Differences between repeated lipid profile measurements in a tertiary hospital over a short time period.

BACKGROUND: Measurement of the plasma lipid profile, mainly low-density lipoprotein cholesterol (LDL-C), is widely used in the management of hospitalized patients as part of their cardiometabolic risk assessment. In common practice, LDL-C is calculated indirectly by the Friedewald equation. For many years, fasting of 8-14 h is needed to obtain an accurate lipid profile measurement, although recent guidelines do not necessitate it. The aim of this study was to find patients with two consecutive LDL-C measurements taken over a short time period on the same admission to see if a significant difference exists and to suggest reasons that may explain it. We also aim to define whether the difference between LDL-C calculated by the Friedewald equation is diminished while using the newer Martin/Hopkins, de Cordova or Sampson/NIH equations. METHODS: This was a retrospective cohort study performed in one medical center in Israel. In a five-year time period, 772 patients with two repeated LDL-C measurements taken on the same admission were found. The median time gap between tests was 2 days. Correlations between laboratory results and LDL-C measurements were determined. RESULTS: A total of 414 patients (53.6%) had a difference greater than the acceptable total error of 8.9% in LDL-C calculation using the Friedewald equation, with a mean 25.8% difference between the two tests. Newer LDL-C calculations showed less diversity. Non-HDL-C was found as the only variable with a major correlation with LDL-C results in all equations. A weaker correlation was found with HDL-C. Triglycerides showed an even weaker correlation, and glucose differences had no correlation with LDL-C differences. CONCLUSIONS: Repeated LDL-C measurements can vary widely, even during a short period of hospitalization. In this study, more than half of the patients had a significant difference between their consecutive LDL-C results. This wide difference between two consecutive tests was diminished using newer calculations, yet not well explained. The fasting state likely has no effect on LDL-C levels. The results of this study might emphasize that many factors influence LDL-C calculation, especially in the disease state. Further research is needed, especially in looking for a more accurate LDL-C calculation from existing formulas.

Hospital Care Efficiency - Measuring Lipid Profile During Hospitalization.

Background: Lipid profile measurement in order to identify patients with elevated low-density lipoprotein cholesterol (LDL-C) is clearly recommended for all age groups. However, the value of screening patients for elevated LDL-C during hospitalization has not been determined. The aim of this study was to investigate the value of lipid screening tests in patients admitted to internal medicine wards, and as part of our efforts to promote a more intelligent and efficient use of laboratory and imaging tests during hospital care. Methods: We conducted this retrospective, observational study, in which medical charts of patients for whom at least one lipid profile measurement was performed during hospitalization were reviewed. The patients were categorized into 5 groups according to admission diagnosis, and for each patient, we looked if the lipid profile was mentioned or referred to, based on guidelines, in the discharge summary. Results: Lipid profile taken during hospitalization was referred to in the discharge letter in only 38.7% of patients, and even in the case of a need to consider according to guidelines, only a 45.7% consideration rate was found. Conclusion: This study highlights the need for a more efficient and focused approach to the use of lipid profile measurement during hospitalization.

Combining reservoir mask oxygenation with high-flow nasal cannula in the treatment of hypoxemic respiratory failure among patients with COVID-19 pneumonia: a retrospective cohort study.

BACKGROUND: Concerns regarding positive-pressure-ventilation for the treatment of coronavirus disease 2019 (COVID-19) hypoxemia led the search for alternative oxygenation techniques. This study aimed to assess one such method, dual oxygenation, i.e., the addition of a reservoir mask (RM) on top of a high-flow nasal cannula (HFNC). METHODS: In this retrospective cohort study, the records of all patients hospitalized with COVID-19 during 2020-2022 were reviewed. Patients over the age of 18 years with hypoxemia necessitating HFNC were included. Exclusion criteria were positive-pressure-ventilation for any indication other than hypoxemic respiratory failure, transfer to another facility while still on HFNC and "do-not-intubate/resuscitate" orders. The primary outcome was mortality within 30 days from the first application of HFNC. Secondary outcomes were intubation and admission to the intensive care unit. RESULTS: Of 659 patients included in the final analysis, 316 were treated with dual oxygenation and 343 with HFNC alone. Propensity for treatment was estimated based on background diagnoses, laboratories and vital signs upon admission, gender and glucocorticoid dose. Inverse probability of treatment weighted regression including age, body mass index, Sequential Organ Failure Assessment (SOFA) score and respiratory rate oxygenation index showed treatment with dual oxygenation to be associated with lower 30-day mortality (adjusted hazard ratio, 0.615; 95% confidence interval, 0.469-0.809). Differences in the secondary outcomes did not reach statistical significance. CONCLUSIONS: Our study suggests that the addition of RM on top of HFNC may be associated with decreased mortality in patients with severe COVID-19 hypoxemia.

Dual Oxygenation in the Treatment of Hypoxemic Respiratory Failure: A Retrospective Cohort Study.

BACKGROUND: At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many patients presented with acute hypoxemic respiratory failure, requiring ventilatory support. One treatment method was the addition of a reservoir mask to a high flow nasal cannula (HFNC) (dual oxygenation). OBJECTIVES: To evaluate the clinical outcomes of combining reservoir mask on top of a high-flow nasal cannula. METHODS: A retrospective cohort of adult patients who were admitted due to COVID-19 during the first year of the pandemic to Rambam Health Care Campus. The primary endpoint was 30-day mortality. Secondary endpoints were incidence of invasive positive pressure ventilation initiation and admission to the intensive care unit (ICU). Patients who received positive pressure ventilation for reasons other than hypoxemic respiratory failure or who were transferred to another facility while still on HFNC were excluded. RESULTS: The final analysis included 333 patients; 166 were treated with dual oxygenation and 167 with HFNC only (controls). No significant differences in baseline characteristics were noted between the groups. The dual oxygenation group was slightly older (69.2 ± 14.8 years vs. 65.6 ± 15.5 years, P = 0.034). The 30-day mortality (24.1% vs. 36.5%, P = 0.013), rates of invasive positive pressure ventilation (47% vs. 59.3%, P = 0.024), and ICU admissions (41.6% vs. 52.7%, P = 0.042) were all significantly lower in the dual oxygenation group. CONCLUSIONS: The addition of reservoir masks to HFNC may improve the oxygenation and overall prognosis in patients with severe hypoxemia due to COVID-19.

Clinical presentations of acute pulmonary embolism: A retrospective cohort study.

We aimed to investigate whether the unusual clinical presentation of pulmonary embolism (PE) varies by the type of provocation. In this retrospective cohort study, we examined the electronic health records (EHR) records of all patients diagnosed with PE (upon presentation or during hospitalization) presented to our tertiary hospital during 2014 to 2019. Inclusion criteria were the diagnosis of acute PE and age above 18 years. Excluded were all patients to whom complete EHR were not available. The primary outcome was the main presenting symptom, categorized by a multidisciplinary consensus expert committee as either typical or atypical of PE. Comorbidities, vital signs, medications and laboratory results on presentations were recorded. 591 patients were included in the final analysis. Dyspnea was significantly less common and hemoptysis and chest pain more common in the unprovoked PE group (35%, 5%, and 25%, respectively) compared with nonmalignant (42.6%, 0%, and 16.3%) and malignancy-associated (47.7%, 0.9%, and 8.2%) PE (Pv = 0.02, 0.002 and 0.001, respectively). No recorded symptoms were the third most common presentation overall, accounting for a significantly (Pv < 0.001) higher proportion of PE patients with malignancy (19%) whereas atypical presentation was the hallmark of patients with nonmalignant provokation (19.7%) (Pv = 0.005). Accounting for multiple potential confounders, the risk of atypical or asymptomatic presentation was higher with lower heart rates (RR = 0.974 95%C.I. [0.957-0.990]) and higher pulse oximetry saturation (RR = 1.114 95%CI [1.034-1.201]). The clinical presentation of PE varies with different types of provoking factors, with atypical presentation most common in nonmalignant provocation and asymptomatic presentation most prevalent in patients with underlying malignancy. Further studies are needed to determine the effect of said variance on long term clinical outcomes.

The association between medical students' motivation with learning environment, perceived academic rank, and burnout.

OBJECTIVES: To assess the correlations between extrinsic and intrinsic motivation, personal growth and quality of life with learning environment perceptions, perceived academic rank and burnout among medical students. METHODS: Cross-sectional questionnaires were administered to medical students at three medical schools in Israel, Malaysia, and China, at the end of one academic year. Surveys included demographic data, students' perceived academic rank, two learning environment perceptions scales, and scales for personal growth, goal orientation, burnout and quality of life. Comparative analyses were made to determine the significance of relationships between the outcome measures and control variables, using a series of t-tests. Pearson correlation coefficients were used to test the hypothesis. RESULTS: Sixty-four percent (400/622) of the students responded. Significant correlations were found between: intrinsic motivation (r(398) =.37, p<.001); personal growth (r(398)=.62, p<.001); and quality of life (r(398)= .48, p <.001) with higher learning environment perceptions, intrinsic motivation (r(398)= .21, p<.001); personal growth (r(398) =.21, p< .001); and quality of life (r(398)=.18, p<.001) with perceived academic rank, and negative correlation between personal growth (r(398) =-.38, p<.001); and quality of life (r(398) =-.42, p<.001) with burnout. CONCLUSIONS: Intrinsic motivation, personal growth and quality of life are correlated with higher learning environment perceptions and perceived academic rank. Burnout is influenced by personal growth and quality of life. We suggest focusing on motivation profiles before acceptance to medical school and during studies.

Placenta-Derived Cell Therapy to Treat Patients With Respiratory Failure Due to Coronavirus Disease 2019.

OBJECTIVES: To determine whether placental cell therapy PLacental eXpanded (PLX)-PAD (Pluristem Therapeutics, Haifa, Israel) may be beneficial to treating critically ill patients suffering from acute respiratory distress syndrome due to coronavirus disease 2019. DESIGN: Retrospective case report of critically ill coronavirus disease 2019 patients treated with PLacental eXpanded (PLX)-PAD from March 26, 2020, to April 4, 2020, with follow-up through May 2, 2020. SETTING: Four hospitals in Israel (Rambam Health Care Campus, Bnai Zion Medical Center, and Samson Assuta Ashdod University Hospital), and Holy Name Medical Center in New Jersey. PATIENTS: Eight critically ill patients on invasive mechanical ventilation, suffering from acute respiratory distress syndrome due to coronavirus disease 2019. INTERVENTIONS: Intramuscular injection of PLacental eXpanded (PLX)-PAD (300 × 106 cells) given as one to two treatments. MEASUREMENTS AND MAIN RESULTS: Mortality, time to discharge, and changes in blood and respiratory variables were monitored during hospitalization to day 17 posttreatment. Of the eight patients treated (median age 55 yr, seven males and one female), five were discharged, two remained hospitalized, and one died. By day 3 postinjection, mean C-reactive protein fell 45% (240.3-131.3 mg/L; p = 0.0019) and fell to 77% by day 5 (56.0 mg/L; p < 0.0001). Pao2/Fio2 improved in 5:8 patients after 24-hour posttreatment, with similar effects 48-hour posttreatment. A decrease in positive end-expiratory pressure and increase in pH were statistically significant between days 0 and 14 (p = 0.0032 and p = 0.00072, respectively). A decrease in hemoglobin was statistically significant for days 0-5 and 0-14 (p = 0.015 and p = 0.0028, respectively), whereas for creatinine, it was statistically significant between days 0 and 14 (p = 0.032). CONCLUSIONS: Improvement in several variables such as C-reactive protein, positive end-expiratory pressure, and Pao2/Fio2 was observed following PLacental eXpanded (PLX)-PAD treatment, suggesting possible therapeutic effect. However, interpretation of the data is limited due to the small sample size, use of concomitant investigational therapies, and the uncontrolled study design. The efficacy of PLacental eXpanded (PLX)-PAD in coronavirus disease 2019 should be further evaluated in a controlled clinical trial.

Pleural Fluid B-Type Natriuretic Peptide Level as an Additional Indicator for the Fluid's Etiology.

BACKGROUND: The identification of the etiology of a pleural effusion can be difficult. Measurement of serum B-type natriuretic peptide (BNP) levels is helpful in the diagnosis of congestive heart failure (CHF) as a cause of respiratory failure, but pleural fluid BNP measurement is still not part of the workup for pleural effusion. OBJECTIVES: To identify the correlation between pleural fluid BNP levels and clinical diagnosis. METHODS: In this cross-sectional study, data from 107 patients admitted to the department of internal medicine between November 2009 and January 2015 were obtained from medical records. Patients underwent a diagnostic thoracocentesis as part of their evaluation. They were grouped according to final diagnosis at discharge and clinical judgment of the attending physician. RESULTS: Serum BNP levels were significantly higher in the CHF patients compared to patients with non-cardiac causes of pleural effusion (1519.2 and 314.1 respectively, P < 0.0001). Mean pleural fluid BNP was also significantly higher in the CHF patients (1063.2 vs. 208.3, P < 0.0001). Optional cutoff points to distinguish between cardiac and non-cardiac etiology of pleural effusion were 273.4 pg/ml (sensitivity 83.3%, specificity 72.3%, accuracy 76.7%) or 400 pg/ml (sensitivity 78.6%, specificity 86.2%, accuracy 83.0%). A strong correlation was found between serum BNP and pleural fluid BNP levels. CONCLUSIONS: High levels of serum BNP in patients presenting with pleural effusion suggest CHF. In cases with doubt regarding the etiology of pleural effusion, high levels of pleural fluid BNP can support the diagnosis, but are not superior to serum BNP levels.

Guaiac faecal occult blood screening in individuals younger than 50 years of age.

To determine the effectiveness of guaiac faecal occult blood tests (gFOBT) in the early detection of colorectal cancer (CRC) within a population of asymptomatic individuals who attended general periodic examinations, and to suggest the recommended age for this screening tool, the electronic database of the periodic examination institute of Rambam Healthcare Campus for the years 2004-2013 was reviewed. Individuals with positive gFOBT results were interviewed for further workup. Proportions of individuals for whom a polyp or CRC was detected were evaluated according to sex and age. 18 858 individuals were examined during the study period, mean age 48 years. The overall gFOBT uptake was 40.8%. Uptake was significantly higher among men and increased with age. Positive gFOBT was detected in 105 individuals (1.4%). The proportion of positive gFOBT was significantly lower among individuals aged 30-50 years than those older than 50 years of age (1.1 and 1.7%, respectively, P=0.005). No positive gFOBT was detected among individuals younger than 30 years of age. Positive gFOBT was higher in men than in women: 1.8 and 0.9% respectively (P=0.002). CRC was detected in six individuals, including two younger than 50 years of age. Polyps were detected in 15 individuals; of these, four were younger than 50 years of age. In the gFOBT-positive group, proportions of polyps and CRC were the same for subgroups according to age. The findings support consideration of annual gFOBT screening from the age of 40 years.

Treatment of Carbapenem-Resistant Acinetobacter baumannii Ventilator-Associated Pneumonia: Retrospective Comparison Between Intravenous Colistin and Intravenous Ampicillin-Sulbactam.

Carbapenem-resistant Acinetobacter baumannii has been increasingly reported as the causative agent of ventilator-associated pneumonia (VAP) among patients in the intensive care units. However, there are insufficient data to guide the appropriate treatment for such infection. Our aim was to compare the outcome of carbapenem-resistant A. baumannii VAP treated with colistin or with ampicillin-sulbactam. We conducted a retrospective study of patients diagnosed with carbapenem-resistant A. baumannii VAP during 2008 and 2009. Clinical and microbiologic cure rates, 30-day mortality, and change in renal function were compared between patients treated with colistin versus those treated with ampicillin-sulbactam. The association between treatment and mortality was examined through multivariable logistic regression analysis. Of the 98 patients diagnosed with carbapenem-resistant A. baumannii VAP, 66 were treated with colistin and 32 with ampicillin-sulbactam. Baseline characteristics of patients were similar, except for a longer intensive care unit stay and lower creatinine clearance test before VAP diagnosis among patients treated with colistin. Clinical cure rates were similar in the 2 groups. In the colistin group, microbiologic failure rates were higher at 7 days [16/33 (48%) vs. 3/17 (18%); P = 0.03]; patients had a more significant elevation in creatinine (+0.2 ± 1.0 mg/dL vs. -0.3 ± 1.1 mg/dL; P = 0.021), and treatment was associated with an increased 30-day mortality (adjusted-odds ratio, 6.5; 95% confidence interval, 1.348-31.342; P = 0.02). In conclusion, patients treated with colistin or ampicillin-sulbactam had similar clinical cure rates. However, colistin was associated with higher rates of microbiologic failure, reduction in renal function, and an increased 30-day mortality. A prospective study comparing high-dose colistin and ampicillin-sulbactam for the treatment of carbapenem-resistant A. baumannii VAP is warranted.

Vogt-Koyanagi-Harada syndrome associated with renal failure: a case report.

Vogt-Koyanagi-Harada (VKH) syndrome is a rare entity characterized by depigmentation of the skin and eye lashes, chronic granulomatous iridocyclitis and exudative retinal detachment, as well as aseptic meningitis and encephalopathy. We describe a 22-year-old male intravenous drug addict, infected with hepatitis B and C virus, suffering from this syndrome, associated with progressive renal sclerosis, malignant hypertension, heart failure and chronic myeloproliferative disorder. The association with these various diseases is discussed and relevant cases are reviewed.

Panaortitis: diagnosis via fluorodeoxyglucose positron emission tomography.

A 57-year-old woman was admitted with a 2-month history of low-grade fever, malaise, and weight loss. Physical examination findings were unremarkable except for a systolic murmur of a known mild aortic regurgitation. Laboratory tests revealed only mild leukocytosis and an elevated sedimentation rate. Serology tests for viral and bacterial pathogens, blood and urine cultures, and immunology tests had negative results. Total body computed tomography, transesophageal echocardiography, and biopsies of bone, liver, and temporal arteries were normal. Wide-spectrum antibiotics effected no change in the patient's illness. Low-dose steroids given for a suspected polymyalgia rheumatica caused only minimal and transient improvement. Re-evaluation showed no new findings. Fluorodeoxyglucose positron emission tomography (FDG-PET) was done and showed an abnormally increased uptake along the aortic arch, the descending aorta, and bilaterally in the subclavian and carotid arteries, compatible with arteritis. High-dose steroids and later methotrexate were given and caused obvious improvement, with complete resolution of symptoms. We conclude that FDG-PET should be a part of the usual work-up of fever of unknown origin, especially in cases in which routine investigation reveals no cause.