Early Detection of Pulmonary Embolism in a General Patient Population Immediately Upon Hospital Admission Using Machine Learning to Identify New, Unidentified Risk Factors: Model Development Study.

BACKGROUND: Under- or late identification of pulmonary embolism (PE)-a thrombosis of 1 or more pulmonary arteries that seriously threatens patients' lives-is a major challenge confronting modern medicine. OBJECTIVE: We aimed to establish accurate and informative machine learning (ML) models to identify patients at high risk for PE as they are admitted to the hospital, before their initial clinical checkup, by using only the information in their medical records. METHODS: We collected demographics, comorbidities, and medications data for 2568 patients with PE and 52,598 control patients. We focused on data available prior to emergency department admission, as these are the most universally accessible data. We trained an ML random forest algorithm to detect PE at the earliest possible time during a patient's hospitalization-at the time of his or her admission. We developed and applied 2 ML-based methods specifically to address the data imbalance between PE and non-PE patients, which causes misdiagnosis of PE. RESULTS: The resulting models predicted PE based on age, sex, BMI, past clinical PE events, chronic lung disease, past thrombotic events, and usage of anticoagulants, obtaining an 80% geometric mean value for the PE and non-PE classification accuracies. Although on hospital admission only 4% (1942/46,639) of the patients had a diagnosis of PE, we identified 2 clustering schemes comprising subgroups with more than 61% (705/1120 in clustering scheme 1; 427/701 and 340/549 in clustering scheme 2) positive patients for PE. One subgroup in the first clustering scheme included 36% (705/1942) of all patients with PE who were characterized by a definite past PE diagnosis, a 6-fold higher prevalence of deep vein thrombosis, and a 3-fold higher prevalence of pneumonia, compared with patients of the other subgroups in this scheme. In the second clustering scheme, 2 subgroups (1 of only men and 1 of only women) included patients who all had a past PE diagnosis and a relatively high prevalence of pneumonia, and a third subgroup included only those patients with a past diagnosis of pneumonia. CONCLUSIONS: This study established an ML tool for early diagnosis of PE almost immediately upon hospital admission. Despite the highly imbalanced scenario undermining accurate PE prediction and using information available only from the patient's medical history, our models were both accurate and informative, enabling the identification of patients already at high risk for PE upon hospital admission, even before the initial clinical checkup was performed. The fact that we did not restrict our patients to those at high risk for PE according to previously published scales (eg, Wells or revised Genova scores) enabled us to accurately assess the application of ML on raw medical data and identify new, previously unidentified risk factors for PE, such as previous pulmonary disease, in general populations.

Hospitalized patients with positive antiphospholipid antibodies who have low complement levels are at increased risk for death-a retrospective cohort study.

PURPOSE: To investigate whether low complement levels can predict worse outcomes in patients hospitalized with positive anti-phospholipid antibodies. METHODS: This was a retrospective cohort study. We obtained demographics, laboratory, and prognostic data of all consecutive patients hospitalized between 2007 and 2021, for whatever reason, with at least one positively abnormal anti-phospholipid antibody, who were also tested for complement levels (C3 or C4). We then compared the rates of long-term mortality, 1-year mortality, deep vein thrombosis, and pulmonary emboli between groups of low complement and normal complement levels. Multivariate analysis was used to control for levels of clinical and laboratory confounders. RESULTS: We identified 32,286 patients tested for anti-phospholipid antibodies. Of those patients, 6800 tested positive for at least one anti-phospholipid antibody and had a documented complement level. Significant higher mortality rates were found in the low complement group, with an odds ratio for mortality (OR 1.93 CI 1.63-2.27 p < .001). Deep vein thrombosis and pulmonary emboli rates were similar. Multivariate analysis confirmed that low complement was an independent predictor for mortality after controlling for age, sex, dyslipidemia, chronic heart failure (CHF), chronic kidney disease (CKD), and anemia. CONCLUSIONS: Our study results indicate that low complement is associated with significantly higher mortality rates in admitted patients with elevated levels of anti-phospholipid antibodies. This finding correlates with recent literature suggesting a vital role for complement activation in anti-phospholipid syndrome.

Association between Thrombin Generation and Clinical Characteristics in COVID-19 Patients.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) disease is associated with coagulopathy and an increased risk of thrombosis. An association between thrombin generation (TG) capacity, disease severity, and outcomes has not been well described. METHODS: We assessed the correlation of TG with sequential organ failure assessment (SOFA) and sepsis-induced coagulopathy (SIC) scores and clinical outcomes by analysis of plasma samples obtained from hospitalized COVID-19 patients. RESULTS: 32 patients (68.8% male), whose median age was 69 years, were assessed, of whom only 3 patients did not receive anticoagulant therapy. D-dimers were uniformly increased. During hospitalization, 2 patients suffered thrombosis, 3 experienced bleeding, and 12 died. TG parameters from anticoagulated COVID-19 patients did not significantly differ from the values obtained from non-anticoagulated healthy controls. Patients who received higher than prophylactic doses of anticoagulant therapy had increased lag time (p = 0.003), lower endogenous thrombin potential (ETP) (p = 0.037), and a reduced peak height (p = 0.006). ETP correlated with the SIC score (p = 0.038). None of the TG parameters correlated with the SOFA score or were associated with mortality. CONCLUSION: TG was not associated with disease severity among patients hospitalized with COVID-19. However, a correlation between ETP and the SIC score was noted and deserves attention.

Six-Lead Electrocardiography Enables Identification of Rhythm and Conduction Anomalies of Patients in the Telemedicine-Based, Hospital-at-Home Setting: A Prospective Validation Study.

BACKGROUND: The hospital-at-home (HAH) model is a viable alternative for conventional in-hospital stays worldwide. Serum electrolyte abnormalities are common in acute patients, especially in those with many comorbidities. Pathologic changes in cardiac electrophysiology pose a potential risk during HAH stays. Periodical electrocardiogram (ECG) tracing is therefore advised, but few studies have evaluated the accuracy and efficiency of compact, self-activated ECG devices in HAH settings. This study aimed to evaluate the reliability of such a device in comparison with a standard 12-lead ECG. METHODS: We prospectively recruited consecutive patients admitted to the Sheba Beyond Virtual Hospital, in the HAH department, during a 3-month duration. Each patient underwent a 12-lead ECG recording using the legacy device and a consecutive recording by a compact six-lead device. Baseline patient characteristics during hospitalization were collected. The level of agreement between devices was measured by Cohen's kappa coefficient for inter-rater reliability (Ϗ). RESULTS: Fifty patients were included in the study (median age 80 years, IQR 14). In total, 26 (52%) had electrolyte disturbances. Abnormal D-dimer values were observed in 33 (66%) patients, and 12 (24%) patients had elevated troponin values. We found a level of 94.5% raw agreement between devices with regards to nine of the options included in the automatic read-out of the legacy device. The calculated Ϗ was 0.72, classified as a substantial consensus. The rate of raw consensus regarding the ECG intervals' measurement (PR, RR, and QT) was 78.5%, and the calculated Ϗ was 0.42, corresponding to a moderate level of agreement. CONCLUSION: This is the first report to our knowledge regarding the feasibility of using a compact, six-lead ECG device in the setting of an HAH to be safe and bearing satisfying agreement level with a legacy, 12-lead ECG device, enabling quick, accessible arrythmia detection in this setting. Our findings bear a promise to the future development of telemedicine-based hospital-at-home methodology.

High Attendance Rate of Family Members During Physician Rounds Is Predictive of Worse Clinical Outcomes: A Historic Cohort Study.

BACKGROUND: The prognosis of long-term clinical outcomes for each patient is of utmost importance. OBJECTIVES: To evaluate the association between rates of family attendance during rounds and long-term outcomes. METHODS: We conducted a historic cohort study. RESULTS: We followed 200 consecutive patients for a median of 19 months. Within the group of patients that had family members present in > 75% of rounds, the 30-day re-hospitalization rate was tenfold higher (P = 0.017). The overall prognosis (including median survival length) of patients who had the highest rates of family attendance (> 75%) was significantly worse compared to patients who had lower rates (P = 0.028). High rates of family attendance were found to correlate with other established risk factors for long-term mortality, including advanced age (r = 0.231, P = 0.001) and in-hospital delirium. CONCLUSIONS: High family attendance during physician rounds in an internal medicine department is associated with worse patient prognosis.

Remote Auscultation of Heart and Lungs as an Acceptable Alternative to Legacy Measures in Quarantined COVID-19 Patients-Prospective Evaluation of 250 Examinations.

The COVID-19 pandemic accelerated the assimilation of telemedicine platforms into medical practice. Nevertheless, research-based evidence in this field is still accumulating. This was a prospective, cross-sectional comparative assessment of a remote physical examination device used mainly for heart and lung digital auscultation. We analyzed usage patterns, user (physician) subjective appreciation and compared it to legacy measures. Eighteen physicians (median age 36 years (IQR 32-45): two interns, seven residents and nine senior physicians; eleven internists, five geriatricians and two pediatricians) executed over 250 remote physical examinations. Their median work duration with quarantined patients was 60 days (IQR 45-60). The median number of patients examined by a single physician was 17 (IQR 10-34). Regarding overall estimation, all participants tended to prefer the remote examination in the setting of quarantined patients (median 6, IQR 3.75-8), while no statistically significant difference was demonstrated compared to the indifference value (p = 0.122). Internists preferred tele-medical examination over non-internists, with significant differences between groups regarding heart auscultation, (median 7, (IQR 3-7) vs. median 2, (IQR 1-5, respectively)), p = 0.044. In the setting of quarantined patients, from the physicians' perspective, a digital platform for remote auscultation of heart and lungs was considered as an acceptable alternative to legacy measures.

[A RARE COMBINATION OF DELAYED TYPE HYPERSENSITIVITY REACTIONS TO BETA-LACTAMS IN A PATIENT WITH MSSA BACTEREMIA].

INTRODUCTION: A male patient aged 81, with a history of atrial fibrillation, pacemaker implantation and hip replacement was admitted due to pneumonia. Subsequent Methicillin Sensitive Staphylococcus Aureus (MSSA) bacteremia and septic arthritis of his prosthetic joint was diagnosed, and treated with Oxacillin. Two weeks later, an exanthematous rash appeared, involving most of his body surface, evolving to blisters that dried up and led to extensive exfoliation of the skin, consistent with a delayed type hypersensitivity drug reaction. Other possible etiologies for this rash were ruled out. Antibiotic treatment was changed to Cefalexin, assuming that there is no cross reactivity between penicillins and cephalosporins, regarding late drug reactions. Thereafter, the rash subsided, but his renal function deteriorated and interstitial nephritis due to a hypersensitivity reaction to cephalosporin was diagnosed. Hypersensitivity to penicillins and other beta-lactam antibiotics is reported by 10% of the population, only 1/10 of them are verified using standardized allergic testing (1-3). Delayed type hypersensitivity to beta-lactams is more common than immediate type allergy. It evolves days and weeks following exposure to the offending drug. Late responses are classified as type II- IV hypersensitivities, type IV being the most prevalent (4-7). We present a patient who developed two distinct delayed type phenomena to two different beta lactam antibiotics during the same hospitalization. The possibility of a hypersensitivity reaction should rise in the differential diagnosis of the deteriorating patient most notably as such might be life threatening on the one hand, and reversible, after drug withdrawal, on the other hand.

Establishing a COVID-19 treatment centre in Israel at the initial stage of the outbreak: challenges, responses and lessons learned.

Anticipating the need for a COVID-19 treatment centre in Israel, a designated facility was established at Sheba Medical Center-a quaternary referral centre. The goals were diagnosis and treatment of patients with COVID-19 while protecting patients and staff from infection and ensuring operational continuity and treatment of patients with non-COVID. Options considered included adaptation of existing wards, building a tented facility and converting a non-medical structure. The option chosen was a non-medical structure converted to a hospitalisation facility suited for COVID-19 with appropriate logistic and organisational adaptations. Operational principles included patient isolation, unidirectional workflow from clean to contaminated zones and minimising direct contact between patients and caregivers using personal protection equipment (PPE) and a multimodal telemedicine system. The ED was modified to enable triage and treatment of patients with COVID-19 while maintaining a COVID-19-free environment in the main campus. This system enabled treatment of patients with COVID-19 while maintaining staff safety and conserving the operational continuity and the ability to continue delivery of treatment to patients with non-COVID-19.

[ASSIMILATING PROMS DURING AND POST-HOSPITALIZATION OF COPD PATIENTS DUE TO DISEASE EXACERBATION MAY IMPROVE THEIR CLINICAL FOLLOW-UP - A CLINICAL, PROSPECTIVE, OBSERVATIONAL STUDY].

BACKGROUND: Chronic obstructive pulmonary disease (COPD) exacerbations necessitating hospitalization are known to have a negative impact on post-discharge clinical outcomes. In the present study, we evaluated the potential benefits in applying Patient-Reported-Outcome-Measures (PROMS) in order to better these patients' post-hospitalization prognostication. METHODS: This was a prospective, observational study. RESULTS: Ninety-nine COPD patients were recruited (aged 9.7±73 years, 61.6% males). All patients filled two separate PROMS (EXACT & PROMIS GLOBAL 10) while 69 of them also filled a second battery of PROMS within 3 months post discharge. The median follow-up time was 14.3 months. The patients' characteristics found to have a statistically significant association with increased risk for 90-days re-hospitalization were: permanent use of oxygen at home [55.2% vs. 32.8%, p=0.045]; significant change in the dyspnea score of the EXACT [54(40-71) vs. 38(11-60), OR=1.115; 95CI 1.006-1.236, p=0.038] and significant change in the cough and sputum, score section of the EXACT [0 (-19-25) vs. -14 (-31-0), OR=1.095; 95CI 1.011-1.187, p=0.027]. Patients' characteristics found to have a statistically significant association with increased risk for 90-days mortality were: age [83±8.43 vs. 72.46±9.53, p=0.047], diagnosis of pneumonia during index hospitalization [60% vs. 14.9%, P=0.034] and low ALT blood activity [10IU (5.5-13.8) vs. 17IU (13-22.8), p=0.016]. Significant change in the EXACT score was associated with increased risk of long-term mortality [-3 (-8.8-9.5) vs. -9 (-21.5-0), OR=1.047; CI95% 1.005-1.091, p=0.03]. CONCLUSIONS: Assimilating PROMS, during and post-hospitalization due to COPD exacerbation could improve our prediction for negative clinical outcomes, both short- and long-term. This may offer better therapeutic interventions in the future. We recommend usage of the EXACT as part of the post-discharge follow-up of COPD patients.

Beneficial effect of awake prone position in hypoxaemic patients with COVID-19: case reports and literature review.

We hereby present two case reports of moderate coronavirus disease patients, suffering from profound hypoxaemia, further deteriorating later on. A schedule pre-planned awake prone position manoeuvres were executed during their hospital stay. Following this, the patients' saturation improved, later to be weaned from oxygen support. Paucity of evidence and data regarding this topic led us to review the concept of awake prone position.

Ferritin as a Marker of Severity in COVID-19 Patients: A Fatal Correlation.

BACKGROUND: Ferritin, the cellular protein storage for iron, has emerged as a key molecule in the immune system, orchestrating the cellular defense against inflammation. At the end of 2019, the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) rapidly spread throughout China and other countries around the world, resulting in a viral pandemic. OBJECTIVES: To evaluate the correlation between ferritin and disease severity in coronavirus disease-2019 (COVID-19). METHODS: In this cross-sectional study, we obtained clinical and laboratory data regarding 39 hospitalized patients with confirmed COVID-19 from two hospitals in Israel. RESULTS: A significant increase in ferritin levels was demonstrated in patients with moderate and severe disease, compared to patients with mild disease (P = 0.006 and 0.005, respectively). Severe patients had significantly higher levels of ferritin (2817.6 ng/ml) than non-severe patients (708.6 ng/ml) P = 0.02. CONCLUSIONS: In this preliminary cross-sectional study, elevated ferritin levels were shown to correlate with disease severity in 39 patients from Israel with confirmed COVID-19 infection. Our results further strengthen the hypothesis that severe COVID-19 disease might be due to an underlying dysregulated hyperimmune response. In order to identify these patients early and prioritized resources, we believe that all patients with COVID-19 should be screened for hyperferritinemia.

Clinical Characterization of 162 COVID-19 patients in Israel: Preliminary Report from a Large Tertiary Center.

BACKGROUND: In February 2020, the World Health Organisation designated the name COVID-19 for a clinical condition caused by a virus identified as a cause for a cluster of pneumonia cases in Wuhan, China. The virus subsequently spread worldwide, causing havoc to medical systems and paralyzing global economies. The first COVID-19 patient in Israel was diagnosed on 27 February 2020. OBJECTIVES: To present our findings and experiences as the first and largest center for COVID-19 patients in Israel. METHODS: The current analysis included all COVID-19 patients treated in Sheba Medical Center from February 2020 to April 2020. Clinical, laboratory, and epidemiological data gathered during their hospitalization are presented. RESULTS: Our 162 patient cohort included mostly adult (mean age of 52 ± 20 years) males (65%). Patients classified as severe COVID-19 were significantly older and had higher prevalence of arterial hypertension and diabetes. They also had significantly higher white blood cell counts, absolute neutrophil counts, and lactate dehydrogenase. Low folic acid blood levels were more common amongst severe patients (18.2 vs. 12.9 vs. 9.8, P = 0.014). The rate of immune compromised patients (12%) in our cohort was also higher than in the general population. The rate of deterioration from moderate to severe disease was high: 9% necessitated non-invasive oxygenation and 15% were intubated and mechanically ventilated. The mortality rate was 3.1. CONCLUSIONS: COVID-19 patients present a challenge for healthcare professionals and the whole medical system. We hope our findings will assist other providers and institutions in their care for these patients.

Personalized diabetes management recommendations at hospital discharge based on a computerized, pre-hospitalization clinical profile analysis: A prospective, electronic health records-based study.

BACKGROUND: While glycemic control of hospitalized diabetic patients is straightforward, personalization of management at discharge is challenging. Treatment guidelines base recommendations on the clinical profile of patients. We checked the feasibility of implementing discharge recommendations, based on the clinical profile in the patients' electronic health records (EHR). METHODS: A decision-making algorithm was devised according to current guidelines. It was incorporated into the EHR. A prospective follow-up of eligible diabetes patients was done. RESULTS: During 15 months, 835 patients (HbA1c was 6.9% [6.2%-7.8%]) met our inclusion criteria. The rate of HbA1c acquisition increased from 55% during Q1 to 85%, 86%, 88%, and 87% thereafter. Also, the rate of incorporating personalized management recommendations to discharge letters increased: from 14.9% during Q1 to 42.9%, 43.0%, 47.2%, and 53.4% thereafter. Fifty-eight (17.3%) of patients who got personalized recommendations upon discharge were found to have HbA1c values that were over 1% deviating from suggested target HbA1c. They got the most stringent recommendations. Twenty-nine (50%) of them had available follow-up HbA1c values showing a significant drop in HbA1c: from 9.1% (8.4%-10.2%) to 8.5% (7.4%-9.5%), P = .03. CONCLUSIONS: Personalized, EHR algorithm-based, management recommendations for diabetes upon discharge from hospitalization are feasible and beneficial.

Characteristics of Pericardial Biopsy: 100 Cases in a Single Center.

BACKGROUND: Pericardial biopsies are rarely performed during the diagnosis and management of pericardial diseases. The circumstances and clinical profile of patients undergoing pericardial biopsies are largely uncharacterized. OBJECTIVES: To examine the circumstances in which pericardial biopsies are obtained and to evaluate their diagnostic yield. METHODS: We studied a total of 100 cases (71% males, mean age 60.8 years, range 8.1-84.5 years) of surgically resected pericardium specimens obtained from 2000 to 2015 at Sheba Medical Center, the largest medical center in Israel. Patients were classified into groups according to four major histological etiologies: idiopathic pericarditis, constrictive pericarditis, malignant pericarditis, and post-cardiac injury syndrome (PCIS). The clinical history and course, laboratory, echocardiography, and histological results were reviewed retrospectively. RESULTS: Causes of pericarditis according to histological definitions included idiopathic pericarditis (29%), constrictive pericarditis (29%), PCIS (9%), and malignant pericarditis (26%). Overall sensitivity of the pericardial biopsy in patients with malignancy was 57.7%. During the study period, we found a trend toward an increased number of biopsies due to constrictive pericarditis and PCIS, along with a decrease in the number of biopsies performed in patients with malignant or idiopathic pericarditis. The diagnosis following biopsy did not change for any of the patients. CONCLUSIONS: Our findings suggest a low diagnostic yield from pericardial biopsies, especially in malignant pericarditis. This conclusion, along with novel therapies, resulted in the infrequent use of pericardial biopsy in recent years.

[ASSIMILATING POINT-OF-CARE-ULTRASOUND AS PART OF COMPETENCY AND ASSESSMENT- BASED MEDICAL EDUCATION IN INTERNAL MEDICINE: THE WAY FOR A BETTER RESIDENCY].

INTRODUCTION: The Israeli Society of Internal Medicine (ISIM) has joined a journey led by the Scientific Council of the Israeli Medical Association (IMA) to improve the residency of physicians in Israel. The process of transformation from time and place-based residency to an outcome-oriented, competencies and assessment-based residency is a multi-step, complex process. We describe the theoretical basis of the need for transformation, examples of specific competencies (basic, relating to all residencies and unique, specific for internal medicine) and their means of assessment. Furthermore, we present several examples of similar processes being conducted worldwide. We describe the process so far and the future anticipated challenges. We foresee the residency transformation resulting in elevated professional excellence amongst internists in Israel. Also, we anticipate that residents' satisfaction will rise and eventually, patients will receive better diagnostic and treatment outcomes in our wards.

Structured, Protocol-Based Pulse-Oximetry Measurement Improves the Evaluation of Hypoxemic Patients at Hospital Admission.

BACKGROUND: Accurate pulse oximetry reading at hospital admission is of utmost importance, mainly for patients presenting with hypoxemia. Nevertheless, there is no accepted or evidence-based protocol for such structured measuring. OBJECTIVES: To devise and assess a structured protocol intended to increase the accuracy of pulse oximetry measurement at hospital admission. METHODS: The authors performed a prospective comparison of protocol-based pulse-oximetry measurement with non-protocol based readings in consecutive patients at hospital admission. They also calculated the relative percentage of improvement for each patient (before and after protocol implementation) as a fraction of the change in peripheral capillary oxygen saturation (SpO2) from 100%. RESULTS: A total of 460 patients were recruited during a 6 month period. Implementation of a structured measurement protocol significantly changed saturation values. The SpO2 values of 24.7% of all study participants increased after protocol implementation (ranging from 1% to 21% increase in SpO2 values). Among hypoxemic patients (initial SpO2 < 90%), protocol implementation had a greater impact on final SpO2 measurements, increasing their median SpO2 readings by 4% (3-8% interquartile range; P < 0.05). Among this study population, 50% of the cohort improved by 17% of their overall potential and 25% improved by 50% of their overall improvement potential. As for patients presenting with hypoxemia, the median improvement was 31% of their overall SpO2 potential. CONCLUSIONS: Structured, protocol based pulse-oximetry may improve measurement accuracy and reliability. The authors suggest that implementation of such protocols may improve the management of hypoxemic patients.

Low ALT blood levels are associated with lower baseline fitness amongst participants of a cardiac rehabilitation program.

BACKGROUND/OBJECTIVE: Objective assessment tools for patients' frailty are lacking. Such tools would have been highly valuable for assessment of candidates for cardiac rehabilitation programs. Low ALT (Alanine aminotransferase) values were recently shown to be a promising parameter for objective, quantitative frailly assessment. METHODS: This was a retrospective study of patients participating in a cardiac rehabilitation program. RESULTS: Patients with lower ALT activity levels at the initiation of rehabilitation program had lower estimated METs values (6.86 vs. 7.73; p < 0.001), shorter stress test duration (06:41 vs. 07:44 min; p < 0.001), higher resting heart rate (72 ± 13 vs. 70 ± 13 BPM; p = 0.01) and lower heart rate reserve (49 ± 24 vs. 54 ± 24; p < 0.001). Multivariate linear modeling demonstrated that ALT values were Independent determinants of baseline exercise capacity (expressed in METs). CONCLUSION: Lower ALT values, measured prior to the initiation of cardiac rehabilitation programs may indicate frailty of patients and be indicative for poor rehabilitation outcomes. Further, prospective studies should assess the potential correlation between ALT values and rehabilitation efficiency. We aimed to assess the potential correlation between the baseline ALT values and the baseline exercise capacity, as expressed in METs (Metabolic equivalent of tasks). 3806 patients were included in our study.

Coexistent malignant conditions in rheumatoid arthritis - A population-based cross-sectional study.

OBJECTIVES: The aim of this study was to evaluate if association exist between rheumatoid arthritis and malignant diseases. METHODS: A cross-sectional study was conducted comparing rheumatoid arthritis patients with age and gender matched controls regarding the proportion of patients with comorbid malignant conditions. Chi-square tests and t-tests were used for univariate analysis. A logistic regression model was used for multivariate analysis. The study was performed utilising the medical database of Clalit Health Services. RESULTS: The study group included 11 782 rheumatoid arthritis patients and 57 973 controls. The total proportion of malignancies was significantly higher in the study group than in the control group (21.4% vs 11.2%; P<.001). The disease for which there was the strongest association among patients with rheumatoid arthritis was non-Hodgkin's lymphoma (1.1% vs 0.6%; P<.01). After multivariate analysis, lung cancer was not found to be significantly associated with rheumatoid arthritis. CONCLUSION: Rheumatoid arthritis is associated with several malignant disorders, in particular non-Hodgkin's lymphoma. Appropriate measures for non-Hodgkin's lymphoma screening in this patient population should be considered.

Risk of falling among hospitalized patients with high modified Morse scores could be further Stratified.

BACKGROUND: Falls during hospitalization harbor both clinical and financial outcomes. The modified Morse fall scale [MMFS] is widely used for an in-hospital risk-of-fall assessment. Nevertheless, the majority of patients at risk of falling, i.e. with high MMFS, do not fall. The aim of this study was to ascertain our study hypothesis that certain patients' characteristics (e.g. serum electrolytes, usage of a walking device etc.) could further stratify the risk of falls among hospitalized patients with MMFS. METHODS: This was a retrospective cohort analysis of adult patients hospitalized in Internal Medicine departments. RESULTS: The final cohort included 428 patients aged 76.8±14.0 years. All patients had high (9 or more) MMFS upon admission, and their mean MMFS was 16.2±6.1. A group of 139 (32.5%) patients who fell during their hospitalization was compared with a control group of 289 (67.5%) patients who did not fall. The fallers had higher MMFS, a higher prevalence of mild dependence, and a greater use of a cane or no walking device. Regression analysis showed the following patients' characteristics to be independently associated with an increased risk of falling: mild dependence (OR=3.99, 95% CI 1.97-8.08; p<0.0001), treatment by anti-epileptics (OR=3.9, 95% CI 1.36-11.18; p=0.011), treatment by hypoglycemic agents (OR=2.64, 95% CI 1.08-6.45; p= 0.033), and hypothyroidism (OR=3.66, 05%CI 1.62-8.30; p=0.002). In contrast to their role in the MMFS, the use of a walker or a wheelchair was found to decrease the risk of falling (OR=0.3, 95% CI 0.13-0.69; p=0.005 and OR=0.25, 95% CI 0.11-0.59; p= 0.002). CONCLUSIONS: Further risk stratification of hospitalized patients, already known to have a high MMFS, which would take into account the characteristics pointed out in this study, should be attained.

The Association Between Giant Cell Arteritis and Ischemic Heart Disease: A Population Based Cross-Sectional Study.

BACKGROUND: Patients with giant cell arteritis (GCA) suffer from inflammatory diseases often treated by large amounts of corticosteroids. Whether this inflammatory burden also carries an increased risk for cardiovascular morbidity, and especially ischemic heart disease, is not clearly established. OBJECTIVES: To clarify the linkage between GCA and ischemic heart disease. METHODS: In a cross-sectional study, we assessed the association between GCA and ischemic heart disease, adjusting for cardiovascular risk factors, among GCA patients and matched controls using the database of the largest healthcare provider in Israel. RESULTS: The study group was comprised of 5659 GCA patients and 28,261 age and gender matched controls. The proportion of ischemic heart disease was higher in the GCA group (27.5% vs. 12.5% among controls, odds ratio 2.65). Diabetes mellitus, hypertension, hyperlipidemia and smoking were also found to have higher concurrency in GCA. After stratifying for those cardiovascular co-morbidities using logistic regression, GCA remained independently associated with ischemic heart disease with an odds ratio of 1.247 (1.146-1.357 P < 0.001). CONCLUSIONS: GCA is associated with both cardiovascular risk factors and ischemic heart disease. Healthcare professionals should not overlook this aspect of the disease when managing GCA patients.