Occult myocardial injury is prevalent amongst elderly patients in the hospital-at-home setting. A retrospective analysis of 213 patients.

Background: Hospital-at-Home (HAH) is a valid alternative for in-hospital stay for a wide variety of clinical indications. Occult myocardial injury, associated with acute illness, mainly occurs in patients with a background of non-obstructive coronary disease. The aim of this study was to describe the prevalence of this phenomenon in our HAH population. Methods: A retrospective description and analysis of data collected for patients admitted to the Sheba beyond's HAH services during 14 months. Results: During a period of 14 months (7/10/21-6/12/22), blood troponin measurements were available for 213 patients (median age 78 years, 52% males) hospitalized mainly for infectious causes. The median HS (highly sensitive) troponin level was 7.7 ng/L (IQR = 13.2 ng/L) (the normal upper limit is 12 ng/L) with 31% of all patients demonstrating an abnormally increased troponin level (68/213). Of all patients, 64% had a background diagnosis of a cardiovascular disease (138/213), of whom, 49% had abnormal HS troponin levels (68/138). No patient suffered from acute cardiac function deterioration and no patient died during their hospital-at-home stay. Conclusion: The prevalence of occult myocardial injury amongst elderly patients admitted to hospital-at-home stay for diagnoses other than myocardial infarction is relatively high but it is not associated with worse short-term clinical outcomes.

"Staying at Home": A pivotal trial of telemedicine-based internal medicine hospitalization at a nursing home.

Background: In-hospital stay of acutely ill elderlies could be reduced by increasing the availability of community-based hospitalizations. The feasibility of remotely managing these patients by specialized internists, without leaving their nursing homes should be sought. In the current pivotal study, we aimed to evaluate the aforementioned model. Methods: This was a prospective, open-label study at a tertiary medical center and a nursing home. The study aimed at comparing clinical outcomes of patients hospitalized in each location. Results: Over a period of 5.5 months, we recruited 18 patients designated for hospitalization, meeting our inclusion criteria to either in-hospital stay or staying in their nursing home and treated by means of telemedicine from our tertiary medical center. The mean age was 85.3 years. Out of 114 hospitalization days, 44 days (48%) were at the nursing home. No significant difference was noted in terms of age, gender, and length of stay between the patients who were hospitalized in either location. In almost all cases, diagnosis changed during hospitalization. Three patients died during the study, all included in the in-hospital group. No safety breaching events happened in the nursing home-hospitalization group. Conclusions: Remote, telemedicine-based hospitalization of nursing home-dwelling elderlies is safe and feasible, potentially reducing the length of in-hospital stay by almost 50%. Larger studies in this realm are warranted.

Low ALT values amongst hospitalized patients are associated with increased risk of hypoglycemia and overall mortality: a retrospective, big-data analysis of 51 831 patients.

BACKGROUND: Sarcopenia and frailty influence clinical patients' outcomes. Low alanine aminotransferase (ALT) serum activity is a surrogate marker for sarcopenia and frailty. In-hospital hypoglycemia is associated, also with worse clinical outcomes. AIM: We evaluated the association between low ALT, risk of in-hospital hypoglycemia and subsequent mortality. DESIGN: This was a retrospective cohort analysis. METHODS: We included patients hospitalized in a tertiary hospital between 2007 and 2019. Patients' data were retrieved from their electronic medical records. RESULTS: The cohort included 51 831 patients (average age 70.88). The rate of hypoglycemia was 10.8% (amongst diabetics 19.4% whereas in non-diabetics 8.3%). The rate of hypoglycemia was higher amongst patients with ALT < 10 IU/l in the whole cohort (14.3% vs. 10.4%, P < 0.001) as well as amongst diabetics (24.6% vs. 18.8%, P < 0.001). Both the overall and in-hospital mortality were higher in the low ALT group (57.7% vs. 39.1% P < 0.001 and 4.3% vs. 3.2%, P < 0.001). A propensity score matching, after which a regression model was performed, showed that patients with ALT levels < 10 IU/l had higher risk of overall mortality (HR = 1.21, CI 1.13-1.29, P < 0.001). CONCLUSIONS: Low ALT values amongst hospitalized patients are associated with increased risk of in-hospital hypoglycemia and overall mortality.

Baseline low ALT activity is associated with increased long-term mortality after COPD exacerbations.

BACKGROUND: COPD exacerbations have negative impact on patients' survival. Several risk factors for grave outcomes of such exacerbations have been descried. Muscle dysfunction and mass loss were shown to impact negatively on prognosis and survival. Low activity of the enzyme ALT (Alanine amino-transferase) in the blood is a known indicator for sarcopenia and frailty, however, no previous studies addressed the association of low ALT amongst patients hospitalized due to COPD exacerbation and long-term survival. METHODS: This is a historic prospective cohort study of patients hospitalized due to acute COPD exacerbation. RESULTS: Included were 232 consecutive COPD exacerbation patients. The median time of follow-up was 34.9 months (IQR 23.13-41.73 months). During this period 104 (44.8%) patients died. All patients were grouped to quartiles according to blood ALT levels (after exclusion of cases considered to have hepatic tissue damage (ALT > 40 IU)). The risk of long-term mortality increased, in a statistically significant manner, amongst patients with low ALT values: the median survival of patients with ALT < 11 IU was 18.5 months only while the median survival for the rest of the study group was not reached. For ALT < 11 IU; 12-16 IU; 17-20 IU and > 21 IU the mortality rates were 69%; 40.9%; 36.3 and 25% respectively (p <  0.001 for comparison of lower quartile with upper three quartiles). The crude hazard ratio for mortality amongst patients with ALT levels lower than 11 IU was 2.37 (95% CI; 1.6-3.5). This increased risk of mortality remained significant after adjustment for age, weight, creatinine, albumin concentration and cardiovascular diseases (HR = 1.83; 95% CI 1.08-3.1, p <  0.05). CONCLUSIONS: Low ALT values, a biomarker of sarcopenia and frailty, are associated with poor long-term survival amongst patients hospitalized due to COPD exacerbation.

Head Motion Predicts Transient Loss of Consciousness in Human Head Trauma: A Case-Control Study of Mixed Martial Artists.

OBJECTIVE: Concussion with transient loss of consciousness is a commonly observed but poorly understood phenomenon with mounting clinical significance. This study aimed to examine the relationship between head motion in varying planes and transient loss of consciousness in athletes with brain injuries. STUDY DESIGN: A case-control design was used. The Ultimate Fighting Championship database was screened for events ending with knockouts from 2013 to 2016. Time of strike, striking implement, strike location, and head motion were recorded for all knockout strikes (cases) and for a subset of nonknockout strikes (controls). Characteristics of winners and losers were compared using two-tailed t tests. Multivariate logistic regression was used to determine odds ratios for strike characteristics associated with transient loss of consciousness. The Kaplan-Meier estimate was used to describe the temporal distribution of knockouts. RESULTS: One hundred thirty-six fights were identified and 110 videos were included. Head motion in the axial plane was strongly associated with transient loss of consciousness (odds ratio, 45.3; 95% confidence interval, 20.8-98.6). Other predictors of transient loss of consciousness were head motion in sagittal and coronal planes, nonfist striking implements, and strikes to the mandible or maxilla. The Kaplan-Meier survival curve demonstrated a decreasing rate of knockouts through time. CONCLUSIONS: Rotational head acceleration, particularly in the axial plane, is strongly associated with transient loss of consciousness.

Reducing drug prescription errors and adverse drug events by application of a probabilistic, machine-learning based clinical decision support system in an inpatient setting.

BACKGROUND: Drug prescription errors are made, worldwide, on a daily basis, resulting in a high burden of morbidity and mortality. Existing rule-based systems for prevention of such errors are unsuccessful and associated with substantial burden of false alerts. OBJECTIVE: In this prospective study, we evaluated the accuracy, validity, and clinical usefulness of medication error alerts generated by a novel system using outlier detection screening algorithms, used on top of a legacy standard system, in a real-life inpatient setting. MATERIALS AND METHODS: We integrated a novel outlier system into an existing electronic medical record system, in a single medical ward in a tertiary medical center. The system monitored all drug prescriptions written during 16 months. The department's staff assessed all alerts for accuracy, clinical validity, and usefulness. We recorded all physician's real-time responses to alerts generated. RESULTS: The alert burden generated by the system was low, with alerts generated for 0.4% of all medication orders. Sixty percent of the alerts were flagged after the medication was already dispensed following changes in patients' status which necessitated medication changes (eg, changes in vital signs). Eighty-five percent of the alerts were confirmed clinically valid, and 80% were considered clinically useful. Forty-three percent of the alerts caused changes in subsequent medical orders. CONCLUSION: A clinical decision support system that used a probabilistic, machine-learning approach based on statistically derived outliers to detect medication errors generated clinically useful alerts. The system had high accuracy, low alert burden and low false-positive rate, and led to changes in subsequent orders.

L3 skeletal muscle index (L3SMI) is a surrogate marker of sarcopenia and frailty in non-small cell lung cancer patients.

Background: Non-small cell lung cancer (NSCLC) is a common and highly lethal disease. As advanced treatment modalities are being developed, improved prognostication methods are sought. L3 skeletal muscle index (L3SMI) and alanine aminotransferase (ALT) levels are accepted surrogate markers of sarcopenia and related frailty. We aimed to evaluate the potential association of these markers with NSCLC patients' survival. Methods: A retrospective, single-center study of an NSCLC patients' cohort. L3SMI was calculated based on skeletal muscle area on computed tomography scans at the level of the L3 vertebra. Clinical data were extracted from clinical charts. Results: A total of 140 patients (56.4% males, median age 66 [range 37-86]) were included in this study, 32% were diagnosed at stage 3 and 45% at stage 4. During the follow-up duration (median of 1.9 years; range 1 month to 6.4 years), 102 patients (72.8%) died. Patients' characteristics that were found to be associated with increased mortality were performance status, albumin and tumor stage at diagnosis. Sarcopenia, defined as low L3SMI (lower than 41 cm2/m2 for women and lower than 53 cm2/m2 for men) was significantly associated with higher risk of mortality compared with patients with normal L3SMI values (77.2%, vs 64.6%, p=0.013) in univariate analysis, but not in a multiple regression analysis. Conclusion: Low L3SMI could serve as a surrogate marker for sarcopenia and frailty and, as such, facilitate the prognostication process of NSCLC patients.

Sodium phosphate enemas do not worsen renal function among hospitalized patients with mild to moderate renal failure: a matched, case-control study.

BACKGROUND: Sodium phosphate enemas (SPEs) are widely used among hospitalized patients despite their potential to worsen renal failure. AIM: We decided to assess the extent to which this side effect is clinically relevant. DESIGN: We conducted a matched case-control, retrospective study in a cohort of hospitalized patients. METHODS: Patients treated and untreated with SPEs were matched for age, gender, baseline creatinine, usage of certain medications and several background diagnoses. Three groups of matched patients (whole study cohort, patients with baseline creatinine > 1.5 mg/dl and those with baseline creatinine > 2 mg/dl) were compared with regards to their creatinine and blood electrolyte concentrations during 3 consecutive hospitalization days after SPE application. RESULTS: Four hundred and twelve patients were included in this study of which 206 were treated by single SPEs. Exact matching was done for the whole study cohort, for 108 patients with baseline creatinine > 1.5 mg/dl and for 58 patients with baseline creatinine > 2 mg/dl. During 3 consecutive days after SPEs, the maximal blood concentrations of creatinine, phosphor and potassium did not differ significantly between treated patients and matched controls, in all three patients' groups. CONCLUSION: Application of SPEs neither seem to worsen mild to moderate renal failure, nor are associated with hyperphosphatemia or hyperkalemia in patients hospitalized in internal medicine departments.

Changing Metrics of Organ Procurement Organization Performance in Order to Increase Organ Donation Rates in the United States.

The shortage of deceased-donor organs is compounded by donation metrics that fail to account for the total pool of possible donors, leading to ambiguous donor statistics. We sought to assess potential metrics of organ procurement organizations (OPOs) utilizing data from the Nationwide Inpatient Sample (NIS) from 2009-2012 and State Inpatient Databases (SIDs) from 2008-2014. A possible donor was defined as a ventilated inpatient death ≤75 years of age, without multi-organ system failure, sepsis, or cancer, whose cause of death was consistent with organ donation. These estimates were compared to patient-level data from chart review from two large OPOs. Among 2,907,658 inpatient deaths from 2009-2012, 96,028 (3.3%) were a "possible deceased-organ donor." The two proposed metrics of OPO performance were: (1) donation percentage (percentage of possible deceased-donors who become actual donors; range: 20.0-57.0%); and (2) organs transplanted per possible donor (range: 0.52-1.74). These metrics allow for comparisons of OPO performance and geographic-level donation rates, and identify areas in greatest need of interventions to improve donation rates. We demonstrate that administrative data can be used to identify possible deceased donors in the US and could be a data source for CMS to implement new OPO performance metrics in a standardized fashion.

Knee osteoarthritis, degenerative meniscal lesion and osteonecrosis of the knee: Can a simple gait test direct us to a better clinical diagnosis.

INTRODUCTION: The purpose of the current study was to compare the gait patterns in patients with three differing knee pathologies - knee osteoarthritis (OA), degenerative meniscal lesion (DML) and spontaneous osteonecrosis of the knee (SONK) and a group of healthy controls. HYPOTHESIS: A simple gait test will detect differences between different knee pathologies. MATERIAL AND METHODS: Forty-seven patients with bilateral knee OA, 47 patients with DML, 28 patients with SONK and 27 healthy controls were included in this analysis. Patients underwent a spatiotemporal gait assessment and were asked to complete the Western Ontario and McMaster University (WOMAC) Index and the Short-Form (SF)-36 Health Survey. ANOVA tests, followed by Bonferroni multiple comparison tests and the Chi2 tests were performed for continuous and categorical variables, respectively. RESULTS: Significant differences were found for all gait measures and clinical questionnaires between healthy controls and all knee conditions. Patients with SONK differed from patients with bilateral knee OA and DML in all gait measures and clinical questionnaires, except for WOMAC subscales. There were no significant differences between patients with bilateral knee OA and patients with DML. Symmetry was also examined and revealed asymmetry in some gait parameters in patients with SONK and DML. DISCUSSION: Based on the differences in gait parameters that were found in the current study, adding an objective functional spatiotemporal gait test may assist in the diagnostic process of knee pathologies. TYPE OF STUDY: Case Control study Level III.

Corrected QT interval anomalies are associated with worse prognosis among patients suffering from sepsis.

BACKGROUND: Patients suffering from sepsis experience organ failure and metabolic derangements, with a negative impact on their prognosis and survival. Objective markers for dismal prognosis in this group of patients are sought. AIMS: To assess the potential role of corrected QT interval anomalies as surrogates for metabolic derangements leading to increased short and medium-term mortality in patients suffering from sepsis. METHODS: This study utilised a historic-cohort analysis of 257 septic patients admitted to internal medicine departments. Personal data, vital signs, laboratory results and electrocardiograms were collected. Patients were grouped according to QTc duration, weather mid-range (395-490 ms) or non-mid-range, and further defined as shorter (<395 ms) or longer (>490 ms). RESULTS: Mortality rates differed significantly between the mid-range QTc group and the non-mid-range groups at 14 days (23.7 vs 38.2%, respectively; P = 0.014) and at 3 months (38.5 vs 59.6%, respectively; P = 0.001). In a three-group analysis, the 14-day mortality was the highest in the longer QTc group and the lowest in the mid-range group compared with the shorter QTc group (44.4, 23.7 and 35.5%, respectively; P = 0.034), and this difference also remained at 3 months (74.1, 38.5 and 53.2%, respectively; P = 0.001). All differences remained statistically significant in a multivariate Cox regression analysis. CONCLUSIONS: QTc duration anomalies are associated with worse short- and medium-term prognosis and may act as a marker for more severe clinical sequelae.

Low ALT Levels Independently Associated with 22-Year All-Cause Mortality Among Coronary Heart Disease Patients.

BACKGROUND: Low alanine aminotransferase (ALT) blood levels are known to be associated with frailty and increased risk of long-term mortality in certain populations. However, the contribution of this marker to long-term outcome has not been assessed in patients with chronic coronary heart disease. OBJECTIVE: The aim of the current study was to assess the association between low ALT values and long-term, 22.8-year, all-cause mortality in this population. PARTICIPANTS: We examined the association of low ALT (<17 IU/l) with long-term all-cause mortality in the Bezafibrate Infarction Prevention (BIP) Registry population. KEY RESULTS: Appropriate laboratory and survival data were available for 6,575 patients, without known liver pathology, included in the BIP registry, with a median follow-up period of 22.8 years. The cumulative probability of all-cause mortality was significantly higher in the low ALT group compared with patients with higher ALT levels (65.6 % vs. 58.4 %; log-rank p < 0.001). Consistently, multivariate analysis, adjusted for multiple established predictors of mortality in this population, demonstrated that low ALT is independently associated with 11 % greater long-term (22.8 years) mortality risk [HR 1.11 (95 % confidence interval: 1.03-1.19; adjusted p < 0.01)]. CONCLUSIONS: Low ALT levels are associated with increased long-term mortality among middle-aged patients with stable coronary heart disease. This association remained statistically significant after adjustment for other well-established risk factors for mortality in this population.

When uncommon and common coalesce: adult onset Still's disease associated with breast augmentation as part of autoimmune syndrome induced by adjuvants (ASIA).

Adult onset Still's disease (AOSD) is an uncommon, multisystemic, auto-inflammatory disorder, while breast augmentation is a very common cosmetic procedure. We describe a case in which these two coalesce, AOSD, manifested with pleuritis and pericarditis, developed after breast mammoplasty. The pathogenetic, missing link, behind the development of AOSD following mammoplasty, is thought to be the autoimmune (auto-inflammatory) syndrome induced by adjuvants (ASIA). We reviewed other cases of AOSD associated with breast mammoplasty published to date and the literature regarding AOSD and ASIA syndrome. The review is followed by a short debate of whether silicone implants should be explanted in similar, future cases.

Early Post-transplant Lymphoproliferative Disease in the Donor Ureter Without Systemic Involvement: A Case Report.

BACKGROUND: Post-transplant lymphoproliferative disease is a serious complication of renal transplantation. Major risk factors include Epstein-Barr virus (EBV) seronegativity and induction immunosuppression with lymphocyte-depleting agents. RESULTS: We present a case of a 50-year year-old woman with very early onset PTLD confined to the donor ureter. Phenotypic studies on the tumor material reveal that the lymphoma was most likely of donor origin. A complete staging workup including the kidney allograft was negative for any other sites of involvement. CONCLUSIONS: This case, which had a fatal outcome, emphasizes the risk of renal transplantation in BV-negative individuals when given induction with lymphocyte-depleting drugs.

Decreased dopaminergic treatment of hospitalized Parkinson's disease patients during infectious diseases is associated with poor outcomes.

A retrospective analysis of consecutive Parkinson's disease (PD) patients hospitalized in internal medicine wards during the years 2008 to 2013 due to infectious disease was performed. PD patients are prone to infections, often leading to hospitalization in internal medicine wards. We observed that during these hospitalizations, chronic anti-Parkinson's medications are frequently overlooked and withdrawn, their reintroduction is delayed and dosages are decreased. Only patients on chronic therapy with at least one anti-Parkinson's medication were included in this study. Multivariate analyses established the association between medication dose reductions on short-term clinical outcomes, including in-hospital mortality and change in discharge destination. Medical records from 528 PD patients were analyzed and 430 were excluded. Of the 98 included, 53 had pneumonia and 58 had urinary tract infections. The overall in-hospital mortality rate was 11.2%. 56.1% of patients' dopaminergic medications were decreased in dose upon admission (22.5% mean decrease in levodopa equivalent daily dose [LEDD]; p<0.001). Both absolute and relative LEDD reductions were associated with significantly increased in-hospital mortality (mean reduction of 394.5 mg versus 188.4 mg; p=0.035 by analysis of variance adjusted to age, sex and renal function) and was also associated with worse discharge destination relative to original place of arrival (mean reduction of 377.8 mg versus 150.7 mg; p=0.014). Decreased dopaminergic medication dosing upon admission of PD patients due to infection is widespread and potentially associated with worse clinical outcomes.

Low ALT blood levels predict long-term all-cause mortality among adults. A historical prospective cohort study.

BACKGROUND: Increased blood levels of alanine amino transferase (ALT, also known as SGPT; serum glutamic pyruvic transaminase) serve as a marker of liver injury by various mechanisms. Less is known about the clinical implications associated with low-normal ALT levels. Previous studies showed low ALT levels to be associated with poor long-term outcomes among elderlies, serving as a biomarker for increased incidence of frailty and subsequent risk of mortality. However, it has not been determined yet whether low-normal ALT values might be predictive of frailty and mortality in younger, middle-aged adults. METHODS: We conducted a historical prospective cohort analysis. RESULTS: A total of 23,506 adults with ALT levels within the normal range, at the mean age of 48 ± 11 years, participating in an annual screening program for preventive medicine, were followed-up for a median period of 8.5 years during which 638 died. Low-normal ALT values (serum ALT activity <17IU/L) were found to be predictive for increased risk of all-cause mortality (HR=1.6; 95% CI 1.34-1.92; p<0.001). Statistically significant correlation was demonstrated even after applying a multifactorial model correction for age, gender, eGFR, low albumin, arterial hypertension, diabetes mellitus and ischemic heart disease. CONCLUSIONS: We suggest that low-normal ALT values may serve as an independent predictive marker for increased long-term mortality in middle-aged adults.

Novel classification of knee osteoarthritis severity based on spatiotemporal gait analysis.

OBJECTIVE: To describe a novel classification method for knee osteoarthritis (OA) based on spatiotemporal gait analysis. METHODS: Gait analysis was initially performed on 2911 knee OA patients. Females and males were analyzed separately because of the influence of body height on spatiotemporal parameters. The analysis included the three stages of clustering, classification and clinical validation. Clustering of gait analysis to four groups was applied using the kmeans method. Two-thirds of the patients were used to create a simplified classification tree algorithm, and the model's accuracy was validated by the remaining one-third. Clinical validation of the classification method was done by the short form 36 Health Survey (SF-36) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. RESULTS: The clustering algorithm divided the data into four groups according to severity of gait difficulties. The classification tree algorithm used stride length and cadence as predicting variables for classification. The correct classification accuracy was 89.5%, and 90.8% for females and males, respectively. Clinical data and number of total joint replacements correlated well with severity group assignment. For example, the percentages of total knee replacement (TKR) within 1 year after gait analysis for females were 1.4%, 2.8%, 4.1% and 8.2% for knee OA gait grades 1-4, respectively. Radiographic grading by Kellgren and Lawrence was found to be associated with the gait analysis grading system. CONCLUSIONS: Spatiotemporal gait analysis objectively classifies patients with knee OA according to disease severity. That method correlates with radiographic evaluation, the level of pain, function, number of TKR.

Effects of a customized biomechanical therapy on patients with medial compartment knee osteoarthritis.

OBJECTIVE: Previous studies have shown that a customized biomechanical therapy can improve symptoms of knee osteoarthritis. These studies were small and did not compare the improvements across gender, age, BMI or initial severity of knee osteoarthritis. The purpose of this study was to evaluate the effect of new biomechanical therapy on the pain, function and quality of life of patients with medial compartment knee osteoarthritis. METHODS: Six hundred and fifty-four patients with medial compartment knee osteoarthritis were examined before and after 12 weeks of a personalized biomechanical therapy (AposTherapy). Patients were evaluated using the Western Ontario and McMaster Osteoarthritis (WOMAC) Index and SF-36 Health Survey. RESULTS: After 12 weeks of treatment, the WOMAC-pain and WOMAC-function subscales were significantly lower compared to baseline (both P≤0.001). All eight categories of the SF-36 health survey significantly improved after treatment (all P≤0.001). Females and younger patients showed greater improvements with therapy. CONCLUSIONS: Twelve weeks of a customized biomechanical therapy (AposTherapy) improved symptoms of patients with medial compartment knee osteoarthritis. We recommend that this therapy will be integrated in the management of knee osteoarthritis.