[EARLY IN-HOSPITAL MORTALITY IN INTERNAL MEDICINE WARDS (WITHIN 24 HOURS): A POTENTIAL QUALITY INDICATOR OR A VARIABLE AFFECTED BY MULTIPLE FACTORS?]

AIMS: To evaluate in-hospital mortality rate within 24 hours in internal medicine wards and to evaluate if it may be used as quality indicator. BACKGROUND: In-hospital mortality rate is an outcome measure which apparently reflects quality of care. There are debates on whether it may be considered a quality indicator since it is difficult to compare different case-mixes between hospitals. Research on mortality within 24 hours had not been published. METHODS: An historical prospective study was conducted including the entire internal wards admissions to the Rabin Medical Center between 1/7/14 and 30/6/15. We evaluated inhospital deaths and 7 days post discharge deaths. We focused on deaths within 24 hours, patients' characteristics, the primary diagnosis (which we assumed is the cause of death) and co-morbidity. The analysis includes descriptive statistics and mortality rates performed with SPSS version 22. RESULTS: Overall, 25,414 patients were admitted to internal wards during the study period. There were 1,620 in-hospitals deaths (6.37%) among which 164 deaths occurred within 24 hours (0.65%), which is 10.1% of in-hospital deaths. These patients were very old (median 82), many were residents of nursing homes and nearly all were brought to the hospital by ambulance. The most frequent primary diagnoses were sepsis (24%), pneumonia (22%), metastatic cancer (10%) and acute neurologic event (5%). CONCLUSIONS: The results exclude excessive inhospital mortality within 24 hours. The patients' characteristics enable researchers to assume that these deaths were expected and not preventable. DISCUSSION: There is no excessive mortality within 24 hours, the deaths were expected and a seasonal modifying effect was evident. All this and the different case mix in between hospitals suggest that early in-hospital mortality seems inadequate as a quality measure.

PET-CT imaging of combined brachial and lumbosacral neurolymphomatosis.

Neurolymphomatosis is a rare manifestation of progressive non-Hodgkin's lymphoma. A 44-yr-old man with diffuse large B-cell lymphoma presented with unilateral progressive peripheral sensorimotor neuropathy after the 7th cycle of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) therapy. No pathology in the nervous system was evident by computerized tomography (CT), magnetic resonance imaging (MRI) of the head, spinal axis and plexuses and by repeated analysis of cerebrospinal fluid. However, the hybrid modality of positron emission tomography (PET) of fluorinated deoxyglucose (FDG) combined with CT scan (PET-CT) showed unilateral involvement of both the brachial and lumbosacral nervous plexuses. A complete recovery of neurological manifestations and normalization of PET-CT followed intensive chemotherapy with autologous stem cell transplantation. The diagnosis and localization of neurolymphomatosis may be supported by PET-CT imaging.

Clinical and ethnic characteristics of stroke in an Israeli population: a study in a community hospital population.

Background: Stroke mainly affects the older population, although it has also been reported in younger patients. In this study, we focused on patients 65 years of age or younger with stroke. Methods: The files of three patient populations were studied: 93 patients aged 65 years or younger with stroke (group A), 93 patients older than 65 with stroke (group B), and 604 patients without stroke representing the general population of patients admitted to our service during January 2000 (group C). We reviewed the patient files and compared patient characteristics, epidemiological features, clinical picture,imaging findings, and coagulation tests. Results: Overall, 318 patients were studied. The mean age of group A was 55 years compared to 77 years in group B and 71 years in group C. In both stroke groups (A and B), the male: female ratio was 2:1, in contrast with a balanced ratio in group C. Most of the patients in group A (63%) were of Sephardic origin compared to 39% in group B (P=0.002) and 30% in group C. The clinical picture in both stroke groups (A and B) was similar. The risk factor smoking was reported by 45% in group A and by only 29% in group B (P=0.034). Hypertension, diabetes mellitus, and hyperlipidemia were evenly prevalent in both stroke groups. The coagulation system was studied in the "young" patients (group A): hyperhomocysteinemia was found in 37%, high titers of anticardiolipin antibodies in 35%, low levels of antithrombin III in 13%, protein C deficiency in 5%, and activated protein C resistance (APCR) in 4%. Overall, 49% of the patients from group A were found to have coagulation abnormalities. Conclusions: We found in our study that the younger patient with stroke tends to be a Sephardic male with the classical risk factors as well as a history of smoking and coagulopathy. These findings suggest strict medical supervision and primary prophylaxis. This work also lays the basis for a prospective, interventional trial with younger patients.

Erythropoietin has an anti-myeloma effect - a hypothesis based on a clinical observation supported by animal studies.

Recombinant human erythropoietin (rHuEpo) was introduced into clinical practice more than a decade ago, and has been found to be effective in the treatment of several types of anemia, including anemia of end-stage renal failure and cancer-related anemia. No study has suggested that Epo might have an effect on the biology of the disease, nor any survival advantage to cancer patients treated with Epo for anemia has been reported. Here we report six patients with advanced multiple myeloma (MM) with very poor prognostic features, whose expected survival was <6 months. All six patients were treated with rHuEpo for their anemia, either without any chemotherapy or very mild chemotherapy for a short time. Yet, surprisingly they lived for 45-133 months totally from MM diagnosis and 38-94 months with rHuEpo (with a good quality of life). In fact, one patient, is still alive and well, more than 8 yr after chemotherapy was discontinued because of a resistant aggressive disease. The course in these six MM patients led us to hypothesize that Epo might have an antineoplastic or antimyeloma effect. We proceeded and tested that hypothesis in mouse models of myeloma (Mittelman M et al., Proc Natl Acad Sci USA 98:5181,2001). In these models we confirmed that rHuEpo induced tumor regression in about 50% of the BALB/c mice inoculated with MOPC-315 myeloma cells. We then presented evidence that the mechanism is a new immune-mediated phenomenon, via activation of CD8+ T cells. Furthermore, evidence from the literature supports the antineoplastic effect of Epo. Epo might be used as an adjunct immune treatment in various malignant diseases, in addition to the current regimens and chemotherapeutic protocols. Future trials should determine the role of Epo in myeloma and cancer treatment, besides clarifying concerns about the presence of Epo receptors on some tumor cells.