The Collateral Benefit of COVID Pandemic: Improved Pharmacological Venous Thromboembolism Prophylaxis Practices in Non-COVID Patients.

Background: COVID-19 creates a hypercoagulable state with a wide spectrum of clinical manifestations. Of those, venous thromboembolism (VTE) is prevalent, and numerous studies have highlighted the importance of VTE prophylaxis. Pre-pandemic VTE prophylaxis practices have already been poor, despite guidelines. We hypothesized that the gap between guidelines and practices might have been closed due to increased awareness. Materials and Methods: Non-COVID-19 patients hospitalized in the internal medicine ward of a university hospital between January 1st, 2021, and June 30th, 2021, were assessed. VTE risk and thromboprophylaxis requirements were assessed using the Padua Prediction Score (PPS). The results were compared with the findings of the study conducted in the same setting before the pandemic. Results: A total of 267 patients were included, and 81 patients (30.3%) received prophylaxis. A total of 128 patients' (47.9%) PPS was ≥ 4, and 69 patients (53.9%) received prophylaxis; 12 low-risk patients (8.6%) received prophylaxis although it was not indicated. Compared to the pre-pandemic figures, both appropriate prophylaxis use and overuse rates have risen. While the increment rate of appropriate prophylaxis was statistically significant, the increment rate of overuse did not reach statistical significance. Patients hospitalized for infectious diseases and respiratory failure were more likely to receive appropriate prophylaxis. Conclusion: We have demonstrated a significant increase in appropriate pharmacologic prophylaxis rates among high-risk patients. Besides all the collateral damage the pandemic has created, it might also have brought collateral benefits with regards to VTE prophylaxis.

Human memory T cell dynamics after aluminum-adjuvanted inactivated whole-virion SARS-CoV-2 vaccination.

This study evaluates the functional capacity of CD4+ and CD8+ terminally-differentiated effector (TEMRA), central memory (TCM), and effector memory (TEM) cells obtained from the volunteers vaccinated with an aluminum-adjuvanted inactivated whole-virion SARS-CoV-2 vaccine (CoronaVac). The volunteers were followed for T cell immune responses following the termination of a randomized phase III clinical trial. Seven days and four months after the second dose of the vaccine, the memory T cell subsets were collected and stimulated by autologous monocyte-derived dendritic cells (mDCs) loaded with SARS-CoV-2 spike glycoprotein S1. Compared to the placebo group, memory T cells from the vaccinated individuals significantly proliferated in response to S1-loaded mDCs. CD4+ and CD8+ memory T cell proliferation was detected in 86% and 78% of the vaccinated individuals, respectively. More than 73% (after a short-term) and 62% (after an intermediate-term) of the vaccinated individuals harbored TCM and/or TEM cells that responded to S1-loaded mDCs by secreting IFN-γ. The expression of CD25, CD38, 4-1BB, PD-1, and CD107a indicated a modulation in the memory T cell subsets. Especially on day 120, PD-1 was upregulated on CD4+ TEMRA and TCM, and on CD8+ TEM and TCM cells; accordingly, proliferation and IFN-γ secretion capacities tended to decline after 4 months. In conclusion, the combination of inactivated whole-virion particles with aluminum adjuvants possesses capacities to induce functional T cell responses.

Physicians' responsibility toward environmental degradation and climate change: A position paper of the European Federation of Internal Medicine.

The current data on climate change and environmental degradation are dramatic. The consequences of these changes are already having a significant impact on people's health. Physicians - as advocates of the patients, but also as citizens - have an ethical obligation to be involved in efforts to stop these changes. The European Federation of Internal Medicine (EFIM) strongly encourages the Internal Medicine societies and internists across Europe to play an active role in matters related to climate change and environmental degradation. At a national level, this includes advocating the adoption of measures that reduce greenhouse gas (GHG) emissions and environmental degradation and contributing to policy decisions related to these issues. At a hospital level and in clinical practice, supporting actions by the health sector to reduce its ecological footprint is vital. At the level of EFIM and its associated internal societies, promoting educational activities and developing a toolkit to prepare internists to better care for citizens who suffer from the consequences of climate change. In addition to advocating and implementing effective actions to reduce the ecological footprint of the health industry, recommending the introduction of these themes in scientific programs of Internal Medicine meetings and congresses and the pre- and postgraduate medical training. At a personal level, internists must be active agents in advocating sustainable practices for the environment, increasing the awareness of the community about the health risks of climate change and environmental degradation, and being role models in the adoption of environmentally friendly behaviour.

[Longitudinal Assessment of Anti-Spike-1 antibody Responses in a Group of Hospitalized Patients with SARS-CoV-2 Infection]. / Hastaneye Yatan SARS-CoV-2 Enfeksiyonlu Bir Grup Hastanin Anti-Spike-1 Antikor Yanitlarinin Boylamsal Degerlendirilmesi.

The coronavirus disease-2019 (COVID-19) has become a global cause of death/injury, particularly for those with limited access to vaccination programs and healthcare systems. The risk of re-infection is not negligible due to the emergence of new variants and the decrease in immunity of those who have recovered COVID-19 before. In this study, it was aimed to show longitudinally the change in antibody levels of patients hospitalized for COVID-19 who had an antibody response in the early stages of their infection and to reveal a response pattern that would help to predict patients whose antibody responses decreased or persisted over time. This observational, single-center study included 38 non-critical patients admitted to COVID-19 wards. Anti-spike-1 IgG levels were investigated by the "enzyme-linked immunosorbent assay (ELISA)" method in two different samples taken at different times in each patient. Two distinct anti-spike-1 IgG antibody response patterns were detected in the study; the first pattern was that with low antibody production at first who had an increase in antibody levels after an average of six months, and the second pattern was that the initially high antibody levels decreased after an average of six months. This paradoxical kinetic may blur physicians' predictions of antibody response. In general, anti-spike-1 antibody levels showed a moderate decrease after six months, but production seems to continue (mean ∆IgG= -0.77; σ= 4; p= 0.24). Higher antibody levels were observed at the beginning in patients with concomitant bacterial pneumonia (mean initial IgG= 7.67; σ= 3.54) (p= 0.03). Although the production of S1-IgG in patients recovered from severe acute respiratory system coronavirus2 (SARS-CoV-2) was modestly reduced compared to the beginning measurements, the production in general persisted during the study period. It appears that IgG responses increase or remain constant in individuals with relatively low IgG index values when controlled after an average of 180 days, while IgG tends to decrease in individuals with high IgG index values.

A COVID-19 first evaluation clinic at a university hospital in Turkey.

BACKGROUND: We aimed to analyze the usefulness of such a reserved area for the admission of the patients' symptoms suggesting COVID-19 and compare the demographic and clinical characteristics of the patients with COVID-19 and without COVID-19 who were admitted to C1 during the first month of the COVID-19 outbreak in our hospital. METHODS: A new area was set up in Hacettepe University Adult Hospital to limit the contact of COVID-19 suspicious patients with other patients, which was named as COVID-19 First Evaluation Outpatient Clinic (C1). C1 had eight isolation rooms and two sampling rooms for SARS-CoV-2 polymerase-chain-reaction (PCR). All rooms were negative-pressurized. Patients who had symptoms that were compatible with COVID-19 were referred to C1 from pretriage areas. All staff received training for the appropriate use of personal protective equipment and were visited daily by the Infection Prevention and Control team. RESULTS: One hundred and ninety-eight (29.4%) of 673 patients who were admitted to C1were diagnosed with COVID-19 between March 20, 2020, and April 19, 2020. SARS-CoV-2 PCR was positive in 142 out of 673 patients. Chest computerized tomography (CT) was performed in 421 patients and COVID-19 was diagnosed in 56 of them based on CT findings despite negative PCR. Four hundred and ninety-three patients were tested for other viral and bacterial infections with multiplex real-time reverse-transcriptase PCR (RTPCR). Blood tests that included complete blood count, renal and liver functions, d-dimer levels, ferritin, C- reactive protein, and procalcitonin were performed in 593 patients. Only one out of 44 healthcare workers who worked at C1 was infected by SARS-CoV-2. DISCUSSION: Early diagnosis of infected patients and ensuring adequate isolation are very important to control the spread of COVID-19. The purpose of setting up the COVID-19 first evaluation outpatient clinic was to prevent the overcrowding of ER due to mild or moderate infections, ensure appropriate distancing and isolation, and enable emergency services to serve for real emergencies. A wellplanned outpatient care area and teamwork including internal medicine, microbiology, and radiology specialists under the supervision of infectious diseases specialists allowed adequate management of the mild-to-moderate patients with suspicion of COVID-19.

Medical and surgical co-management - A strategy of improving the quality and outcomes of perioperative care.

With the increase of ageing population, rates of chronic diseases and complex medical conditions, the management of high-risk surgical patients is likely to become a great concern in most countries. Considering all these factors, it is certainly rational and intuitive that internists should be included into a collaborative model of medical and surgical co-management, where their multi-potentiality and synthesis capacity require them to coordinate the multidisciplinary team and to be the leading agent of change. In this regard, our aim was to present the official position and approach of the Working Group on Professional Issues and Quality of Care of the European Federation of Internal Medicine (EFIM), for implementation of this strategy of care, encouraging internists to assume an important role and to provide continuity of multidisciplinary care, from the decision to operate through to rehabilitation and recovery. Moving from the traditional model of medical care of the surgical patients to the co-management model, from a reactive simple consultation to a new pro-active continued service, may optimize the quality and perioperative care, improving the survival, shortening hospital stays, replacing the old strategy of late and complication treatment to an early and preventive one.

Hospital ambulatory medicine: A leading strategy for Internal Medicine in Europe.

Addressing the current collision course between growing healthcare demands, rising costs and limited resources is an extremely complex challenge for most healthcare systems worldwide. Given the consensus that this critical reality is unsustainable from staff, consumer, and financial perspectives, our aim was to describe the official position and approach of the Working Group on Professional Issues and Quality of Care of the European Federation of Internal Medicine (EFIM), for encouraging internists to lead a thorough reengineering of hospital operational procedures by the implementation of innovative hospital ambulatory care strategies. Among these, we include outpatient and ambulatory care strategies, quick diagnostic units, hospital-at-home, observation units and daycare hospitals. Moving from traditional 'bed-based' inpatient care to hospital ambulatory medicine may optimize patient flow, relieve pressure on hospital bed availability by avoiding hospital admissions and shortening unnecessary hospital stays, reduce hospital-acquired complications, increase the capacity of hospitals with minor structural investments, increase efficiency, and offer patients a broader, more appropriate and more satisfactory spectrum of delivery options.

Perceptions and Attitudes of Patients About Adult Vaccination and Their Vaccination Status: Still a Long Way to Go?

BACKGROUND Immunization is one of the most effective public health measures to prevent disease, but vaccination rates in adult populations still remain below the targets. Patient and physician attitudes about vaccination are important for adult vaccination. In this study, we aimed to determine patient attitudes and perceptions about vaccination and the vaccination coverage rates of adult patients in a university hospital in Turkey. MATERIAL AND METHODS A survey was conducted between October 2014 and May 2015 at the Internal Medicine Outpatient Clinics of a university hospital. Adult patients were asked to fill out a questionnaire on their perceptions and attitudes about vaccination and their vaccination status. RESULTS We interviewed 512 patients ages 19-64 years. Eighty percent of the study population thought that adults should be vaccinated, while only 36.1% of the patients stated that vaccination was ever recommended to them in their adult life. Forty-eight percent of the patients stated that they were vaccinated at least once in their adulthood. The most commonly received vaccine was tetanus vaccine in general, while influenza vaccine was the leading vaccine among patients with chronic medical conditions. While 71.4% of the patients to whom vaccination was recommended received the vaccine, 34.9% of the patients received a vaccine without any recommendation. CONCLUSIONS Although the vaccine coverage rates among adults in this survey were low, the perceptions of patients about adult vaccination were mainly positive and of many of them positively reacted when their physician recommended a vaccine.

[Mortality related factors in patients requiring hospitalization for influenza like illness]. / Influenza benzeri hastalik nedeniyle hastaneye yatis gerektiren hastalarda mortaliteyle iliskili faktörler.

The knowledge about the viral etiologies causing respiratory disease in adults is limited. Viral respiratory diseases may lead deterioration in certain patient populations. The aim of this study was to determine the viral etiologies of influenza-like illness among patients requiring hospitalization and to document the risk factors for mortality. This prospective study was performed in one of the 7 centers in Turkey in the context of influenza surveillance by the Global Influenza Hospital Surveillance Network. A 35-bed Adult Emergency Service and 10-bed Acute Care Unit were screened for consequent recruitment of eligible patients daily, on weekdays only. ICD-10 codes in the electronic health records and direct patient encounters were used to screen for the following eligibility diagnoses: acute respiratory tract infection, asthma, heart failure, pneumonia, influenza, chronic obstructive lung disease, dyspnea/respiratory abnormality, respiratory symptoms, cough and fever. A total of 334 patients who were admitted with the eligible ICD-10 codes within the 24th and 48th hours were screened during the study period and of those eligible ones, 106 consented and were swabbed. Nasal or nasopharyngeal swabs were collected using Virocult (Medical Wire & Equipment, UK) and sent to the central laboratory in 1-3 days. Swabs were collected and specimens were introduced to real-time polymerase chain reaction based multiplex kits, as well as, ABI 7500 platform with CDC primers and probes. A total of 106 patients were swabbed. Hospital mortality was 12.2%. More than one fourth of the patients needed a sort of mechanical ventilation support and at least one organ failure developed in one third of the patients. One or more viral pathogens were detected in 56 (52.8%) of the swabbed patients, with influenza H3N2 being the most prevalent one. Having a lower body mass index (OR, 0.845, p= 0.034) was associated with mortality. Chronic lung diseases were shown to confer a survival advantage (OR, 0.127, p= 0.009). Community acquired viral respiratory infections might lead to significant compromise in adult patients. Prevention of malnutrition might result in better outcomes in patients who need acute admission. The survival advantage of those with chronic lung diseases warrants further investigation.

Prospective Evaluation of Infection Episodes in Cancer Patients in a Tertiary Care Academic Center: Microbiological Features and Risk Factors for Mortality.

OBJECTIVE: We aimed to determine the frequency, type, and etiology of infections and the risk factors for infections and mortality in hospitalized cancer patients. MATERIALS AND METHODS: We prospectively enrolled adult cancer patients hospitalized in the internal medicine wards of a tertiary care academic center between January and August 2004. Patients were followed during their hospitalization periods for neutropenia, infections, culture results, and mortality. RESULTS: We followed 473 cancer patients with 818 hospitalization episodes and 384 infection episodes in total. Seventy-nine percent of the infections were nosocomial, and febrile neutropenia (FN) was observed in 196 (51%) of the infection episodes. Bacteremia was found in 29% of FN episodes and in 8% of nonneutropenic patients. Gram-positive bacteria were the leading cause of bacteremia in both neutropenic and nonneutropenic cases (70% and 58%, respectively). Presence of an indwelling central catheter increased bacteremia risk by 3-fold. The overall mortality rate was 17%, whereas 34% of the patients with bloodstream infections died. Presence of bacteremia and advanced disease stage increased overall mortality by 6.1-fold and 3.7-fold, respectively. CONCLUSION: Nearly half of the cancer patients developed an infection during their hospital stays, with gram-positive bacteria being the predominant etiologic microorganisms. This demonstrates the changing trends in infections considering that, until 2004, gram-negative bacteria were the most predominant microorganisms among cancer patients in our institute.

Measurement of pulmonary artery to aorta ratio in computed tomography is correlated with pulmonary artery pressure in critically ill chronic obstructive pulmonary disease patients.

AIM: Chronic obstructive pulmonary disease (COPD) is one of the leading chronic diseases and a common cause of death. Identification of COPD patients at high risk for complications and mortality is of utmost importance. Computed tomography (CT) can be used to measure the ratio of the diameter of the pulmonary artery (PA) to the diameter of the aorta (A), and PA/A ratio was shown to be correlated with PA pressure (PAP). However, the prognostic value of PA size remains unclear in patients with COPD. We hypothesized that PA enlargement, as shown by a PA/A ratio greater than 1, could be associated with a higher risk of mortality in COPD patients admitted to the intensive care unit. METHODS: Data of patients admitted to a medical intensive care unit of a university hospital were retrospectively reviewed between January 2008 and December 2012. Patients who were identified to have a diagnosis of acute exacerbation of COPD and who had an echocardiogram and CT scan were included. Pulmonary artery to aorta ratio was calculated and patients were grouped as PA/A ≤1 and PA/A >1. Comparisons were made between the groups and between patients who died and survived. Correlation analysis, survival analysis, and logistic regression analysis were done, where appropriate. RESULTS: One hundred six COPD patients were enrolled. There were 40 (37.4%) patients who had a PA/A >1. Echocardiography measured PAP was higher in the group with PA/A >1 than in those with PA/A ≤1 (62.1 ± 23.2 mm Hg vs 45.3 ± 17.9 mm Hg, P = .002). Mortality rate of patients with PA/A >1 was higher (50%) than of those patients with PA/A ≤1 (36.4%), although the difference did not reach a statistical significance (P = .17). Correlation was found between vmeasured PA diameter and PAP (r = 0.51, P = .001) as well as between the Acute Physiology and Chronic Health Evaluation II values and PAP (r = 0.25, P = .025). CONCLUSION: The PA/A ratio is an easily measured method that can be performed on thorax CT scans. Although, we failed to demonstrate a statistically significant association between higher PA/A and increased mortality, PA/A can be used as a surrogate marker to predict the pulmonary hypertension.

Daily surveillance with early warning scores help predicthospital mortality in medical wards.

BACKGROUND/AIM: To analyze the potency of a modified early warning score (EWS) to help predict hospital mortality when used for surveillance in nonacute medical wards. MATERIALS AND METHODS: Patients in internal medicine wards were prospectively recruited. First, highest, and last scores; and mean daily score recordings and values were recorded. Nurses calculated scores for each patient upon admission and every 4 h. The last score was the score before death, discharge, or transfer to another ward. The highest scores in total and for each single parameter were used for analysis. RESULTS: Fifty-nine percent of 182 recruited patients had recordings eligible for data analysis. Patients admitted from the emergency room had higher mortality rates than patients admitted from outpatient clinics (15% vs. 1.5%; P = 0.01) as well as patients whose first (40% vs. 4.9%; P = 0.033) and highest scores (18.8% vs. 1.3%; P = 0.003) were equal to or more than 3. The first recorded EWS was not predictive for mortality while the maximum score during the admission period was. CONCLUSION: This study underlines the fact that each physiological variable of EWS may not have the same weight in determining the outcome.

Burnout syndrome during residency in internal medicine and pediatrics in a country without working time directive.

PURPOSE: The purpose of this paper is to demonstrate burnout syndrome among internal medicine and pediatrics residents in a country that does not have the working time directive (WTD) and also to determine the risk factors and consequent impact on efficient functioning in clinical areas. DESIGN/METHODOLOGY/APPROACH: A 57-item questionnaire was given to internal medicine and pediatrics residents. Responses from 22 pediatrics and 33 internal medicine residents were evaluated. FINDINGS: Demographic findings, burnout scores, having hobbies, social activities and reading books unrelated to medicine were similar between the two groups. Six pediatrics residents (27.3 per cent) and 11 (33.3 per cent) internal medicine residents met the criteria for clinically significant burnout. Personal accomplishment scores and reading books unrelated to medicine were found to be related to burnout. ORIGINALITY/VALUE: Burnout is a syndrome characterized by depersonalization, emotional exhaustion and a low sense of personal accomplishment. It is important to document burnout in countries where WTDs are not implemented. Further studies might demonstrate burnout's effect on patient safety, service quality and physician's performance.

Splenic artery embolization: An alternative approach in a critically ill patient with autoimmune hemolytic anemia.

Assessment of general health status and hematological parameters usually precedes the use of invasive diagnostic and therapeutic procedures in critically ill patients. Angiography can be effective and safe as a substitute for major surgical procedures, or as a bridging therapy in such cases. We present a critically ill patient with hemolytic anemia that underwent splenic artery embolization as a bridging therapy. We aimed to emphasize that minimally invasive approaches and multidisciplinary care can be utilized in the treatment of critically ill patients with accompanying hematological disease.

Common diagnoses in internal medicine in Europe 2009: a pan-European, multi-centre survey.

OBJECTIVE: Information on the medical problems and diseases encountered by practicing Internists in the hospital environment is lacking. The aim of this study is to assess the prevalence of various diagnostic categories that present to internists in the hospital setting in Europe. DESIGN: A pan-European study used the Young Internists Research Network of the European Federation of Internal Medicine. RESULTS: Data on 1501 patients from 31 physicians in 18 European countries were included in the study. The patients carried an average of 2.75 (+/-2.22) chronic medical diagnoses, ranging from 0 to 18. The most common presenting complaint was shortness of breath, followed by chest pain and abdominal pain. A cardiac condition was most common, followed by infectious disease. The complexity of patients averaged 2.5 (+/-1.14). CONCLUSIONS: The results of this study will be useful for the development of a modern internal medicine curriculum, both at the graduate and postgraduate level, which reflects the competencies required for the delivery of comprehensive patient care in internal medicine wards.

Evaluation of the effects of vitamin D receptor and estrogen receptor 1 gene polymorphisms on bone mineral density in postmenopausal women.

The aim of this study is to evaluate the effects of estrogen receptor 1 (ESR1) and vitamin D receptor (VDR) gene polymorphisms on bone mineral density (BMD) in a group of previously untreated osteoporotic women. Effects of demographic, environmental, and hormonal factors were also evaluated in this context. Fifty women who did not have a prior diagnosis or treatment of osteoporosis were compared with 50 nonosteoporotic postmenopausal women. Demographic and morphometric characteristics, medical history, dietary habits, exercise history, and sunlight exposure were recorded. The diagnosis of osteoporosis was made with regard to BMD measurements with DEXA. Blood samples were obtained for serum biochemistry, bone turnover markers, and VDR and ESR1 gene polymorphism analysis. Polymorphic sites of VDR and ESR1 genes were amplified by polymerase chain reaction and examined using restriction fragment length polymorphism. Bb genotype was significantly higher in the osteoporotic group when compared to controls (p=0.022). Each 1 U decrease in the body mass index (BMI) increased the risk of osteoporosis by 8% independent of the genotype. We could not observe a significant effect of ESR1 polymorphism on BMD or osteoporosis risk. The interaction of ApaI and BsmI genotypes were found to be significant (p=0.041) and the AaBb genotype, when corrected for BMI, was shown to increase the risk of osteoporosis five times (p=0.005). However, the results demonstrated insignificant p values when correction for multiple testing was performed with the Bonferroni method in the logistic regression model. A predominance of Bb genotype of the VDR gene was evident in this group of postmenopausal Turkish women. Moreover, the combined genotype AaBb conferred a five times increased risk for osteoporosis when corrected for clinical variables.