D, Bennett DM, Cameron PA. A paradigm shift in the nature of care provision in emergency departments. Emerg Med J 2004; 21(6): 681–4.
Disclosure None. doi: 10.1111/ijcp.12358
LETTER
Response to McElwaine and Robinson Linked Comment: McElwaine and Robinson. Int J Clin Pract 2014; 68: 405–6.
To the Editor: I thank McElwaine and Robinson for their letter, particularly for emphasising that as we become better at selecting patients suitable for management in ambulatory settings, the complexity of patients in the hospital environment increases. Allied health intervention has an important role in facilitating discharge from the emergency department for ambulatory care, yielding a positive, albeit modest, impact on discharge rates (1) with an acceptable risk profile (2). As the population burden of frailty and complex chronic illness in
older people increases, refining our knowledge of which groups benefit most from specialist geriatric allied health services will enable better targeting of this valuable resource. G. Arendts, CCREM, WAIMR, Perth, Australia E-mail: [email protected]
rates in older people: a non-randomized clinical study. BMC Geriatrics 2012; 12: 8. 2 Arendts G, Fitzhardinge S, Pronk K, Hutton M. Outcomes in older patients requiring comprehensive allied health care prior to discharge from the emergency department. Emerg Med Australas 2013; 25(2): 127–31.
Disclosure
References
None.
1 Arendts G, Fitzhardinghe S, Pronk K, Donaldson M, Hutton M, Nagree Y. The impact of early emergency department allied health intervention on admission
doi: 10.1111/ijcp.12357
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, March 2014, 68, 3, 403–406
