A SIMPLE FRAILTY INDEX PREDICTS IN-HOSPITAL MORTALITY.

INTRODUCTION: Comparing frailty models in different settings that predict in-hospital mortality might modify patient disposition and treatment, but models are often complex. METHODS: In the following study we selected all acutely admitted adult patients in 2020- 2021 to the three internal medicine departments at a regional 400-bed hospital. We attempt to determine (a) if a new scale (Laniado-4 scale) that includes only three yes/no questions derived from the Norton scale and the presence of a urinary catheter performs as well as the graded Norton scale (including all five domains), in predicting in-hospital mortality and (b) to determine the predictive value of a simple frailty index that includes the new scale as well as categories of age, serum albumin, and creatinine values. We calculated odds ratios with 95% confidence intervals and c-statistics for the various models predicting in-hospital mortality. RESULTS: The mean patient age was 73±19 years, and 49.1% (5665/11542) were males. A Laniado-4 scale performed better than the Norton scale for predicting in-hospital mortality. A simple frailty index ranging from 0 to ≥8 points was associated with rates of in-hospital mortality that increased from 0 to 37.7%, with an odds ratio of 2.13(2.03-2.25) per 1 index point. The c-statistic was 0.887 (0.881-0.893). CONCLUSIONS: We conclude the Laniado-4 scale performed better than the Norton scale in predicting in-hospital mortality and that a simple frailty index that included the 4-question scale and categories of age, serum creatinine, and serum albumin performed as well or better than more complicated models.

Is It Safe to Treat Stable Patients with Bacteremic Urinary Tract Infections with High-Resistant-Rate Antibiotics?

BACKGROUND AND OBJECTIVES: In most areas of the world, urine bacteria have high resistance rates to third-generation cephalosporins, and it is unclear if it is safe to treat stable patients with bacteremic urinary tract infections (UTI) with those antibiotics. There are recommendations that empiric therapy for a suspected UTI should include only antibiotics with resistance rates less than 10%. MATERIALS AND METHODS: In this historical observational single center study, we selected 180 stable internal medicine patients hospitalized between January 2019 and December 2021, with identical bacteria isolated from blood and urine cultures. Charts were reviewed to determine if deaths and readmissions up to 30 days after discharge were due to bacterial resistance to initial antibiotic therapy (BRIAT). RESULTS: The patient's median age was 82 years (1st-3rd quartiles, 73-87 years). A total of 54.4% were female. There were 125 patients treated with ceftriaxone. A total of 38 (30.3%) had BRIAT. Four patients died, but none were because of a delay in appropriate treatment. The median days of hospitalization for all patients was 7 days, and 9 days versus 6 days in those with and without BRIAT. There were no re-hospitalizations for a UTI in patients with BRIAT. CONCLUSIONS: We conclude that, despite high resistance rates, empiric ceftriaxone in stable hospitalized patients with a bacteremic UTI is safe. There was no urosepsis-related mortality during the hospitalization or on follow-up. The treatment of all patients with wider-spectrum antibiotics might have decreased the median hospital stay by only one day. The potential effect would be even lower if all patients with a suspected systemic UTI were treated with wide-spectrum antibiotics, because some patients do not have an infection of the urinary tract. A reassessment of the recommendation that empiric therapy for a suspected systemic urinary tract infection should include only wider-spectrum antibiotics is warranted.

Laboratory Tests, Bacterial Resistance, and Treatment Options in Adult Patients Hospitalized with a Suspected Urinary Tract Infection.

Patients treated for systemic urinary tract infections commonly have nonspecific presentations, and the specificity of the results of the urinalysis and urine cultures is low. In the following narrative review, we will describe the widespread misuse of urine testing, and consider how to limit testing, the disutility of urine cultures, and the use of antibiotics in hospitalized adult patients. Automated dipstick testing is more precise and sensitive than the microscopic urinalysis which will result in false negative test results if ordered to confirm a positive dipstick test result. There is evidence that canceling urine cultures if the dipstick is negative (negative leukocyte esterase, and nitrite) is safe and helps prevent the overuse of urine cultures. Because of the side effects of introducing a urine catheter, for patients who cannot provide a urine sample, empiric antibiotic treatment should be considered as an alternative to culturing the urine if a trial of withholding antibiotic therapy is not an option. Treatment options that will decrease both narrower and wider spectrum antibiotic use include a period of watching and waiting before antibiotic therapy and empiric treatment with antibiotics that have resistance rates > 10%. Further studies are warranted to show the option that maximizes patient comfort and safety.

Do Laboratory Blood Tests Change Medical Care in Patients Hospitalized with Community-Acquired Pneumonia?

Background and Objectives: The prevalence of inappropriate laboratory testing is believed to be high, but only a limited number of studies have reviewed medical charts to determine whether tests impact medical care. Materials and Methods: From the electronic database, we selected 500 consecutive patients with community-acquired pneumonia who were hospitalized between January 2020 and October 2021. We excluded eight patients who had COVID-19, but were not identified in the database, and were only identified after chart review. To assess the impact of tests on medical care, we conducted a thorough review of the patients' charts. Results: The age of the patients was 78 ± 16 years, with 42.3% female (n = 208) hospitalized for a median of 4 days (25-75%, 3-6 days). There were 27957 laboratory test results during 2690 hospital days (10.4 tests per day of hospitalization). Of the 2997 tests carried out on admission 5.7% (n = 170) resulted in changes of medical care in 34.5% (170/492) of the patients, nearly all from the results of electrolytes, renal function tests, and serum glucose measurements. Tests that did not lead to any decision on medical care included 75.8% (7181/9478) on admission and 86.0% (15,898/18,479) on repetitive testing, i.e., repetitive testing accounted for 68.9% (15,898/23,079) of tests that did not change medical care. By excluding tests that did not change medical care, the overall testing rate would decrease by 82.6% (23,079/27,947), and from 10.4 tests per day to 2.1 tests per day. Conclusions: We conclude that the estimate of the overuse of laboratory testing, which includes all testing that does not change patient care, is much higher than reported using other methodologies. Most of the overuse was from repetitive testing that included unnecessary testing in patients without admission test results that changed medical care. Further investigation is needed to determine if these findings can be applied to patients with diverse health conditions and in different healthcare settings.

Asymptomatic Microscopic Hematuria in Inpatient Nonsurgical Adults.

OBJECTIVES: This study sought to determine the proportion of nonsurgical inpatients with asymptomatic microscopic hematuria (AMH) who qualified for urologic investigation according to consensus guidelines. METHODS: The study population included all patients acutely admitted to the internal medicine departments of Israeli regional hospitals between 2014 and 2017. RESULTS: Of 29,086 consecutive admissions, 10,116 (34.8%) underwent dipstick urinalysis and 8,389 (28.8%) underwent reflex microscopic urinalysis. After the exclusion of patients with a urethral catheter or a positive urine culture, 2,206 had 3 or more RBCs per high-power field, and as many as 2,052 (7.1% of the entire cohort and 24.4% of all patients undergoing microscopic urinalysis) met the criteria for a urologic workup. CONCLUSIONS: We conclude that according to the consensus guidelines, an unreasonably high proportion of hospitalized nonsurgical patients would be referred for a urologic workup of uncertain clinical utility because of an incidental AMH finding.

Observational study of peripheral intravenous catheter outcomes in an internal medicine department.

BACKGROUND: In elderly patients hospitalised in internal medicine departments, risk factors, preferable placement area and methods of securement of short peripheral venous catheters (SPVC) a unclear. AIM: To determine the incidence and risk factors of adverse events using a transparent bordered dressing for securement in the dorsum of the hand or cubital fossa in consecutive patients hospitalised in an internal medicine department. METHODS: In a prospective observational study of patients admitted to a regional hospital with a SPVC, the dependent variable was the need to replace the catheter because of an adverse event (phlebitis, accidental removal, infiltration/occlusion). The independent variables were age, gender, disorientation, placement area, intravenous antibiotic therapy and indwelling time. Risk factors were determined by Cox regression model analysis. RESULTS: There were 709 catheters placed in 499 patients. Per catheter placed the mean age was 75 ± 17 years. Accidental removal, infiltration/obstruction and phlebitis occurred in 21.5, 16.2 and 15.0 events per 1000 days respectively. There was a significantly increased risk on Day 3 compared to Days 2 and 4. An older age, intravenous antibiotics and disorientation increased the hazard for accidental displacement, whereas phlebitis was associated only with intravenous antibiotics and occlusion/infiltration only with age. CONCLUSIONS: The observed low rates of adverse events suggests that placement in the dorsum of the hand or cubital fossa secured by a transparent dressing is acceptable. It is important to consider the indwelling catheter time when studying adverse events, and elderly patients, disoriented patients and/or patients receiving intravenous antibiotics deserve special attention.

The Norton scale is an important predictor of in-hospital mortality in internal medicine patients.

BACKGROUND: The Norton scale, a marker of patient frailty used to predict the risk of pressure ulcers, but the predictive value of the Norton scale for in-hospital mortality after adjustment for a wide range of demographic, and abnormal admission laboratory test results shown in themselves to have a high predictive value for in-hospital mortality is unclear. AIM: The study aims to determine the value of the Norton scale and the presence of a urinary catheter in predicting in hospital mortality. METHODS: The study population included all acutely admitted adult patients in 2020 through October 2021 to one of three internal medicine departments at the Laniado Hospital, a regional hospital with 400 beds in Israel. The main objective was to (a) identify the variables associated with the Norton Scale and (b) determine whether it predicts in-hospital mortality after adjustment for these variables. RESULTS: The Norton scale was associated with an older age, female gender, presence of a urinary catheter, and abnormal laboratory tests. The odds of in-hospital mortality in those with intermediate, high, and very high Norton scale risk groups were 3.10 (2.23-3.56), 6.48 (4.02-10.46), and 12.27 (7.37-20.44), respectively, after adjustment for the remaining predictors. Adding the Norton scale and the presence of a urinary catheter to the prediction logistic regression model that included age, gender, and abnormal laboratory test results increased the c-statistic from 0.870 (0.864-0.876) to 0.908 (0.902-0.913). CONCLUSIONS: The Norton scale and presence of a urinary catheter are important predictors of in-hospital mortality in acutely hospitalized adults in internal medicine departments.

COVID-19 vaccination is associated with reduced non-COVID in-hospital mortality.

We retrieved data on a cohort of medical patients at a regional Israeli hospital. The dependent variable was non-COVID-19 hospital mortality; the independent variables were vaccination status, age, and laboratory data. Serum sodium, age, serum creatinine, and COVID-19 vaccination status were the main independent variables associated with non-COVID-19 mortality. The odds ratio for in-hospital deaths of non-vaccinated patients was 2.01 (1.65-2.44) (unadjusted) and 1.61 (1.29-2.03) after adjustment for the independent variables. This "healthy adherer effect" may confound observational assessments of the clinical efficacy of COVID-19 vaccines.

The presence of a urinary catheter is an important predictor of in-hospital mortality in internal medicine patients.

RATIONALE AND OBJECTIVE: Mortality rates are used to assess the quality of hospital care after appropriate adjustment for case-mix. Urinary catheters are frequent in hospitalized adults and might be a marker of patient frailty and illness severity. However, we know of no attempts to estimate the predictive value of indwelling catheters for specific patient outcomes. The objective of the present study was to (a) identify the variables associated with the presence of a urinary catheter and (b) determine whether it predicts in-hospital mortality after adjustment for these variables. METHODS: The study population included all acutely admitted adult patients in 2020 (exploratory cohort) and January-October 2021 (validation cohort) to internal medicine, cardiology and intensive care departments at the Laniado Hospital, a regional hospital with 400 beds in Israel. There were no exclusion criteria. The predictor variables were the presence of a urinary catheter on admission, age, gender, comorbidities and admission laboratory test results. We used bivariate and multivariate logistic regression to test the associations between the presence of a urinary catheter and mortality after adjustment for the remaining independent variables on admission. RESULTS: The presence of a urinary catheter was associated with other independent variables. In 2020, the odds of in-hospital mortality in patients with a urinary catheter before and after adjustment for the remaining predictors were 14.3 (11.6-17.7) and 6.05 (4.78-7.65), respectively. Adding the presence of a urinary catheter to the prediction logistic regression model increased its c-statistic from 0.887 (0.880-0.894) to 0.907 (0.901-0.913). The results of the validation cohort reduplicated those of the exploratory cohort. CONCLUSIONS: The presence of a urinary catheter on admission is an important and independent predictor of in-hospital mortality in acutely hospitalized adults in internal medicine departments.

An Index Predicting Histological Acute Cholecystitis in Patients Undergoing an Urgent Laparoscopic Cholecystectomy.

BACKGROUND: It is important to predict acute cholecystitis (AC) before a laparoscopic cholecystectomy because inflammation of the gallbladder predicts the need for open conversion and subsequent morbidity after a laparoscopic cholecystectomy. OBJECTIVES: To create an index based on clinical, laboratory, and ultrasound criteria on admission that will predict AC on pathological examination in patients presenting acutely. METHODS: We retrospectively reviewed consecutive cases of emergency laparoscopic cholecystectomies conducted by three experienced surgeons between 1 October 2014 and 31 January 2018. Independent variables were age, sex, presenting symptoms, admission laboratory tests, and ultrasound findings. The outcome variable was AC on histological examination. An index was created from all variables that added significantly to the logistic regression analysis. RESULTS: Eight variables that contributed significantly to the model, included age, male sex, vomiting on admission, an increased proportion of neutrophils, a normal aspartate aminotransferase test, a normal serum amylase test result, a thick gall bladder wall, and pericholecystic fluid. An index of ≤ 2 to ≥ 8 created from those variables had a graded risk for AC of 1.8% to 92.0% with a c-statistic of 0.86 (95% confidence interval 0.81-0.91). Operating time and bleeding increased in those with a higher index. CONCLUSIONS: An index including age, sex, symptoms, and selected laboratory results as well as ultrasound characteristics had an excellent graded risk in the prediction of histological AC that was associated with operating time and an increased risk of bleeding during the operation.

Parameters of the complete blood count predict in hospital mortality.

INTRODUCTION: Mortality rates are used to evaluate the quality of hospital care after adjusting for disease severity and, commonly also, for age, comorbidity, and laboratory data with only few parameters of the complete blood count (CBC). OBJECTIVE: To identify the parameters of the CBC that predict independently in-hospital mortality of acutely admitted patients. POPULATION: All patients were admitted to internal medicine, cardiology, and intensive care departments at the Laniado Hospital in Israel in 2018 and 2019. VARIABLES: Independent variables were patients' age, sex, and parameters of the CBC. The outcome variable was in-hospital mortality. ANALYSIS: Logistic regression. In 2018, we identified the variables that were associated with in-hospital mortality and validated this association in the 2019 cohort. RESULTS: In the validation cohort, a model consisting of nine parameters that are commonly available in modern analyzers had a c-statistics (area under the receiver operator curve) of 0.86 and a 10%-90% risk gradient of 0%-21.4%. After including the proportions of large unstained cells, hypochromic, and macrocytic red cells, the c-statistic increased to 0.89, and the risk gradient to 0.1%-29.5%. CONCLUSION: The commonly available parameters of the CBC predict in-hospital mortality. Addition of the proportions of hypochromic red cells, macrocytic red cells, and large unstained cells may improve the predictive value of the CBC.

High rate of bacterial respiratory tract co-infections upon admission amongst moderate to severe COVID-19 patients.

BACKGROUND: The role of bacterial and viral co-infection in the current COVID-19 pandemic remains elusive. The aim of this study was to describe the rates and features of co-infection on admission of COVID-19 patients, based on molecular and routine laboratory methods. METHODS: A retrospective study of COVID-19 and non-COVID-19 patients undergoing Biofire®, FilmArray® Pneumonia Panel, bioMérieux, and routine cultures during the first 3 days from admission, between June 2019 and March 2021. RESULTS: FilmArray tests were performed in 115 COVID-19 and in 61 non-COVID-19 patients. Most (>99%) COVID-19 patients had moderate-critical illness, 37% required mechanical ventilation. Sputa and endotracheal aspirates were the main samples analyzed. Positive FilmArray tests were found in 60% (70/116) of the tests amongst COVID-19 patients and 62.5% (40/64) amongst non-COVID-19 patients. All 70 cases were positive for bacterial targets, while one concomitant virus (Rhinovirus/Enterovirus) and one Legionella spp. were detected. The most common bacterial targets were Haemophilus influenzae (36%), Staphylococcus aureus (23%), Streptococcus pneumoniae (10%) and Enterobacter cloacae (10%). Correlation between FilmArray and cultures was found in 81% and 44% of negative and positive FA tests, respectively. Positive FilmArray results typically (81%) triggered the administration of antibiotic therapy and negative results resulted in antimicrobials to be withheld in 56% of cases and stopped in 8%. Bacterial cultures of COVID-19 patients were positive in 30/88 (34%) of cases. CONCLUSIONS: Bacterial co-infection is common amongst moderate-critical COVID-19 patients on admission while viral and atypical bacteria were exceedingly rare. Positive FilmArray results could trigger potentially unnecessary antibiotic treatment.KEY POINTWe found high rates of on-admission bacterial co-infection amongst hospitalized moderate to severe COVID-19 patients. Molecular tests (Biofire, FilmArray) and routine microbiological tests revealed 60% and 34% bacterial co-infection, respectively, while viral and fungal co-infections were rare.

Proteinuria in hospitalised internal medicine adult patients.

RATIONALE: Dipstick proteinuria may be a sign of a renal disorder, false-positive or associated with acute disease, and consequently, transient in hospitalised patients. OBJECTIVE: To assess (a) the prevalence of proteinuria in hospitalised patients; (b) its association with estimated glomerular filtration rate (eGFR), findings known to cause false-positive test results and indicators of acute disease and (c) the need for follow-up after discharge. SETTING AND PARTICIPANTS: All patients who had a dipstick urinalysis on admission to medical wards of a 400-bed regional hospital in 2018-2019. OUTCOME VARIABLE: Proteinuria. INDEPENDENT VARIABLES: (a) Other findings on dipstick urinalysis; (b) patients' age, gender, presence of urinary catheter and eGFR and (c) white blood cell count (WBC) and fever. RESULTS: Of 22 329 patients, 6609 (29.6%) had urinalysis. Of those, 2973 patients (45.0%) had proteinuria of ≥+1 (≥0.30 g/L). The variables independently associated with proteinuria were other dipstick findings known to cause false-positive test results, elevated WBC, fever on presentation, presence of a urethral catheter and a low eGFR. eGFR alone was a poor predictor of proteinuria (c-stat 0.62); however, addition of the remaining independent variables to the model significantly improved its predictive ability (c-stat 0.80). CONCLUSIONS: Dipstick proteinuria is common in hospitalised patients. Although weakly associated with eGFR, proteinuria is mainly associated with confounding factors that may result in false-positive test results. The need for follow-up of proteinuria after discharge has questionable clinical utility and its high frequency would entail a considerable cost.

Stop routine microscopic urinalysis in hospitalized patients with dipstick abnormalities?

BACKGROUND: Restricting the performance of microscopic urinalyses only to patients in whom it was specifically requested has been shown to reduce their number in laboratories servicing both inpatients and outpatients. OBJECTIVE: To determine the effect of such restriction solely in in-patients in a 400-bed regional hospital. METHODS: In 2017, we discontinued routine ('reflex') microscopic urinalysis for all positive dipstick results, and restricted such testing to in-patients in whom it was specifically requested by a doctor. We compared the numbers of patients in three internal medicine departments who had a urinalysis over 2-year periods before and after 2017, and reviewed doctors' complaints. RESULTS: Before 2017, more than 80% of all dipstick tested samples had one or more abnormalities that led to a microscopic examination. Discontinuation of reflex microscopy reduced microscopic urinalysis to less than 10% of all patients with dipsticks on admission. Requests for repeat urinalysis decreased from 4.3% to 2.5% and there were no complaints after the change in policy. CONCLUSIONS: Discontinuation of a 'reflex' microscopic urinalysis in patients with abnormal dipstick results did not increase repeat urine testing. Doctors apparently felt that the microscopic urinalysis does not have clinical utility in the vast majority of hospitalized adult patients.

Value of Troponin in Predicting Hospital Mortality of Older Adult Patients without Suspected Acute Coronary Syndromes.

OBJECTIVES: Some authors have recommended troponin measurement to stratify patient mortality risk, but it is unclear whether troponin values add to age and routine admission laboratory tests in the prediction of in-hospital mortality of older adult patients without suspected acute coronary syndrome (ACS). The aim of our study was to determine whether troponin testing adds significantly to routine admission laboratory testing in predicting in-hospital mortality in patients without a suspected ACS. METHODS: In 2018-2019, we reviewed all acutely admitted patients aged 60 years or older to Internal Medicine wards of a regional hospital after excluding those admitted to intensive care or with chest pain. The independent variables were troponin, age, sex, and routine admission laboratory tests. The outcome measure was in-hospital mortality. We compared c-statistics and the observed 10% to 90% risk gradients using logistic regression models for age and routine laboratory testing before and after the addition of troponin. RESULTS: The mortality risk gradient for age and admission laboratory tests was 0.2% to 29.5%. Adding troponin did not increase the gradient significantly (0.2%-34.6%, P = 0.170), and the 95% confidence intervals for the c-statistics overlapped, increasing from 0.845 (0.818-0.876) to 0.866 (0.839-0.892). CONCLUSIONS: In older adult patients without suspected ACS, troponin testing did not improve the prediction of hospital mortality above that of a model including age and common admission blood tests. In the absence of suspected ACS, troponin testing is not needed to predict the hospital mortality of older adult patients.

Head Computed Tomography Scans in Elderly Patients with Low Velocity Head trauma after a Fall.

BACKGROUND: Recommendations for a head computed tomography (CT) scan in elderly patients without a loss of consciousness after a traumatic brain injury and without neurological findings on admission and who are not taking oral anticoagulant therapy, are discordant. OBJECTIVES: To determine variables associated with intracranial hemorrhage (ICH) and the need for neurosurgery in elderly patients after low velocity head trauma. METHODS: In a regional hospital, we retrospectively selected 206 consecutive patients aged ≥ 65 years with head CT scans ordered in the emergency department because of low velocity head trauma. Outcome variables were an ICH and neurological surgery. Independent variables included age, sex, disability, neurological findings, facial fractures, mental status, headache, head sutures, loss of consciousness, and anticoagulation therapy. RESULTS: Fourteen patients presented with ICH (6.8%, 3.8-11.1%) and three (1.5%, 0.3-4.2%) with a neurosurgical procedure. One patient with a coma (0.5, 0.0-2.7) died 2 hours after presentation. All patients who required surgery or died had neurological findings. Reducing head CT scans by 97.1% (93.8-98.9%) would not have missed any patient with possible surgical utility. Twelve of the 14 patients (85.7%) with an ICH had neurological findings, post-trauma loss of consciousness or a facial fracture were not present in 83.5% (95% confidence interval 77.7-88.3) of the cohort. CONCLUSIONS: None of our patients with neurological findings required neurosurgery. Careful palpation of the facial bones to identify facial fractures might aid in the decision whether to perform a head CT scan.