A simple index predicting mortality in acutely hospitalized patients.

BACKGROUND: Mortality rates used to evaluate and improve the quality of hospital care are adjusted for comorbidity and disease severity. Comorbidity, measured by International Classification of Diseases codes, do not reflect the severity of the medical condition, that requires clinical assessments not available in electronic databases, and/or laboratory data with clinically relevant ranges to permit extrapolation from one setting to the next. AIM: To propose a simple index predicting mortality in acutely hospitalized patients. DESIGN: Retrospective cohort study with internal and external validation. METHODS: The study populations were all acutely admitted patients in 2015-16, and in January 2019-November 2019 to internal medicine, cardiology and intensive care departments at the Laniado Hospital in Israel, and in 2002-19, at St. James Hospital, Ireland. Predictor variables were age and admission laboratory tests. The outcome variable was in-hospital mortality. Using logistic regression of the data in the 2015-16 Israeli cohort, we derived an index that included age groups and significant laboratory data. RESULTS: In the Israeli 2015-16 cohort, the index predicted mortality rates from 0.2% to 32.0% with a c-statistic (area under the receiver operator characteristic curve) of 0.86. In the Israeli 2019 validation cohort, the index predicted mortality rates from 0.3% to 38.9% with a c-statistic of 0.87. An abbreviated index performed similarly in the Irish 2002-19 cohort. CONCLUSIONS: Hospital mortality can be predicted by age and selected admission laboratory data without acquiring information from the patient's medical records. This permits an inexpensive comparison of performance of hospital departments.

Variability in duration of follow up may bias the conclusions of cohort studies of patients with patent foramen ovale.

Closure of patent foramen ovale (PFO) is expected to prevent paradoxical emboli. In the absence of randomized trials, its efficacy has been assessed by comparing uncontrolled cohort studies of medically treated patients with those treated by PFO closure. The objective of this study was to highlight a confounder of such studies, namely, the variability in the duration of follow-up. We searched the literature for cohort studies of patients with ischaemic strokes, including those with PFO. During the first year of follow-up, recurrence hazards in patients younger than 55 years were 1-4% in those with any ischaemic stroke, 1-6% in medically treated patients with PFO and 0-5% in those after PFO closure. In most studies, the recurrence hazards were highest immediately after the index stroke and declined thereafter. Still, hazards were commonly reported in terms of annual averages over a wide range of follow-up periods for the various cohort studies, thereby ignoring the possibility that the duration of the follow-up may in and of itself affect the derived average recurrence hazards. A disregard of the time variance of stroke recurrence may confound the conclusions from comparisons between uncontrolled studies of patients with stroke and PFO.

The time horizons of formal decision analyses.

Clinical decision analyses use time horizons that vary from hours to the patient's entire life. Analyses of decisions with a lifetime horizon commonly use Markov models, which simulate the patient's lifespan by dividing it into equal periods (cycles). At each cycle, the model exposes a hypothetical cohort to the competing hazards of normal aging and of the disease in question (disease-specific hazards), and the results are presented as years of life expectancy. This paper highlights two limitations of lifetime Markov models that have been ignored in recent publications. First, since there are no readily available data on changes in disease-specific hazards over time, these hazards are often derived from short-term follow-up studies, and assumed to be constant over the patient's entire life. Second, results may be better presented in terms of health states (i.e. proportions of patients expected to recover completely, recover with a disability or die) rather than life expectancy. Although well-known, these two limitations require re-emphasis. They may be avoided by restricting the time horizon of decision analyses and presenting results as health states as well as life expectancies. When a lifetime horizon is necessary, the performance of Markov models may be improved by the using of time-variant disease-specific hazards derived from long-term follow-up studies, or from theoretical models that simulate more closely the disease progression over time, rather than assuming constant disease-specific hazards.

Risk of gastric cancer after gastric surgery for benign disorders.

The objective of this review was to evaluate published evidence for the association between gastric resection for benign disorders and subsequent cancer of the gastric remnant. We searched the literature through Medline (1970 to 1988) and through the references of relevant articles. Fifty-eight studies consisting of case series, uncontrolled surveys, and case control or cohort analyses were identified and critically assessed using defined methodological criteria. There were no consistent differences between the expected and observed number of cancers occurring within 15 years after gastric resection. However, all case control studies and seven of the eight cohort analyses, in which the prevalence of cancer was stratified by time since gastric resection, indicated a twofold to fourfold increase in the risk of gastric cancer in patients who survived 15 or more years after gastric surgery. We conclude that most studies of the association of gastric surgery with subsequent gastric cancer have relatively weak designs. Still, the repetitive demonstration of this association by different investigators using different research designs supports the hypothesis that gastric resection increases the risk of cancer in the gastric remnant.

Blood pressure response to exercise as a predictor of hypertension.

Published studies of the blood pressure response to exercise were reviewed to assess the probability of future hypertension in a subject with a "hypertensive" response to exercise. The reviewed data indicate that the sensitivity of a hypertensive response to exercise for future hypertension varied between 16% and 60%, and the specificity between 53% and 95%. The prevalence of hypertension on follow-up among normotensive subjects with a hypertensive response to exercise testing was 2.06 to 3.39 times higher than that among subjects with a normotensive response. Therefore, blood pressure response to exercise does have a predictive value for future hypertension. However, this predictive value is limited, since 38.1% to 89.3% of those with a hypertensive response to exercise did not have hypertension on follow-up, and a normotensive response only marginally reduced the risk of future hypertension. The use of exercise testing as a predictor of hypertension is still in need of experimental development and confirmation.

Hospital readmissions as a measure of quality of health care: advantages and limitations.

We reviewed the recent literature on hospital readmissions and found that most of them are believed to be caused by patient frailty and progression of chronic disease. However, from 9% to 48% of all readmissions have been judged to be preventable because they were associated with indicators of substandard care during the index hospitalization, such as poor resolution of the main problem, unstable therapy at discharge, and inadequate postdischarge care. Furthermore, randomized prospective trials have shown that 12% to 75% of all readmissions can be prevented by patient education, predischarge assessment, and domiciliary aftercare. We conclude that most readmissions seem to be caused by unmodifiable causes, and that, pending an agreed-on method to adjust for confounders, global readmission rates are not a useful indicator of quality of care. However, high readmission rates of patients with defined conditions, such as diabetes and bronchial asthma, may identify quality-of-care problems. A focus on the specific needs of such patients may lead to the creation of more responsive health care systems for the chronically ill.

The importance of leukocyturia in young adults.

The records of 1,000 asymptomatic male air force personnel were examined retrospectively for the results of 15 yearly examinations (1968 through 1983) of urinary sediment, beginning with subjects aged 18 to 33 years. The cumulative incidence of four to six or more WBCs per high-power field on one or more examinations was 31.8% after an average of 12.2 examinations per person over the 15-year period. In 107 subjects the WBCs were found on two or more occasions within five consecutive examinations. In 106 subjects, 140 urine cultures were sterile. In 28 cases the urine was also sterile after culture for Mycobacterium tuberculosis. Intravenous pyelograms, obtained in eight cases, were normal. Renal biopsy in one case with recurrent hematuria and trace proteinuria showed focal glomerulonephritis. All subjects are currently active and free of urinary symptoms an average of 7.6 years after detection of leukocyturia.

Healthy volunteer effect in industrial workers.

Volunteers for epidemiological research, have lower mortality rates than non-volunteers, thereby producing a bias referred to as the "healthy volunteer effect" (HVE). Occupationally active persons have been similarly shown to have a reduced mortality relatively to the general population (the "healthy worker effect"). To determine whether a HVE exists in occupationally active persons, we followed for 8 years a cohort of Israeli male industrial employees, of whom 71.6% agreed to participate in 1985 in screening examinations for cardiovascular disease. We calculated standardized mortality ratios (SMRs) of the entire cohort relative to the general population, and compared the mortality among participants with that of the non-participants. Over 8 years follow up, SMRs were 78% for the entire cohort, 71% for participants and 99% for non-participants. Participants were older than non-participants and worked more commonly in smaller factories. A proportional hazard model indicated that after adjusting for these variables, the all cause mortality hazard ratio among participants and non-participants was 0.69 (95% CI = 0.51-0.94). During the first and last two years of the 8-year follow-up there were 39.6 and 30.0 age-adjusted deaths per 10,000 person-years among participants, and 58.6 and 51.5 respectively among non-participants. We conclude that the HVE occurs in occupationally active persons, and that it may persist for up to 8 years follow-up.

Significance of erythrocyte sedimentation rate in young adults.

The erythrocyte sedimentation rate (ESR) was examined annually for 15 years in 1,000 asymptomatic men aged 18-33 years at entry into the study in 1968. The upper limit of the normal (mean + 2 SD) increased from 8 mm in the first hour in persons aged 18 years to 18 mm in those age 45. An increase in the ESR above the age adjusted upper limit of normal on at least three of four consecutive annual examinations was observed in 44 (4.4%) cases. The elevated ESR was associated with a diagnosed disorder in 10 of these 44 cases: myocardial infarctions (four), ankylosing spondylitis (three), inflammatory bowel disease (one), psoriasis (one), and "benign" monoclonal gammopathy (one). A persistently elevated ESR increased the likelihood of disease in general from 3.8% to 22.7% and of myocardial infarction from 0.7% to 9.1%. In eight patients the elevation of the ESR preceded the clinical manifestations by 2-10 years. It is concluded that a persistent moderate elevation in ESR detected in a young adult in the course of screening examinations is a risk factor for the development of disease.

The effect of age on the prevalence of asymptomatic microscopic hematuria.

The medical files of a sample of men who had been followed by annual examinations from 1968 through 1978 were selected, using a random number sequence from the records of the Israel Air Force. One group of 430 men, ages 21-23 at entry, and a second group of 264 men, ages 25-28 at entry, were studied. The results of the urinalysis at entry and after ten years of follow-up were recorded. The point prevalence of all degrees of microhematuria increased significantly with age in both groups. One to three or more red blood cells (RBCs) per high-power field (HPF) were found in 3.5% of the subjects ages 21-23 at entry and in 14.2% in the same subjects ten years later (P = 0.001). Similarly, one to three or more RBCs per HPF were found in 4.9% of men ages 25-28 at entry and in 11.7% of the same subjects ten years later (P = 0.001). The authors conclude that age needs to be taken into consideration in drawing the line between physiologic and pathologic microhematuria.

Symptomless microhaematuria in schoolchildren: causes for variable management strategies.

We reviewed published data on the frequency of underlying disorders in schoolchildren with microscopic or gross isolated haematuria (IH), and evaluated management strategies. We found five reports of microscopic IH in screened asymptomatic schoolchildren, three reports of microscopic IH detected by case-finding, and five surveys of kidney biopsies in referred children with microscopic and gross IH. We listed the reported underlying disorders, and estimated the benefit from their early detection and treatment. Most children with microscopic IH, whether detected by screening or case-finding, had no significant underlying disease. Some had disorders that may benefit from early treatment (membranoproliferative glomerulonephritis, obstructive uropathy, urolithiasis), or counselling (hereditary nephropathy, renal cystic disease). The combined prevalence of these five diseases was 0-7.2% in children with microscopic IH detected by screening, and 3.3%-13.6% in those with microscopic IH detected by case-finding. The combined prevalence of membranoproliferative glomerulonephritis and hereditary nephropathy among kidney biopsies was 11.6%-31.6% in children with microscopic IH, and 3.6%-42.1% in children with gross IH. Variable management strategies for schoolchildren with IH result from uncertainty about the frequency of underlying disorders and the efficacy of their early treatment. With no evidence that detecting IH leads to prevention of renal function impairment, screening for IH in symptomless schoolchildren is not warranted. Once detected, however, IH justifies further investigation.

Treatment of envenomation by Echis coloratus (mid-east saw scaled viper): a decision tree.

Envenomation by Echis coloratus causes a transient hemostatic failure. Systemic symptoms, hypotension and evident bleeding are rare, with only one reported fatality. In this paper, we examine the decision to treat victims of Echis coloratus by a specific horse antiserum. The decision model considers the mortality of treated and untreated envenomation, and the side effects of antiserum treatment: fatal anaphylaxis, serum sickness and increased risk of death after a possible repeated exposure to horse antiserum in the future. The results of the analysis are not sensitive to variations in the probability of side effects of antiserum treatment. They are sensitive to variations in the risk of bleeding after envenomation, in the degree of reduction of this risk by antiserum treatment and in the risk of dying after an event of bleeding. Prompt administration of antiserum appears to be the treatment of choice if it reduces the risk of bleeding from 23.6% to 20.3% and if 1.6% or more of the bleeding events are fatal. We conclude that presently available data support antiserum treatment of victims of Echis coloratus who present with hemostatic failure, even though the advantage imparted by this treatment appears to be small.

Risk indicators after envenomation in humans by Echis coloratus (mid-east saw scaled viper).

To determine the frequency, severity and predictors of bleeding and azotemia after envenomation in humans by Echis coloratus, a retrospective survey of 68 cases in Israel between 1970 and 1989 was carried out. We used univariate and multivariate analyses of clinical variables on admission for the outcome variables of bleeding, hemoglobin and platelet levels, and blood urea. Within hours or days after envenomation, a major bleeding episode occurred in 18% of the victims, a drop in hemoglobin to 10 g/dliter or less in 14%, and an increase in blood urea to 9 mmole/liter or more in 15%. These complications correlated with time interval between envenomation and hospital admission, and the following admission variables: degree of bleeding, hemoglobin level, platelet and white blood cell counts, blood urea and proteinuria. Complications were unlikely in patients who were presented with all of the following: a hemoglobin level of 13 g/dliter or more, a platelet count of 100,000/mm3 or more, a blood urea level of 7 mmole/liter or less, no proteinuria and no bleeding. Treatment on admission with a specific monovalent antiserum was associated with a shorter duration of hemostatic failure and a reduced incidence of anemia and thrombopenia. Infusion of fresh frozen plasma on admission did not appear to be effective in preventing complications.

Inaccuracies in estimates of life expectancies of patients with bronchial cancer in clinical decision making.

Approximations of life expectancy in clinical decision making frequently assume constant disease-specific ("excess") mortality hazards over age at diagnosis and over time from diagnosis. This assumption is inconsistent with the longer relative survival of younger patients with bladder cancer and with the declines in mortality hazards from bladder and breast cancers over time from diagnosis. To estimate the error that may result from these assumptions, the authors derived excess mortality hazards from the Surveillance, Epidemiology and End Result (SEER) tumor registry for bronchial cancers stratified by age at diagnosis and time from diagnosis. They compared the life expectancies calculated by a model using an average constant annual cancer-specific mortality hazard over time from diagnosis with those calculated using data-derived cancer-specific annual mortality hazards that varied as a function of time from diagnosis. For younger patients with less advanced disease, the constant-average-mortality model underestimated life expectancies by up to 50% relative to those predicted by the time-variant model. For those over 75 years old at diagnosis, and for all patients with advanced disease, the constant-average-mortality model overestimated life expectancies by up to 65% relative to those predicted by the time-variant model. The authors conclude that predictions of life expectancy with bronchial cancer, and probably with other neoplasms, are limited by the widespread use of oversimplified methods of calculation and by the lack of data describing mortality hazards as a function of time from diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Lead exposure in battery-factory workers is not associated with anemia.

Anemia is a manifestation of lead toxicity. However, there are conflicting reports of its prevalence among lead-exposed workers, and it is uncertain whether they should be monitored by periodic hemoglobin (Hb) examinations. To explore the relationship between Hb and lead exposure, we examined the correlation between Hb, blood lead (PbB), and zinc protoporphyrin (ZPP) levels in 961 blood samples obtained from 94 workers in a lead-acid battery plant in Israel between 1980 and 1993. Blood lead levels exceeded 60 micrograms/dL (2.90 mumol/L) in 105 (14%) of the blood samples. The correlation between PbB and logZPP was 0.594. Hb levels did not correlate with PbB or ZPP. We conclude that (a) periodic Hb determinations are not a useful indicator of lead exposure in Israeli industrial workers; (b) the discrepancies between the reported correlation between PbB and Hb levels remain unexplained and in need of further study; and (c) a finding of anemia in a person with PbB levels of up to 80 micrograms/dL should be considered to be due to lead toxicity only after other causes for anemia have been excluded.

Referral to occupational medicine clinics and resumption of employment after myocardial infarction.

Rehabilitation after acute myocardial infarction (AMI) consists of education, exercise, and an encouragement to return to work (RTW). This study attempts to (1) determine whether the time interval between AMI and the visit at occupational medicine (OM) clinics predicts resumption of full employment, and (2) estimate the incidence of work-related recurrent AMI after RTW. We followed 216 consecutive AMI patients at a single OM clinic. The independent variables were clinical and personal data, physical workload and time between AMI, and first visit to the OM clinic. The outcome variables were full employment 24 months after the acute event and recurrent AMI during this period. Of all patients, 168 attempted RTW. Of these, 18 stopped working subsequently. Of the remaining 150 patients, 54 returned to part-time work and 96 were employed full-time after 2 years. Logistic regression indicated that a failure to resume full employment was independently associated with diabetes, older age, Q wave AMI, angina before AMI, heavy work, and a late visit to the OM clinic. For each month's delay in referral to the OM clinic, there was a 30% decrease in the chance for full employment 24 months after AMI. Six (4%) of the 150 patients who resumed employment sustained a recurrent AMI, two of them while at work. A delayed referral to the OM clinic was associated with work disability after AMI. Late referrals to OM clinics should receive a more intensive and sustained rehabilitation than early referrals. Whether an earlier referral to OM clinics will result in increased RTW rates is unknown. Patients who attempted to resume employment had a 1.2% risk of a recurrent ischemic event at their workplace.

Teaching doctor-patient interviewing skills using an integrated learner and teacher-centered approach.

BACKGROUND AND OBJECTIVE: We describe an approach for the resolution of difficulties that some preclinical medical students appeared to have when acquiring patient interviewing skills. SETTING: Two medical schools in Israel. TYPE OF STUDY: Descriptive. OBSERVATIONS: Students' difficulties were related to the inconsistency between the patient-centered approach that was emphasized in the preclinical teaching programs and the disease-centered (biomedical) approach that was practiced on the wards. Others were confused by ambiguous vocabulary and by the multiplicity of rules that they had to remember. Still others appeared to resent attempts to teach them what they thought was elementary courtesy, to reject counterintuitive interviewing rules, and to be bored by the repetitive nature of the practice sessions. TEACHING INTERVENTION: We used an integrated learner- and teacher-centered approach, which is based on the premise that students learn more effectively when autonomous and self-motivated than when responding to instructions from others. Rather than the students being lectured, they were asked to identify the problems in doctor-patient communication and to propose solutions. We conducted live demonstrations of patient- and disease-centered interviews and encouraged students to discuss the advantages and disadvantages of each of them. Lastly, we supervised students as they interviewed patients with increasingly difficult communication problems. CONCLUSIONS: The described approach is consistent with current theories of adult learning. It permits the instructor's input and also supports students' autonomy in identifying and resolving problems in patient interviewing and in choosing the balance between patient- and disease-centered interviewing styles according to the patient's needs. The feasibility of our approach is conditional on the availability of instructors who feel comfortable conducting group discussions, are familiar with the literature on doctor-patient relations, and are experienced enough to demonstrate different interviewing techniques using live patients.

Myeloid metaplasia of the central nervous system in patients with myelofibrosis and agnogenic myeloid metaplasia. Report of 3 cases and review of the literature.

Foci of meningeal myeloid metaplasia were found in 3 of 11 consecutive autopsied patients with myelofibrosis and agnogenic myeloid metaplasia. The clinical and pathological findings in an additional seven published patients with agnogenic myeloid metaplasia who developed neurological manifestations due to pressue of hemopoietic tumors in the central nervous system are reviewed.

Monoclonal immunoglobulin disorders: a report of 154 cases.

One hundred and fifty-four patients with a monoclonal gammopathy, diagnosed between 1965-1974 in the Hadassah University Hospital are reviewed with special reference to the relative incidence of associated disorders. Most patients (63 per cent) had immunoproliferative disorders (multiple myeoloma, macroglobulinemia of Waldenstrom, chronic lymphocytic leukemia, and other non-Hodgkin lymphomata). A non-B-cell malignancy, either of blood-forming tissues or of epithelial origin, was found in 6.5 per cent. Miscellaneous nonmalignant diseases (chronic liver disease, diseases of known or suspected autoimmune origin, chronic infections, Gaucher's disease), which have been reported in the past in association with a monoclonal gammopathy, were diagnosed in 15 per cent of the patients in this series. Twelve per cent of the patients were either asymptomatic or had diseases not known to be associated with monoclonal gammopathies. Amyloidosis was diagnosed in 3.3 per cent of the patients.

Physicians' attitudes toward litigation and defensive practice: development of a scale.

The authors' threefold purpose in this article was to (a) propose a model of the relationship between the emotional aspects of physicians' attitudes to medical errors (e.g., fear of litigation) and their functional consequences (e.g., tendency to defensive practice); (b) develop a measure of some of these attitudes; and (c) provide empirical support for some of the relationships in the model. Medical students and physicians responded to a questionnaire concerning their attitudes toward uncertainty and medical error. The dependent variables were two dimensions of attitudes to uncertainty ("reluctance to disclose uncertainty" and "stress from uncertainty") and four dimensions of attitudes to medical error ("fear of litigation," "support for self-regulation," "tendency to defensive practice," and "self-disclosure of errors"). Stress from uncertainty correlated with fear of malpractice litigation and defensive practice. They concluded that interventions that aim to increase physicians' tolerance of uncertainty may also reduce their fear of malpractice litigation and their tendency to defensive practice.