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PURPOSE: The study aimed to characterize the erythrocytic profile in patients with cushing's syndrome (CS) versus controls from the normal population according to etiology, sex, presence of diabetes mellitus (DM) and hypercortisolemia remission status. METHODS: This retrospective cohort analysis compared erythrocytic parameters between patients with CS of pituitary (CD) and adrenal (aCS) etiology and age, sex, body mass index (BMI) and socioeconomic status-matched controls in a 1:5 ratio. Laboratory values at baseline were calculated as mean values during the year preceding CS diagnosis, and over one year thereafter. RESULTS: The cohort included 397 CS patients (68.26% female; mean age 51.11 ± 16.85 years) and 1970 controls. Patients with CS had significantly higher baseline median levels of hemoglobin (Hgb) (13.70 g/dL vs. 13.12 g/dL [p < 0.0001]) and hematocrit (Hct) (41.64% vs. 39.80% [p < 0.0001]) compared to controls. These differences were observed for both CD and aCS and for both sexes. Patients who attained remission had Hgb and Hct levels comparable to controls (13.20 g/dL and 40.08% in patients with CD and aCS vs. 13.20 g/dL and 39.98% in controls). Meanwhile, those with persistent/recurrent disease maintained elevated levels. Patients with comorbid DM had similar Hgb but higher Hct (p = 0.0419), while patients without DM showed elevated erythrocytic values compared to controls (p < 0.0001). CONCLUSION: Our data illustrates that erythrocytic parameters are directly influenced by glucocorticoid excess as Hgb and Hct are higher in patients with CS, and normalize after remission. We have identified the influence of DM on erythrocytic parameters in patients with CS for the first time.
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Síndrome de Cushing , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Síndrome de Cushing/sangue , Síndrome de Cushing/epidemiologia , Estudos Retrospectivos , Adulto , Idoso , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/sangue , Hematócrito , Eritrócitos/metabolismo , Hemoglobinas/metabolismo , Fatores SexuaisRESUMO
BACKGROUND: The impact of physiological adjustments throughout pregnancy on maternal vital signs and laboratory values has yet to be fully defined. The present study was designed to determine the normal range of these parameters among healthy pregnant women during the peripartum period. METHODS: This is a retrospective analysis of data collected during real-time deliveries in a single medical center. Vital signs and laboratory results from the 24 hours preceding delivery room admission and up to 72 hours postpartum were collected. Only pregnant women at term (37 to 41 weeks' gestation) with a liveborn, singleton gestation, and no chronic disease or obstetric complication that could affect the physiological parameters under study were included. The mean, range, and standard deviations of the extremes of all parameters at 3 distinct time points (prelabor, intrapartum, and postpartum) were calculated. The 2.5 and 97.5 percentiles for each parameter were reported as the normal range. RESULTS: A total of 32,161 cases fulfilled inclusion criteria. The average gestational age at delivery was 39 weeks ± 8 days, and one-third of the cases were primiparous. During labor and after delivery, the upper limits of normal blood pressure values were 147/94 and 145/94 mm Hg, respectively. The lower limits were 83/43 and 83/42 mm Hg, respectively. Normal heart rates were 60-115 beats/min prelabor, 51-120 beats/min intrapartum, and 50-120 beats/min postpartum. Lowest normal temperatures ranged between 36.0°C and 36.3°C in the 3 study time points, and highest normal temperatures were 37.2°C prelabor and 37.6°C intra- and postpartum. The normal ranges of white blood cell counts were 6.1-16.8 prelabor, 6.5-22.5 intrapartum, and 6.4-23.9 K/µL postpartum. Normal low values of hemoglobin were 9.7, 8.7, and 7.1 g/dL and of platelets were 117, 113, and 105 K/µL, respectively. CONCLUSIONS: Our findings justify the practice of using ≥2 repeated measurements for diagnosing hypertensive disorders of pregnancy. Lower normal blood pressure limits may be below those defining hypotensive shock. Normal heart rates exceed the accepted definitions of both tachy- and bradycardia. Normal temperatures at all times have a more narrow range than previously thought, and the normal range of white blood cell count has outliers exceeding the current definitions of leukocytosis or leukopenia at all times. The normal lower range of hemoglobin was constantly below 10 g/dL, and normal platelet counts were considerably lower than those previously described. The vital signs and complete blood count values thus far considered normal for the peripartum period may require some adjustment. New definitions for hypotension, tachy- and bradycardia, fever, and leukocyte quantitative disorders should be considered.
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Contagem de Células Sanguíneas , Parto , Sinais Vitais , Adulto , Bases de Dados Factuais , Feminino , Idade Gestacional , Voluntários Saudáveis , Humanos , Trabalho de Parto , Paridade , Valor Preditivo dos Testes , Gravidez , Valores de Referência , Estudos RetrospectivosRESUMO
BACKGROUND: Lung cancer (LC) screening using low-dose computed tomography (CT) is recommended according to standard risk criteria or personalized risk calculators. Machine learning (ML) models that can predict disease risk are an emerging method in medicine for identifying hidden associations that are personally unique. MATERIALS AND METHODS: Using the tree-based pipeline optimization tool (TPOT), we developed an ML-based model, which is an ensemble of the Random Forest and XGboost models, based on known risk factors for LC, as part of a larger trial for ML prediction using electronic medical records and chest CT. We used data from patients with LC vs. controls (1:2) of patients aged ≥ 35 years. We developed a model for all LC patients as well as for patients with and without a smoking background. We included age, gender, body mass index (BMI), smoking history, socioeconomic status (SES), history of chronic obstructive pulmonary disease (COPD)/emphysema/chronic bronchitis (CB), interstitial lung disease (ILD)/pulmonary fibrosis (PF), and family history of LC. RESULTS: Of the 4076 patients, 1428 (35â¯%) were in the LC group and 2648 (65â¯%) were in the control group. For the entire study population, our model achieved an accuracy of 71.2â¯%, with a sensitivity of 69â¯% and a positive predictive value (PPV) of 74â¯%. Higher accuracy was achieved for the two subgroups. An accuracy of 74.8â¯% (sensitivity 72â¯%, PPV 76â¯%) and 73.0â¯% (sensitivity 76â¯%, PPV 72â¯%) was achieved for the smoking and never-smoking cohorts, respectively. For the entire population and smoker cohort, COPD/emphysema/CB were the most important contributors, followed by BMI and age, while in the never-smoking cohort, BMI, age and SES were the most important contributors. CONCLUSION: Known risk factors for LC could be used in ML models to modestly predict LC. Further studies are needed to confirm these results in new patients and to improve them.
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BACKGROUND: Venous thromboembolism (VTE) is considered a preventable cause of mortality. The evidence for the benefit of VTE prophylaxis in acute medical patients is non-conclusive. Meta-analysis of RCTs failed to demonstrate reduction of all-cause mortality, while showing higher risk of bleeding. The Israeli Ministry of Health has instructed to assess all acute medical patients for the risk for VTE using the Padua Prediction Score, without mandating prophylaxis. AIM: To evaluate the effect of filling the Padua score on clinical outcomes and VTE prophylaxis rates. METHODS: Retrospective Study was performed in Israel during the years 2014-2017. The participants were divided to Padua compliance vs non-compliance group. Primary outcome: 30-day mortality. Secondary outcomes: 90-day incidence of VTE and suspected major bleeding. A propensity-weighted logistic multiple regression was performed. RESULTS: 18,890 patients were included in the study. The fulfillment of the Padua score was associated with an increased use of VTE prophylaxis, OR 1.66 (95% CI 1.49-1.84). However, there was no reduction of mortality or VTE events, OR 1.13 (95% CI 0.97-1.31) and OR 1.22 (95% CI 0.79-1.8) respectively. Hospitalizations related to hemoglobin decrease were not statistically different between the two groups. CONCLUSIONS: Padua score for the assessment of VTE risk in medical wards was associated with higher administration of pharmacological prophylaxis without reduction in VTE or mortality rate. Its usage should be reassessed as a performance measure.
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Tromboembolia Venosa , Humanos , Estudos Retrospectivos , Tromboembolia Venosa/tratamento farmacológico , Anticoagulantes/uso terapêutico , Hospitalização , Hospitais , Hemorragia/tratamento farmacológico , Fatores de RiscoRESUMO
OBJECTIVE: Cancer incidence in patients with endogenous Cushing's syndrome (CS) has never been established. Here, we aimed to assess the cancer risk in patients with CS as compared with individually matched controls. DESIGN: A nationwide retrospective matched cohort study of patients with endogenous CS diagnosed between 2000 and 2023 using the database of Clalit Health Services in Israel. METHODS: Patients with adrenal carcinoma or ectopic CS were excluded. Patients with CS were matched in a 1:5 ratio, with controls individually matched for age, sex, socioeconomic status, and body mass index. The primary outcome was defined as the first diagnosis of any malignancy following a CS diagnosis. Risk of malignancy was calculated using the Cox proportional hazard model, with death as a competing event. RESULTS: A total of 609 patients with CS and 3018 controls were included [mean age at diagnosis, 48.0 ± 17.2â years; 2371 (65.4%) women]. The median follow-up was 14.7â years (IQR, 9.9-20.2â years). Patients with CS had an increased cancer risk, with a hazard ratio (HR) of 1.78 (95% CI 1.44-2.20) compared with their matched controls. The risk of malignancy was elevated in patients with Cushing's disease (251 cases and 1246 controls; HR 1.65, 95% CI 1.15-2.36) and in patients with adrenal CS (200 cases and 991 controls; HR 2.36, 95% CI 1.70-3.29). The increased cancer risk in patients with CS persists after exclusion of thyroid malignancies. CONCLUSION: Endogenous CS is associated with increased malignancy risk. These findings underscore the need for further research to establish recommendations for cancer screening in this population.
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Síndrome de Cushing , Neoplasias , Humanos , Feminino , Masculino , Síndrome de Cushing/epidemiologia , Síndrome de Cushing/diagnóstico , Síndrome de Cushing/complicações , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto , Neoplasias/epidemiologia , Israel/epidemiologia , Incidência , Idoso , Fatores de Risco , Estudos de Casos e Controles , Estudos de Coortes , Modelos de Riscos ProporcionaisRESUMO
Urinary tract infections (UTIs) in childhood are common and are associated with considerable acute morbidity and long-term complications. The need for updated data to optimize empiric antibiotic therapy is crucial. We aimed to investigate the pathogens causing pediatric community acquired UTIs, their correlation with demographic characteristics, and trends in their antimicrobial resistance. This nationwide cross-sectional study included all 53,203 children (<18 years) diagnosed with UTI in community outpatient clinics in the following selected years: 2007, 2011, 2015, 2019 and 2021. Escherichia coli (E. coli) (82.1%) was the most common uropathogen, followed by Enterobacter, Klebsiella, Proteus, Pseudomonas, and Enterococcus species. The bacterial distribution displayed statistically significant (p < 0.0001) gender- and sector-specific patterns with a higher relative prevalence of non-E. coli UTI in Jewish and males. The rate of extended-spectrum beta-lactamase-positive E. coli increased substantially and significantly (p < 0.001) from only 6.1% in 2007 to 25.4% in 2021. Most non-E. coli uropathogens exhibited resistance to commonly used empiric antibiotics for UTIs in children. These findings are significant in guiding optimal empiric antibiotic treatment for pediatric community acquired UTIs. The resistance of uropathogens to antimicrobials is region- and time-dependent. Therefore, the periodic and local assessment of antibiotic resistance trends is essential to update guidelines and provide the most appropriate antibacterial therapy for children with UTIs.
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BACKGROUND: Current guidelines are inconsistent regarding the follow-up of patients with 1-2 diminutive (1-5 mm) non-advanced adenomas (DNAAs). AIMS: To evaluate the risk of metachronous advanced neoplasia (AN), defined as cancer or advanced adenoma (AA), among patients with either normal colonoscopy or 1-2 DNAAs. METHODS: A retrospective cohort study. Cohort I included 2,347 subjects with normal colonoscopy and 483 subjects with polypectomy of 1-2 DNAAs followed by colonoscopy. Cohort II included 11,881 subjects with normal colonoscopy and 1,342 subjects with 1-2 DNAAs followed through the cancer registry. RESULTS: In cohort I, the rate of AN, cancer and AA among the polypectomy group vs. normal colonoscopy was 5.0% vs. 2.5%, Hazard Ratio (HR) 2.96 (95%CI [Confidence Interval]1.86-4.78) for AN; 0.6% vs. 0.3%, HR 3.32 (95%CI 0.85-13) for cancer; 4.3% vs. 2.2% HR 2.91 (95%CI 1.75-4.86) for AA. In cohort II, cancer occurred in 0.4% of the polypectomy group and 0.2% of the normal colonoscopy group, HR 2.27 (95% CI 0.56-9.19). CONCLUSION: Compared to subjects with normal colonoscopy, subjects with polypectomy of 1-2 DNAAs, are at increased risk for AA when followed by colonoscopy, while the risk for cancer is non-significantly increased. Our findings suggest that patients with 1-2 DNNAs should be followed more tightly than patients with normal colonoscopy.
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Adenoma , Pólipos do Colo , Neoplasias Colorretais , Segunda Neoplasia Primária , Colonoscopia , Humanos , Estudos Retrospectivos , Fatores de RiscoRESUMO
AIMS: Develop and validate a model for predicting hypoglycemia in inpatients. METHODS: Derivation cohort: patients treated with hypoglycemic drugs and admitted to the departments of medicine of a university hospital during 2016. VALIDATION: patients admitted to a community hospital, and patients admitted to a university hospital in the north of Israel, 2017-2018. Data available in the electronic patient record (EPR) during the first hours of hospital stay were used to develop a logistic model to predict the probability of hypoglycemia. The performance of the model was measured in the validation cohorts. RESULTS: In the derivation cohort, hypoglycemia was measured in 474 out of 3605 patients, 13.1%. The logistic model to predict hypoglycemia included age, nasogastric or percutaneous gastrostomy tube, Charlson score, vomiting, chest pain, acute renal failure, insulin, hemoglobin and diastolic blood pressure. The area under the ROC curve (AUROC) was 0.71 (95% CI 0.69-0.73). In the highest probability group the percentage of hypoglycemia was 24.3% (258/1061). In the two validation groups hypoglycemia was measured in 269/2592 patients (11.1%); and 393/3635 (10.8%). AUROC was 0.72 (95% CI 0.68-0.76); and 0.71 (95% CI 0.68-0.74). In the highest probability groups hypoglycemia was measured in 28.1% (111/395); and 23.0% (211/909) of patients. CONCLUSIONS: The derived model performed well in the validation cohorts. Assuming that most of the hypoglycemia episodes could be prevented we would need to invest efforts to avoid hypoglycemia in 4-5 patients to prevent one episode of hypoglycemia.
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Complicações do Diabetes/complicações , Hipoglicemia/diagnóstico , Tempo de Internação/tendências , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização , Humanos , Pacientes Internados , Insulina/uso terapêutico , Masculino , Pessoa de Meia-IdadeRESUMO
Burden of COVID-19 on Hospitals across the globe is enormous and has clinical and economic implications. In this retrospective study including consecutive adult patients with confirmed SARS-CoV-2 who were admitted between 3/2020 and 30/9/20, we aimed to identify post-discharge outcomes and risk factors for re-admission among COVID-19 hospitalized patients. Mortality and re-admissions were documented for a median post discharge follow up of 59 days (interquartile range 28,161). Univariate and multivariate analyses of risk factors for re-admission were performed. Overall, 618 hospitalized COVID-19 patients were included. Of the 544 patient who were discharged, 10 patients (1.83%) died following discharge and 50 patients (9.2%) were re-admitted. Median time to re-admission was 7 days (interquartile range 3, 24). Oxygen saturation or treatment prior to discharge were not associated with re-admissions. Risk factors for re-admission in multivariate analysis included solid organ transplantation (hazard ratio [HR] 3.37, 95% confidence interval [CI] 2.73-7.5, p = 0.0028) and higher Charlson comorbidity index (HR 1.34, 95% CI 1.23-1.46, p < 0.0001). Mean age of post discharge mortality cases was 85.0 (SD 9.98), 80% of them had cognitive decline or needed help in ADL at baseline. In conclusion, re-admission rates of hospitalized COVID-19 are fairly moderate. Predictors of re-admission are non-modifiable, including baseline comorbidities, rather than COVID-19 severity or treatment.
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Atividades Cotidianas/psicologia , COVID-19/mortalidade , Disfunção Cognitiva/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/psicologia , Disfunção Cognitiva/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Análise Multivariada , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVE: Current guidelines recommend pharmacologic prophylaxis for medical patients at high risk for venous thromboembolism. We aimed to assess the benefit and safety of venous thromboembolism prophylaxis in acutely ill medical patients hospitalized. METHODS: We prepared a retrospective cohort study in a tertiary hospital in Israel with patients hospitalized in medical departments with an admission lasting more than 48 hours during 2014-2017. PRIMARY OUTCOME: 30-day mortality. SECONDARY OUTCOMES: 90-day incidence of pulmonary embolism, symptomatic deep vein thrombosis, and major bleeding. Propensity-weighted logistic multivariate analysis was performed. RESULTS: A total of 18,890 patient-unique episodes were included in the analysis. Of them, 3206 (17.0%) received prophylaxis. A total of 1309 (6.9%) died, 540/3206 (16.8%) of those who received venous thromboembolism prophylaxis and 769/15,864 (4.9%) of those who did not. Prophylaxis was not associated with a reduction in mortality, multivariable-adjusted odds ratio propensity-weighted (OR) 0.99 (95% confidence interval [CI], 0.84-1.14). One hundred forty-two patients (0.7%) developed venous thromboembolism, 44/3206 (1.4%) of those who received prophylaxis and 98/15,864 (0.6%) of those who did not. Prophylaxis was not associated with reduction in venous thromboembolism in the whole cohort, multivariable-adjusted propensity-weighted OR 1.09 (95% CI, 0.52-2.29). Prophylaxis was associated with an increase in major bleeding (multivariable-adjusted propensity-weighted OR 1.24; 95% CI, 1.04-1.48). CONCLUSION: The current practice of routinely administering venous thromboembolism prophylaxis to medically ill patients considered at high risk for thrombosis resulted in a high risk for bleeding without a clear clinical benefit, and should be reassessed.
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Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Hemorragia/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Estudos de Coortes , Humanos , Razão de Chances , Estudos Retrospectivos , Fatores de RiscoRESUMO
Use of GeneXpert MRSA/SA in diagnostic algorithms of Staphylococcus aureus bacteremia may influence both patients' clinical outcomes and antibiotic stewardship. We evaluated these outcomes in a retrospective cohort before (1/6/2015-31/5/2016) and after (1/6/2016-31/8/2017) the introduction of the test in adult patients with Gram-positive cocci in clusters in blood cultures. We included 254 patients (125 preintervention, 129 postintervention). No significant difference in 30-day mortality or clinical success was demonstrated between periods. Appropriate antibiotic therapy rates were significantly higher in the postintervention group, and vancomycin use was significantly reduced (80.6% vs 53.6%, Pâ¯<â¯0.01; 2.3±0.38 vs 2.98±1.02 defined daily doses/100 patient days, Pâ¯=â¯0.026, respectively). Appropriate beta-lactam use was also significantly higher (56.7% postintervention vs 23.1% preintervention, Pâ¯<â¯0.01). Use of GeneXpert MRSA/SA test has a positive effect on antibiotic stewardship measures, though it has no significant effect on clinical outcomes including mortality in this fatal infection.