A 2017 SURVEY OF THE CLINICAL PRACTICE PATTERNS IN THE MANAGEMENT OF RELAPSING GRAVES DISEASE.

OBJECTIVE: Previous surveys from different world regions have demonstrated variations in the clinical management of Graves disease (GD). We aimed to investigate the clinical approach to GD relapse among endocrinologists. METHODS: Electronic questionnaires were e-mailed to all members of the Israeli Endocrine Society. Questionnaires included demographic data and different scenarios regarding treatment and follow-up of patients with GD relapse. RESULTS: The response rate was 49.4% (98/198). For a young male with GD relapse, 68% would restart antithyroid drug (ATD) (98% methimazole), while 32% would refer to radioactive iodine (RAI) treatment. Endocrinologists who treat >10 thyroid patients a week tended to choose ATDs over RAI ( P = .04). In the case of GD relapse with ophthalmopathy, 50% would continue ATDs, whereas 22.4% would recommend RAI treatment and 27.6% surgery. Most endocrinologists (56%) would continue ATDs for 12 to 24 months. Seventy-five percent would monitor complete blood count and liver function (39% for the first month and 36% for 6 months), and 44% would recommend a routine neck ultrasound. In a case of thyrotoxicosis due to a 3-cm hot nodule, most endocrinologists (70%) would refer to RAI ablation, 46.4% without and 23.7% with a previous fine-needle aspiration. No significant differences were found regarding gender, year of board certification, or work environment. CONCLUSION: Our survey demonstrates diverging patterns in the diagnosis and management of GD relapse that correlate well with previous surveys from other countries on GD-naïve patients and a less than optimal adherence to recently published clinical guidelines. ABBREVIATIONS: ATA = American Thyroid Association; ATD = antithyroid drug; CBC = complete blood count; GD = Graves disease; GO = Graves ophthalmopathy; LFT = liver function test; MMI = methimazole; PTU = propylthiouracil; RAI = radioactive iodine; TSI = thyroid-stimulating immunoglobulin.

Prognostic significance of platelet count changes during hospitalization for community-acquired pneumonia.

The prognostic significance of platelet count (PC) changes during hospitalization for community-acquired pneumonia (CAP) has not been investigated. For 976 adults, clinical data during hospitalization for CAP and all-cause mortality following discharge were compared according to ΔPC (PC on discharge minus PC on admission): groups A (declining PC, ΔPC < -50 × 109/l), B (stable PC, ΔPC ± 50 × 109/l), and C (rising PC, ΔPC >50 × 109/l), and according to the presence of thrombocytopenia, normal PC, and thrombocytosis on admission/discharge. Groups A, B, and C comprised 7.9%, 46.5%, and 45.6% of patients, respectively. On hospital admission/discharge, thrombocytopenia, normal PC, and thrombocytosis were observed in 12.8%/6.4%, 84.1%/84.4%, and 3.1%/9.2% of patients, respectively. The respective 90-day, 3-year, and total (median follow-up of 54 months) mortality rates were significantly higher: in group A (40.3%, 63.6%, and 72.7%), compared to groups B (12.3%, 31.5%, and 39.0%) and C (4.9%, 17.3%, and 25.4%), p < 0.001; and in patients with thrombocytopenia at discharge (27.4%, 48.4%, and 51.6%), compared to those with normal PC (10.2%, 26.9%, and 35.4%) and thrombocytosis (8.9%, 17.8%, and 24.4%) at discharge (p < 0.001). Mortality rates were comparable among groups with thrombocytopenia, normal PC, and thrombocytosis at admission (p = 0.6). In the entire sample, each 100 × 109/l increment of ΔPC strongly predicted lower mortality (p < 0.001, relative risk 0.73, 95% confidence interval 0.64-0.83). In conclusion, PC changes are common among CAP inpatients. Rising PC throughout hospitalization is a powerful predictor of better survival, while declining PC predicts poor outcome. Evaluation of PC changes during hospitalization for CAP may provide useful prognostic information.

Changes in Red Cell Distribution Width During Hospitalization for Community-Acquired Pneumonia: Clinical Characteristics and Prognostic Significance.

PURPOSE: We investigated outcomes of patients hospitalized with community-acquired pneumonia (CAP) according to the changes in red cell distribution width (RDW). METHODS: For 980 adults, clinical characteristics, outcomes during hospitalization for CAP (transfer to the intensive care unit, treatment with mechanical ventilation, prolonged hospital stay, and death), and all-cause mortality following discharge were compared: according to RDW changes versus stable RDW during hospitalization, and according to normal (≤14.7 %) versus high (>14.7 %) RDW values on admission/discharge. RESULTS: RDW changes (n = 386) during hospitalization were associated with more severe clinical and laboratory characteristics than stable RDW (n = 594). Changes in RDW strongly predicted poor in-hospital outcomes (p < 0.001). The respective 30, 90-day, and total (median follow-up 54 months) mortality rates were significantly higher (9.8, 16.0 and 43.5 %) among patients with RDW changes, compared to 4.0, 7.6 and 30.5 % among those with stable RDW (p < 0.001 for all comparisons). RDW changes, as well as high RDW (each 1 % increment) on admission and discharge, were powerful predictors of mortality (the respective relative risks 1.41, 1.13, and 1.15, and 95 % confidence intervals 1.13-1.74, 1.08-1.19, and 1.10-1.21). CONCLUSIONS: RDW changes during hospitalization for CAP are common and associated with a severe clinical profile. Time-dependent RDW changes strongly predict poor in-hospital outcomes and increased short- and long-term mortality. Repeated RDW determinations during hospitalization for CAP may provide useful prognostic information.

Factors associated with prevention of postural hypotension by leg compression bandaging.

AIM: We evaluated the eventual effects of leg compression on seating-induced postural hypotension (PH) in the context of various relevant clinical variables. METHODS: Included were 73 hospitalized patients with various acute conditions, aged ≥ 60 years, bedridden for ≥ 8 h, with diagnosed PH [≥ 20 mmHg systolic and/or ≥ 10 mmHg diastolic blood pressure (BP) falls] at the first seating. BP, heart rhythm, dizziness and palpitations were recorded before and during 5 min of sitting. The next day, the patients were reevaluated, this time using compression bandages applied along both legs before seating. RESULTS: Compared with the non-bandaged state, PH was registered in only 53% of bandaged patients (p < 0.001). Moreover, the appearance of PH symptoms decreased (p < 0.001). On the second day (bandaged), supine diastolic BP values were higher in the persisting vs non-persisting PH group (p = 0.027). In the bandaged state, PH symptoms were significantly reduced in the non-persisting PH group (p = 0.003). Even in patients with persistent PH, the magnitude of BP decline and appearance of PH symptoms were decreased while wearing bandages (p = 0.004 and 0.002, respectively). CONCLUSION: During mobilization of inpatients, leg compression seems to reduce the seating-induced PH and relevant symptoms. Even in patients with persisting PH, bandaging may improve hemodynamics and attenuate associated symptoms.

[Cutis verticis gyrata as an early rare presenting sign of acromegaly].

Cutis verticis gyrata (CVG) is a descriptive term for a dermal sign in which deep furrows and convoluted ridges are seen upon the scalp. They are formed due to thickening of the skin folds of the scalp and produce an appearance that resembles the gyri of the brain. The condition is classified primary when the etiology is unknown or neurologically based. CVG will be considered secondary when a definite cause, systemic or localized, is responsible for the sign. We describe a 34 year-old male who was presented with a one-month history of arthralgia in his interphalangeal joints. His physical examination revealed scalp changes compatible with CVG, which appeared 3 years earlier. Following a thorough investigation of the patient, acromegaly was diagnosed. Although CVG is a rare condition, it has been described in patients with acromegaly. The appearance of SVG as an early sign of acromegaly makes this case unique and important. In a patient developing CVG, acromegaly and other treatable disorders should always be excluded.

Seating-induced postural hypotension is common in older patients with decompensated heart failure and may be prevented by lower limb compression bandaging.

BACKGROUND: Postural hypotension induced by transition from supine to sitting position and measures for its prevention in heart failure has not been investigated. OBJECTIVE: Our purpose was to evaluate the prevalence of postural hypotension and associated clinical manifestations as well as the contribution of various risk factors for postural hypotension on transition from lying to sitting in older patients with decompensated heart failure, and to study the eventual preventive effect of leg bandaging. METHODS: Seating-induced postural hypotension (>or=20 mm Hg systolic and/or >or=10 mm Hg diastolic blood pressure fall) was assessed on the first study day in 108 patients aged >or=60 years, hospitalized for acutely decompensated heart failure. On the next day, in patients manifesting postural hypotension, compression bandages were applied along both legs before seating. Blood pressure, heart rate, O(2) saturation, and the occurrence of dizziness or palpitations were recorded prior to and 1, 3 and 5 min following seating. RESULTS: Postural hypotension occurred in 49.1% of patients. Dizziness and/or palpitations manifested in 25%. Diastolic (36.1%) versus systolic (23.1%) postural hypotension prevailed (p=0.05). On univariate analysis, postural hypotension was associated with female sex (p=0.03), more severe heart failure (p=0.05), longer bedrest (p=0.04), higher supine systolic (p=0.01) or diastolic (p=0.002) blood pressure, nonischemic heart failure (p=0.002), and not using nitrates (p = 0.01). On multivariate analysis, longer bedrest (OR=1.58, 95% CI=1.13-2.2, p<0.001), higher supine diastolic blood pressure (OR=1.33, 95% CI=1.1-1.61, p=0.001), and nonischemic heart failure (OR=3.48, 95% CI=1.4-8.63, p=0.009) were the most predictive of postural hypotension. Compression bandages prevented postural hypotension in 21 of 49 patients and decreased the degree of postural blood pressure fall (p<0.001). CONCLUSION: Seating-induced postural hypotension is common among older inpatients with decompensated heart failure, especially with longer bedrest, higher supine diastolic blood pressure and non-ischemic etiology. Leg compression bandaging may be useful for the prevention of postural hypotension in these patients.

Reassessment of Differentiated Thyroid Cancer Patients Using the Eighth TNM/AJCC Classification System: A Comparative Study.

BACKGROUND: Facing the prevailing concept that increased diagnosis with no change in mortality drives the increased incidence of differentiated thyroid cancer (DTC), considerable modifications have been introduced in the new edition of the tumor node metastasis (TNM)/American Joint Committee on Cancer (AJCC) staging system. The aim of this study was to compare a group of DTC patients before and after restaging, by mortality, disease severity, and disease outcomes. METHODS: DTC patients (N = 433) were restaged according to the eighth TNM/AJCC edition, and the results were compared to the seventh edition for clinicopathologic data, treatment modalities, and disease outcomes. RESULTS: When switched to the eighth edition, 97.5% of patients fell into stage I-II compared to 76.4% before, and only 11/102 patients remained in stages III-IV. Disease-specific mortality was recorded in 11/433 patients, six of whom were in stages I-II upon restaging, compared to none before (p > 0.05). In addition, more recurrences were seen in stages II (p = 0.05) and III (p = 0.03) using the eighth edition compared to the seventh edition. Stage II was affected the most, with recurrence risk increasing from 29% to 76% (p = 0.001) and persistence at last visit from 19% to 43% when switching to the eighth edition (p = 0.01). Considering stages I and II together, the recurrence risk increased from 16.7% to 28.2% (p = 0.01), lymph node metastases from 1.9% to 26.5% (p = 0.01), and persistence at last visit from 10% to 15% (p > 0.05). Of the 129 patients in the 45- to 54-year-old age group, 53 shifted to stage I (20 from stage II, 29 from stage III, and 4 from stage IV) and five shifted to stage II (all from stage IV). When comparing this age group in stage II only, the eighth edition showed more lymph node metastases (p = 0.001), more distant metastases (p = 0.003), higher recurrence risk (p = 0.002), and more persistence at the last visit (p > 0.05). CONCLUSION: The eighth TNM/AJCC edition provides a more accurate system to discriminate mortality and persistence in DTC patients. Yet, the severity of disease, especially in the 45- to 55-year-old age group and in stage II patients, should not be underestimated following the downstaging of these patients.

Effect of various clinical variables on total intracellular magnesium in hospitalized normomagnesemic diabetic patients before discharge.

Deficiency of intracellular magnesium (icMg) may coexist with normal serum Mg levels. Little is known about clinical and pharmacological factors affecting icMg in normomagnesemic patients with diabetes mellitus (DM). Moreover, no information exists regarding the icMg state in diabetic patients after acute illness and before hospital discharge. We have evaluated the effect of antihyperglycemic medications and other relevant clinical variables on icMg in 119 such patients. Total icMg was measured in peripheral blood mononuclear cells. Twenty healthy volunteers served as controls. IcMg content (microg/mg cell protein) was lower in DM compared to controls (1.74 +/- 0.44 vs 2.4 +/- 0.39, p < 0.001). It was also significantly lower in patients treated with insulin (1.57 +/- 0.31 vs 1.8 +/- 0.46, p = 0.01), while metformin treatment was associated with higher icMg (1.86 +/- 0.49 vs 1.63 +/- 0.35, p = 0.003). After adjustment for age, gender, and concomitant use of other hypoglycemic drugs, only treatment with metformin was independently associated with increased icMg (p = 0.03). No statistically significant association or correlation was found between icMg content and age, causes of hospitalization, comorbid conditions, treatment with other drugs, concentrations of HbA1c, serum glucose, Mg, or creatinine. In conclusion, icMg is depleted in normomagnesemic DM patients. Insulin treatment is associated with worsening of icMg status, while metformin treatment may confer protective effect.

Patient-related variables predicting acute coronary syndrome following admission for chest pain of possible coronary origin.

OBJECTIVE: Improving risk stratification of patients experiencing acute chest pain with non-revealing electrocardiogram and cardiac biomarkers could reduce missed acute coronary syndrome and avoid unnecessary hospitalization. METHODS: We assessed the ability of situational, circumstantial, and other patient-related variables in predicting acute coronary syndrome in 921 consecutive patients randomly admitted to this medical department with chest pain of possible coronary origin. A reference group comprised 107 patients referred promptly to the coronary care unit with acute myocardial infarction. RESULTS: Acute coronary syndrome eventually developed in 219 (23.7%) patients. Age and proportions of male patients and those with diabetes, which were significantly lower in the heterogeneous chest pain group than in the reference group, did not differ when re-evaluation was performed between the latter group and the subgroup of patients who eventually developed acute coronary syndrome. Overweight and a family history of premature coronary artery disease remained significantly higher in the reference group, while prevalence of pre-existing coronary artery disease, previous coronary angiography, and coronary intervention remained significantly lower. Variables most significantly predictive of acute coronary syndrome resulted: pre-existing coronary artery disease [odds ratio (OR) 3.2; 95% confidence interval (CI) 2.17-4.71; P<0.001), older age (OR 1.35; 95% CI 1.17-1.57; P<0.001), male sex (OR 1.77; 95% CI 1.19-2.61; P=0.004), diabetes (OR 1.6; 95% CI 1.11-2.32; P=0.01), self-initiation of pain relief treatment before seeking medical help (OR 1.54; 95% CI 1.07-2.23; P=0.02), and conviction that hospitalization for acute coronary disease was mandatory (OR 1.46; 95% CI 1.03-2.07; P=0.03). CONCLUSIONS: Easily obtainable patient-related variables might improve risk stratification and assist physicians to decide on policy in the emergency department and upon hospitalization.

Intracellular magnesium in elderly patients with heart failure: effects of diabetes and renal dysfunction.

Hypomagnesemia is frequent in diabetes mellitus (DM), while renal dysfunction (RD) may be associated with hypermagnesemia. Severe cardiac arrhythmias and other adverse clinical manifestations are frequent in heart failure (HF), in DM and in RD. Depletion of intracellular magnesium (icMg), which may coexist with normal serum Mg, might contribute to these deleterious effects. However, icMg content in normomagnesemic HF patients with RD or DM has not been studied. We assessed total icMg in peripheral blood mononuclear cells (PBMC) from 80 normomagnesemic furosemide-treated HF patients who were divided as follows: subgroups A (DM), B (RD), C (DM and RD), and D (free of DM or RD). PBMC from 18 healthy volunteers served as controls. IcMg content (microg/mg cell protein) in HF was lower compared to controls (1.68+/-0.2 vs. 2.4+/-0.39, p<0.001). In the entire HF group, a significant inverse correlation was evident between icMg and serum creatinine (r=-0.37) and daily furosemide dosages (r=-0.121). IcMg in the HF subgroups A, B, C, and D was 1.79+/-0.23, 1.57+/-0.23, 1.61+/-0.25, and 1.79+/-0.39, respectively (p=0.04 between A and B, p=0.08 between B and D, and non-significant in the remaining comparisons). Serum Mg, potassium, calcium, furosemide dosages and left ventricular ejection fraction were comparable in all subgroups. In conclusion, icMg depletion was demonstrable in PBMC, which may be responsible for some of the adverse clinical manifestations in HF patients. In particular, icMg depletion in RD might contribute to cardiac arrhythmias in this patient group. Mg supplementation to normomagnesemic HF patients might therefore prove beneficial.

Prognostic significance of changes in red cell distribution width in an internal medicine ward.

BACKGROUND: The prognostic significance of red cell distribution width (RDW) during hospitalization in internal medicine wards was not sufficiently investigated. METHODS: Demographic, clinical and laboratory characteristics were collected from 586 internal medicine inpatients. Following discharge, all-cause mortality was recorded. The data were compared according to ΔRDW during hospitalization (primary endpoint), and to normal (≤14.7%) vs. high (>14.7%) RDW values on admission/discharge (secondary endpoint). RESULTS: Group A (rise in RDW, ΔRDW +0.4%), group B (nonsignificant RDW changes, ΔRDW up to 0.4%) and group C (drop in RDW, ΔRDW -0.4%) comprised 20.3%, 60.6% and 19.1% of the patients, respectively. High RDW on admission and discharge was found in 31.7% and 31.4% of patients, respectively. In-hospital mortality rates were higher in group A than in groups B and C (14.3% vs. 2.8% and 4.5%, p<0.001), whereas increased long-term (median follow-up 43 months) mortality rates were observed in group C (35.7%), compared to groups A (17.6%) and B (23.4%), p=0.009. Mortality rates were significantly higher (p<0.001) in patients with high than normal RDW on admission (51.1% vs. 20.3%) and on discharge (50.5% vs. 20.6%). Every 1% increment of RDW on admission and discharge strongly predicted mortality (relative risks 1.21 and 1.21; 95% confidence intervals 1.12-1.31 and 1.13-1.32, respectively). CONCLUSIONS: High RDW on admission and discharge predicted poor prognosis. Rising RDW throughout hospitalization was associated with higher in-hospital mortality, while an elevated long-term mortality rate was observed in patients with declining RDW. Repeated RDW measurements may improve risk stratification for internal medicine inpatients.

Sex-related bedside clinical variables associated with survival of older inpatients with heart failure.

BACKGROUND: Little is known about sex-related differences in factors affecting prognosis of heart failure (HF). We prospectively investigated the relationship between bedside clinical variables and survival of older females vs. males with HF. METHODS: Included were consecutive unselected inpatients, age >/=60 years, admitted for various acute conditions. HF was chronic and of diverse etiologies. Follow-up extended up to 5 years. All-cause mortality was registered and statistically analyzed for association with in-hospital clinical variables. RESULTS: Included were 162 females and 200 males. Survival rates were 52.4% and 59%, respectively, (P=0.1). Advanced age and renal dysfunction (RD) were associated with low survival in both sexes (P<0.03 and 0.02, P<0.001 and 0.01, respectively). An association with low survival was found with respect to; admission for pulmonary edema (P<0.02), using furosemide >/=80 mg/day (P<0.005) and severe HF [NYHA class III-IV (P<0.01)] in females, as well as for hypokalemia (P<0.03) and hypocalcemia (P<0.03) in males. On multivariate analysis RD (P<0.001), increasing age (P=0.008) and furosemide dosage >/=80 mg (P=0.02) were most significantly associated with low survival in females, while RD only was significantly associated with low survival in males (P=0.03). CONCLUSIONS: Several clinical variables, which affect prognosis in older HF patients are sex-related and probably carry practical significance.

Clinical characteristics and prognostic significance of changes in platelet count in an internal medicine ward.

BACKGROUND: The clinical characteristics and prognostic significance of changes in platelet count (PC) during hospitalization in internal medicine wards have not been well investigated. METHODS: Demographic, clinical and laboratory data were collected from 345 patients admitted to an internal medicine ward. Following discharge, all-cause mortality was recorded. These data were compared, according to deltaPC (PC on discharge minus PC on admission): group 1 (drop in PC, deltaPC -50×10(9)/l), group 2 (no significant PC changes, deltaPC up to 50×10(9)/l) and group 3 (rise in PC, deltaPC +50×10(9)/l). RESULTS: Groups 1, 2 and 3 comprised 64 (18.5%), 200 (58%) and 81 (23.5%) patients, respectively. Patients from group 3 were younger, more likely admitted for infection and less likely for cardiovascular disorder, and less often presenting with coronary artery disease, complex nursing care and thrombocytosis on admission or thrombocytopenia on discharge than patients from groups 1 and 2. Mean platelet volume was higher in group 2 on admission and lower in group 3 on discharge. During a median follow-up of 25 months, 146 (42.3%) of 345 patients died. The survival rate was higher for group 3 (65.4%) than for groups 1 (45.3%) and 2 (58.5%), p=0.003. In the entire cohort, each 100×10(9)/l increment of deltaPC was a powerful predictor of lower mortality (p=0.03, relative risk=0.83, 95% confidence interval=0.71-0.98). CONCLUSIONS: Increased PC throughout hospitalization was associated with better prognosis than a drop or blunted rise in PC. The assessment of PC changes in an internal medicine ward may provide useful prognostic information.

Clinical characteristics and prognostic significance of serum albumin changes in an internal medicine ward.

BACKGROUND: The prognostic significance of hypoalbuminemia and the dynamic changes in serum albumin during hospitalization in internal medicine wards has not been sufficiently investigated. METHODS: Demographic, clinical and laboratory data were collected from 276 patients admitted to our internal medicine ward for a variety of acute disorders. Following discharge, all-cause mortality was recorded. These data were compared between patient groups, according to levels of albumin: hypoalbuminemia or normoalbuminemia (serum albumin <34 g/l and ≥ 34 g/l, respectively), on admission and discharge. RESULTS: Hypoalbuminemia on admission and on discharge was found in 46% and 54% of patients, respectively. Anemia, renal dysfunction, malignant disease, hypocholesterolemia, lymphopenia and albuminuria were more prevalent in patients with hypoalbuminemia, compared to those with normoalbuminemia (p ≤ 0.03). During a median follow-up period of 23 months, 107 of 276 patients died. Mortality was significantly higher (p<0.001) in patients with hypoalbuminemia than normoalbuminemia on admission (52.0% vs. 27.5%) and on discharge (53.7% vs. 21.2%), including those admitted with normoalbuminemia and discharged with hypoalbuminemia (43.6%). Survival rate was higher for patients admitted with hypoalbuminemia and discharged with normoalbuminemia than for those remaining with hypoalbuminemia (82.4% vs. 42.8%, p=0.004). The level of albumin on discharge (each 10 g/l decrement) was the most powerful predictor of shortened survival (relative risk 2.79, 95% confidence interval 2.04-3.70). CONCLUSIONS: Hypoalbuminemia on admission, as well as persistence or development of hypoalbuminemia throughout hospitalization, was associated with poor prognosis. Treatment aimed at increasing low albumin or maintaining its normal level may improve survival.

Atrial Fibrillation at an Internal Medicine Ward: Clinical and Prognostic Implications.

Background: Little is known about atrial fibrillation (AF) appearing during hospitalization in an Internal Medicine ward. Purpose: We aimed to investigate characteristics and prognostic significance of in-hospital onset AF. Methods: We studied 249 consecutive unselected patients admitted to this medical department with paroxysmal or persistent AF (out-of-hospital group) or AF developed during hospitalization (in-hospital group). Demographic, clinical, laboratory, electrocardiographic and echocardiographic data and all-cause mortality following discharge were recorded and compared between the groups Results: Diabetes mellitus (p=0.05), renal dysfunction (p<0.001), chronic lung disease (p=0.03) and history of stroke (p=0.01) were found more common in the in-hospital group (56 patients), compared to the out-of-hospital group (193 patients). Patients from the in-hospital group were more likely to have recurrent episodes of AF during hospitalization (p=0.002), were more frequently treated with amiodarone (p<0.001), discharged in sinus rhythm (p=0.04) and with medications for rhythm control (p=0.04). Time from onset to termination of AF (p<0.001) and hospital stay (p<0.001) were longer in the in-hospital group. On a median of 39-months follow-up, survival rate was lower in the in-hospital vs. out-of-hospital group (69.6% vs. 81.3%, p=0.025). Older age was significantly associated with shorter survival in the in-hospital group [odds ratio (OR)=1.87, 95% confidence interval (CI) 1.15-3.03, p=0.009]. In the out-of-hospital group, advanced age (OR=2.17, 95%CI 1.51-3.10, p<0.001), no prior AF episode (OR=3.41, 95%CI 1.56-7.46, p=0.002), diabetes mellitus (OR=2.22, 95%CI 1.12-4.39, p=0.006) and renal dysfunction (OR=2.44, 95%CI 1.10-5.38, p=0.049) were significantly associated with shorter survival. Conclusion: Patients developing in-hospital AF differed from subjects hospitalized for AF with respect to the severity of the clinical profile and prognosis.

Shortened erythrocyte sedimentation rate evaluation is applicable to hospitalised patients.

BACKGROUND: Westergren method, commonly used for erythrocyte sedimentation rate (ESR) determination, is simple and inexpensive. However, the 60 min required for the test are disadvantageous, especially for those departments/facilities where prompt evaluation is necessary. We investigated the possibility that earlier ESR recordings might correlate with standard 60-minute ESR and/or be predictive of the latter. METHODS: Demographic and clinical data were collected from 220 randomly chosen adult patients hospitalised for various diseases in a medical department. ESR, determined by slightly modified Westergren method, was recorded at 15, 30 and 60 min. Correlation coefficients (r) between the standard and early ESR measurements were calculated for the entire group and for the separate subgroups divided according to patient age, sex and presence of anaemia or of inflammation. RESULTS: Mean+/-SD age of the patients was 61.3+/-19.6, 55% were males; 45% had some inflammatory condition. Mean+/-SD ESR values (mm) at 15, 30 and 60 min were 9.0+/-12.1, 21.4+/-21.8 and 35.9+/-27.5, respectively. A statistically significant correlation was found between ESR measurements at 15 and 60 min (r=0.833, p<0.001). However, the strongest correlation was observed between 30 and 60 min measurements (r=0.926, p<0.001), irrespective of age, sex and presence of anaemia or of inflammation. Based on the ESR determination at 30 min (X), the predicted ESR value at 60 min (Y) could be calculated by a simple equation: Y=10.7+1.2X. CONCLUSION: Sixty-minute ESR values can be predicted by the 30-minute estimation. Shortening the test by half an hour might bear practical importance.

Anemia in diabetic patients at an internal medicine ward: clinical correlates and prognostic significance.

BACKGROUND: Characteristics and prognostic significance of anemia in hospitalized diabetic patients are unknown. METHODS: We studied 3145 unselected patients admitted to two Internal Medicine Departments, 872 (27.7%) of whom were diabetic. Forty diabetic patients died during the first hospitalization period. Out of the remaining 832 patients, 334 (40.2%) were anemic and evaluated for survival. In 87 diabetic patients, the cause of anemia was evident on admission, whereas the other 247 had to be further investigated for etiology of anemia. RESULTS: Compared to non-anemic diabetic patients, the diabetic anemic patients were older (mean age 71.4 vs. 64.4 years, P<.001) and predominantly females (52.4% vs. 44.4%, P<.02). Of the 247 evaluated patients, 38% were deficient in iron, 12% in vitamin B(12) and/or folate, 54% had anemia of chronic disease, 47% suffered from heart failure, 39% had renal dysfunction and 22% were complex nursing care patients and/or had diabetic foot. On median follow-up of 19.2 months, mortality rate was higher in anemic compared to non-anemic diabetic patients (17.3% vs. 4%, P<.001), the main cause of death being infection. Male sex (P=.03), albuminuria (P=.01) and heart failure (P=.06) were associated with shorter survival, male sex being the most significant (OR 2.02, 95% CI 1.04-4.00). CONCLUSION: Frequency of anemia was increased in diabetic patients admitted to the Internal Medicine Departments, compared to the studies performed on ambulatory patient populations. Anemia was multifactorial and associated with higher mortality, predominantly from infections. Males with albuminuria and heart failure were at higher risk of death.

Application of HRV-CD for estimation of life expectancy in various clinical disorders.

BACKGROUND: Low heart rate variability (HRV) was found in various medical conditions including heart failure and acute myocardial infarction. Decreased HRV in these conditions predicted poor prognosis. METHODS: HRV was estimated in 133 unselected inpatients with relevant clinical bedside conditions by non-linear analysis derived from chaos theory, which calculates the correlation dimension (CD) of the cardiac electrophysiologic system (HRV-CD). RESULTS: Mean HRV-CD in the entire group was 3.75+/-0.45. Heart failure, coronary artery disease, cardiac arrhythmia, low serum potassium, renal dysfunction, and diabetes mellitus were significantly associated with reduced HRV-CD compared to their counterparts [3.6 vs. 3.9 (P<.001), 3.65 vs. 3.87 (P=.005), 3.58 vs. 3.8 (P=.01), 3.38 vs. 3.81 (P=.02), 3.59 vs. 3.8 (P=.04), and 3.66 vs. 3.82 (P=.04), respectively]. Stepwise logistic regression showed heart failure to be the condition most significantly associated with low HRV-CD (odds ratio 4.2, 95% confidence interval 1.90-9.28, P<.001). In the entire group, decreased HRV-CD (< or =3.75 vs. >3.75) was associated with lower survival (P=.01). Mortality of diabetic patients with HRV-CD < or =3.75 exceeded the mortality in patients with HRV-CD >3.75 (P=.02). Heart failure, renal dysfunction or age over 70 combined with HRV-CD < or =3.75 also appeared to be associated with augmented mortality. CONCLUSIONS: Diminished HRV-CD is associated with heart failure, coronary artery disease, cardiac arrhythmia, renal dysfunction, diabetes mellitus and low serum potassium. Among the latter, heart failure is most significantly associated with decreased HRV-CD. Decreased HRV-CD values, especially in diabetics, are also associated with lower survival.