[Methotrexate use: untangling the real from the fake]. / Utilisation du méthotrexate : démêler le vrai du faux.

Methotrexate is one of the most important treatments for rheumatologists, however often of great concern to the non-specialist. This article reviews some useful aspects to know, in terms of safety with no major infectious risk or risk of pulmonary fibrosis, but also the benefits of using the subcutaneous route, the addition of low dose folic acid, the association with hydroxychloroquine or a short stop with flu vaccination, practical elements to demystify a safe and useful treatment.

Le méthotrexate est l'un des traitements incontournables du rhumatologue, suscitant toutefois de nombreuses inquiétudes chez le non-spécialiste. Cet article révise quelques notions utiles à connaître, comme l'absence de risque infectieux majeur ou de fibrose pulmonaire, les avantages associés à l'utilisation de la voie sous-cutanée, l'ajout de faible dose d'acide folique, l'association à l'hydroxychloroquine ou un court arrêt lors de la vaccination antigrippe, des éléments pratiques pour démystifier un traitement sûr et utile.

[Aortic calcification and the risk of osteoporotic fractures]. / Calcification des grandes artères et risque de fracture ostéoporotique.

Osteoporosis and atherosclerosis seem to be epidemiologically correlated. Several medical conditions are risk factors for both osteoporosis and atheromatosis (i.e. age, diabetes, end stage renal disease, sedentarity, smoking), but a common pathogenic link may be present beyond this. The burden of cardiovascular events and of osteoporotic fracture is considerable for the health care system in term of costs and resources. However, both diseases are rarely managed together. This article is a review of the recent studies in this new field.

Performance-based functional impairment and readmission and death: a prospective study.

OBJECTIVES: Readmission and death are frequent after a hospitalisation and difficult to predict. While many predictors have been identified, few studies have focused on functional status. We assessed whether performance-based functional impairment at discharge is associated with readmission and death after an acute medical hospitalisation. DESIGN, SETTING AND PARTICIPANTS: We prospectively included patients aged ≥50 years admitted to the Department of General Internal Medicine of a large community hospital. Functional status was assessed shortly before discharge using the Timed Up and Go test performed twice in a standard way by trained physiotherapists and was defined as a test duration ≥15 s. Sensitivity analyses using a cut-off at >10 and >20 s were performed. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary and secondary outcome measures were unplanned readmission and death, respectively, within 6 months after discharge. RESULTS: Within 6 months after discharge, 107/338 (31.7%) patients had an unplanned readmission and 31/338 (9.2%) died. Functional impairment was associated with higher risk of death (OR 2.44, 95% CI 1.15 to 5.18), but not with unplanned readmission (OR 1.34, 95% CI 0.84 to 2.15). No significant association was found between functional impairment and the total number of unplanned readmissions (adjusted OR 1.59, 95% CI 0.95 to 2.67). CONCLUSIONS: Functional impairment at discharge of an acute medical hospitalisation was associated with higher risk of death, but not of unplanned readmission within 6 months after discharge. Simple performance-based assessment may represent a better prognostic measure for mortality than for readmission.

Association of Stress Biomarkers With 30-Day Unplanned Readmission and Death.

BACKGROUND: The theory that posthospitalization stress might increase the risk of postdischarge complications has never been investigated. OBJECTIVE: To assess whether serum levels of stress biomarkers at discharge are associated with readmission and death after an acute-care hospitalization. DESIGN: We prospectively included 346 patients aged ≥50 years admitted to the department of general internal medicine at a large community hospital between April 8, 2013 and September 23, 2013. We measured the serum levels of several biomarkers at discharge: midregional pro-adrenomedullin, copeptin, cortisol, and prolactin. All patients were followed for up to 90 days after discharge (none was lost to follow-up). The main outcome was first unplanned readmission or death within 30 days after hospital discharge. We assessed the additional value of biomarkers to 2 validated readmission prediction scores: the LACE index (Length of stay, Admission Acuity, Charlson Comorbidity Index, and number of Emergency department visits within preceding 6 months) and the HOSPITAL score (Hemoglobin level at discharge, discharge from Oncology service, Sodium level at discharge, any Procedure performed during index hospitalization, Index admission Type, number of Admissions within preceding 12 months, and Length of stay). RESULTS: Forty patients (11.6%) had a 30-day unplanned readmission or death. High serum copeptin and cortisol levels were associated with an increase in the odds of unplanned readmission or death (odds ratios [95% confidence interval] 2.69 [1.29-5.64] and 3.43 [1.36, 8.65], respectively). We found no significant association with midregional pro-adrenomedullin or prolactin. Furthermore, these stress biomarkers increased the performance of two readmission prediction scores (LACE index and HOSPITAL score). CONCLUSION: High serum levels of copeptin and cortisol at discharge were independently associated with 30-day unplanned readmission or death, supporting a possible negative effect of hospitalization stress during the postdischarge period. Stress biomarkers improved the performance of prediction models and therefore could help better identify high-risk patients.

Prospective validation and adaptation of the HOSPITAL score to predict high risk of unplanned readmission of medical patients.

PRINCIPLES: The HOSPITAL score is a simple prediction model that accurately identifies patients at high risk of readmission and showed good performance in an international multicentre retrospective study. We aimed to demonstrate prospectively its accuracy to predict 30-day unplanned readmission and death. METHODS: We prospectively screened all consecutive patients aged ≥50 years admitted to the department of general internal medicine of a large community hospital in Switzerland. We excluded patients who refused to give consent, who died during hospitalisation, or who were transferred to another acute care, rehabilitation or palliative care facility. The primary outcome was the first unplanned readmission or death within 30 days after discharge. Some of the predictors of the original score (discharge from an oncology service and length of stay) were adapted according to the setting for practical reasons, before the start of patient inclusion. We also assessed a simplified version of the score, without the variable "any procedure performed during hospitalisation". The performance of the score was evaluated according to its overall accuracy (Brier score), its discriminatory power (C-statistic), and its calibration (Hosmer-Lemeshow goodness-of-fit test). RESULTS: Among the 346 included patients, 40 (11.6%) had a 30-day unplanned readmission or death. The HOSPITAL score showed very good accuracy (Brier score 0.10), good discriminatory power (C-statistic 0.70, 95% confidence interval [CI] 0.62-0.79), and an excellent calibration (p = 0.77). Patients were classified into three risk categories for the primary outcome: low (59%), intermediate (20.8%) and high risk (20.2%). The estimated risks of unplanned readmission/death for each category were 8.2%, 11.3% and 21.6%, respectively. The simplified score showed the same performance, with a Brier score of 0.10, a C-statistic of 0.70 (95% CI 0.61-0.79), and a goodness-of-fit statistic of 0.40. CONCLUSIONS: The HOSPITAL score prospectively identified patients at high risk of 30-day unplanned readmission or death with good performance in medical patients in Switzerland. Its simplicity and good performance make it an easy-to-use tool to target patients who might most benefit from intensive transitional care interventions.